The Practice
25. The law says a complaint must be brought to us within one year of the complainant becoming aware that they had a reason to complain. We can only put this time limit aside if we consider it reasonable to do so.
26. We initially considered the date Mr D became aware he had reason to complain. Mr D explained this was following his father’s cancer diagnosis in March 2021.
27. We are aware Mr D, and his family were unhappy with the Practice’s actions prior to this point (expressed in his complaint from May 2021). Despite this, we accept they would not have known the serious impact of the lack of care until Mr J received a cancer diagnosis in March 2021. We consider this to be the date Mr D became aware he was unhappy with the Practice’s care and treatment of his father prior to his diagnosis. Therefore, after careful consideration, we consider Mr D had reason to complain to the Practice from March 2021.
28. Mr D would have had one year, until March 2022 to complain to us. He did not complain to us until May 2024, (sharing the Practice’s final response with a Caseworker in December). This means his complaint is approximately two years and two months outside of our legal time limit. We considered the reasons for this delay.
29. We first considered the time the Practice took to respond to Mr D’s complaint. Mr D complained to NHS England about the Practice on 4 May 2021. He says he did not receive a response. He next chased the Practice on 12 May 2024. The Practice formally responded on 4 June. We would have expected Mr D to chase a response from the NHS England or the Practice within the initial months after he first complained.
30. We asked Mr D whether he chased his complaint about his father’s cancer diagnosis between May 2021 and May 2024. He explained, he worked night shifts through this period, changed jobs and moved house. He told us he left things with his younger sister.
31. He also said he thought his father had complained as he was unhappy with the care he was receiving. Mr D explained he lost track of the complaint during this period. This is understandable and we appreciate Mr D had a lot going on in his own life at this time.
32. We would still have expected Mr D or his family to complain or chase the complaint with the Practice during this two-year period. We have not seen evidence Mr D did this or that there were barriers preventing him or his family from doing so. For these reasons, we have decided we have not seen a good reason to put aside our time limit for this period. Therefore, we will not consider this complaint further.
The Trust
33. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Monitoring of oxygen saturation levels
34. Mr D complains the Trust did not correctly monitor Mr J’s oxygen levels.
35. At the start of his inpatient stay in October 2023, Mr J’s medical notes show his lungs were effectively transferring oxygen to his body without assistance and his oxygen saturation levels were normal, (equal to, or above 96%).
36. To monitor oxygen saturation levels, clinicians use the national early warning score (NEWS2). This is a universal tool which helps clinicians to see if a patient is deteriorating and to escalate deterioration when needed.
37. NEWS2 guidance provides information on how this score should be used. It also provides information on how often clinicians should monitor oxygen saturation levels. This is dependent their overall NEWS2 score.
38. At 5.32pm on 22 October 2023, Mr J’s oxygen saturation levels dropped to 93%. The Trust then delivered oxygen to Mr J through a nasal cannula (a flexible tube that fits into the nose). The Trust increased the amount of oxygen from two to four litres per minute (L).
39. Unfortunately, this did not improve Mr J’s oxygen saturations, and they decreased to 92%. The Trust changed the way in which it delivered the oxygen to humidified oxygen (oxygen that has been passed through a humidifier to add moisture) through a face mask and increased it to 11L.
40. At 7.37pm, Mr J’s oxygen saturations improved and were at 94%. This was still below the target, normal range of 96% or above. At this time Mr J’s breathing rate also increased to 30 (a normal breathing rate is between 12 to 20). Nurses escalated this to doctors.
41. A doctor reviewed Mr J at 7.40pm and prescribed antibiotics (medicine to combat bacterial infections) and nebulisers (a medical device that coverts liquid medication into a mist to allow it to be inhaled easily) for a chest infection. The doctor also referred Mr J to the Critical Care Outreach Team (CCOT). Our adviser helped us to understand, throughout this time, the Trust monitored Mr J’s oxygen saturations in line with NEWS2 guidance.
42. CCOT started Mr J on high flow oxygen, and this improved his oxygen saturation levels to between 96 -99%. The Trust checked this every half hour until they were stable. There was a drop in his oxygen saturations to 87% at 2.45am on 23 October.
43. Mr J’s medical notes show, nurses quickly recognised this and ensured his oxygen saturations increased to 95% at 2.49am and 98% at 4am. Mr J’s oxygen saturations remained stable throughout the rest of his inpatient stay.
44. We have reviewed Mr J’s medical notes in line with the NEWS2 guidance, and we have seen indications the Trust monitored his oxygen saturations appropriately. Specifically, we can see the Trust monitored Mr J’s oxygen saturations with the appropriate level of frequency and escalated their concerns when his results were lower than normal.
45. We appreciate the incredibly difficult time Mr D and his family have been through. We understand they are still grieving for their father, and we hope our report can provide some reassurance the Trust did everything it should have to monitor Mr J’s oxygen saturations.
46. We have seen no indications of failings in the actions of the Trust in this part of the complaint. Therefore, we have decided not to consider this part of the complaint further.
Poor nursing communication
47. Mr D told us nursing staff did not communicate effectively with each other and this contributed to the poor nursing care his father received.
48. The NMC Code says nurses should:
‘8.6 share information to identify and reduce risk’, and ‘10.2 identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who use the records have all the information they need’.
49. Additionally, NMC standards say nurses should:
‘1.16 demonstrate the ability to keep complete, clear, accurate and timely records’.
50. Our adviser helped us to understand whether nurses at the Trust communicated well and whether they followed the NMC Code. Our adviser considered Mr J’s medical records and told us they indicate that communication between nursing staff was effective. They explained the level of detail within the nursing records supports this. We consider this was in line with the above NMC standards and NMC Code.
51. We can see nurses kept detailed notes which ensured clinicians using Mr J’s records had all the information they needed to meet his medical needs. Our adviser did not identify any gaps in nursing care that suggested poor communication. Additionally, we have not seen indications Mr J received a poor standard of nursing care.
52. Overall, we have not seen indications of failings in the communication between nurses at the Trust and we have decided not to consider this part of the complaint further.
Lack of escalation to more senior staff
53. Mr D says the Trust did not escalate Mr J’s care during critical deterioration periods. He says this contributed to his father’s deterioration and death.
54. The NMC Code say nurses should:
‘13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care 13.2 make a timely referral to another practitioner when any action, care or treatment is required 13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’.
55. Mr J’s condition deteriorated on 22 October and his oxygen saturations dropped. In response, nurses paused his NG feed. At 2pm, they escalated their concerns to doctors. At this point Mr J was experiencing abdominal pain. A doctor saw Mr J at 4pm, and nurses restarted the NG feed at 4.30pm. Our adviser helped us to understand this escalation was timely and appropriate. We therefore consider it was in line with the above NMC Code.
56. The Trust documented Mr J started coughing ten minutes after nurses restarted his NG feed and nurses suctioned him. At 6.33pm nurses informed the doctor that Mr J had an ongoing cough, but they did not request any further action. The Trust also escalated him to CCOT.
57. At 7.15pm, CCOT attended and they did deep suctioning. At 7.37pm, Mr J’s oxygen saturation levels were not improving on increasing doses of oxygen, suctioning and nebulisers. At this point the Trust escalated him for a medical review which took place three minutes later. Our adviser explained this was timely and appropriate. This was in line with the above NMC Code.
58. After Mr J’s deterioration on 22 October, nurses continued to liaise with medical staff and CCOT regularly regarding his chest and abdominal symptoms. Our adviser helped us to understand this was appropriate.
59. Throughout Mr J’s inpatient stay, we have seen indications the Trust escalated Mr J’s care at appropriate times and after careful consideration of his medical condition. We consider the Trust acted in line with the above NMC guidance. As such, we have decided not to consider this part of the complaint further.
Conclusion
60. We have set out the reasons why we have decided Mr D’s complaint about the Practice falls outside of the time limit. We appreciate this may be disappointing for Mr D and his family. We hope we have fully explained the reasons for our decision.
61. We have seen no indication that anything went seriously wrong with the care and treatment the Trust provided to Mr J. We hope this is of some reassurance to Mr D and his family as they continue to grieve for their father.
62. We are grateful Mr D, and his family brought their complaint to us. We appreciate how difficult it can be to make a complaint in these circumstances.