The Princess Alexandra Hospital NHS Trust

3. Mrs R complains about the care The Princess Alexandra Hospital NHS Trust (the Trust) gave her husband, Mr R in 2023. She specifically complains the Trust: • failed to perform a mental capacity assessment between 15 and 18 October 2023 • delayed providing antibiotics when she reported a chesty cough on 5 November.

4. Mrs R feels if the Trust carried out a capacity assessment, Mr R would have been sedated and cared for in the Intensive Care Unit (ICU). As a result, he would not have developed respiratory failure in October. She says this led to a prolonged hospital stay, pneumonia and his death.

5. She says if the Trust had not delayed providing antibiotics, Mr R would have avoided sepsis, multi-organ failure and would not have died.

6. Mrs R says the Trust’s actions have led to her losing her husband and their daughter losing her father.

7. As an outcome for her complaint, Mrs R is seeking financial remedy.

8. Mr R was 56 years old, with myotonic dystrophy (a genetic condition that causes progressive muscle weakness), chronic obstructive pulmonary disease (a lung condition) and obstructive sleep apnoea (a sleep disorder affecting breathing).

9. The Trust admitted him on 13 October 2023 with shortness of breath and treated him for community acquired pneumonia. He self-discharged on 14 October. An ambulance brought him back overnight with low oxygen saturations.

10. The Trust put him on non-invasive ventilation (NIV). NIV uses a tight-fitting mask to helps support breathing. On 18 October, Mr R developed respiratory failure, and staff transferred him to the ICU.

11. Mr R was in ICU for two weeks. The Trust returned him to the ward, where he developed pneumonia and worsening kidney function. He sadly died on 15 November.

15. 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.

Mental Capacity Assessment

16. When the Trust admitted Mr R on 15 October, staff assessed and documented he had capacity. Over the next three days he refused oxygen, medications and observations. He signed a self-discharge form on 16 October, but staff found him in the car park and brought him back to the ward.

17. Mrs R feels if staff had done a capacity assessment, and found Mr R lacked capacity, they could have considered sedating and treating him on ICU in his best interests.

18. The Trust noted that Mr R was in a cycle of accepting treatment when he was unwell but declining it as he became more alert.

19. The Mental Capacity Act says, ‘a person must be assumed to have capacity unless it is established that he lacks capacity’ and ‘a person is not to be treated as unable to make a decision merely because he makes an unwise decision’.

20. The MCA Code of Practice explains staff must assess capacity in relation to a specific decision. Mrs R told us she felt her husband lacked capacity to make a decision about his treatment.

21. Mr R’s medical records show on 15 October, his oxygen levels were dangerously low, and staff treated him with NIV for three hours in his best interests. After he improved, he declined treatment and wished to self-discharge. A doctor assessed him and found he had capacity to make these decisions.

22. Mrs R encouraged him to stay in hospital. Over the next three days, staff noted Mr R had periods of confusion and he refused treatment.

23. Our adviser said when Mr R had full capacity on 15 October, he refused treatment. Mr R’s continued refusal was consistent with his decision when he had full capacity. For that reason, the Trust had no reason to consider a capacity assessment was necessary.

24. The MCA says the starting point is that all patients have capacity. We recognise Mr R’s confusion fluctuated through his admission, but he refused treatment when he had documented full capacity.

25. We have considered the relevant guidance, Mr R’s medical records and our adviser’s comments. Mr R’s decisions remained consistent. We therefore consider the Trust acted in line with the MCA in not performing a capacity assessment on Mr R when he refused treatment.

Antibiotics

26. Mrs R said she noted her husband had a chesty cough on 5 November. She told a nurse and asked them to request antibiotics from the doctor.

27. NICE guidance defines a lower respiratory tract (chest) infection as an acute illness with cough and at least one of the symptoms of fever, sputum production, breathlessness, wheeze or chest pain, and no alternative explanation.

28. Mr R had a weak cough due to his underlying conditions. His notes show he had airway secretions that needed suctioning and chest physiotherapy.

29. On 5 November, Mr R’s breathing rate and oxygen levels were normal, and he did not have a fever. His blood tests showed his CRP (a marker of inflammation) was going down.

30. Our adviser explained Mr R’s cough could be explained by his myotonic dystrophy and there were no other symptoms or signs to suggest an infection on 5 November. Mr R did not show the relevant signs of chest infection set out in the NICE guidance.

31. Without indication of a chest infection, staff would not have prescribed antibiotics on this day.

32. Mr R’s medical records show on 8 November, his oxygen levels lowered, and markers of inflammation increased. The Trust diagnosed him with aspiration pneumonia and gave him antibiotics in line with the NICE guidance.

33. Taking the above into consideration, we consider the Trust acted in line with NICE guidance in not diagnosing an infection or providing antibiotics on 5 November.

34. We recognise Mr R’s hospital admission and sad death was incredibly distressing for Mrs R and their daughter. We hope she can be reassured the Trust acted in line with guidance.

1. We have carefully considered Mrs R’s complaint about The Princess Alexandra Hospital NHS Trust. We were sorry to hear of the circumstances of her complaint and the distress this caused.

2. We have considered all the available evidence, and we have seen no indication the Trust did anything wrong. We recognise the upset Mrs R experienced and extend our sincere condolences on the loss of her husband.