The Trust did not administer intravenous antibiotics when he was admitted to hospital on 7 January 2024 – not upheld
18. Mrs J says the Trust should have given Mr J intravenous antibiotics when he was admitted to hospital on 7 January 2024. It its response, the Trust said the blood tests Mr J had on admission did not indicate a clinical need for intravenous antibiotics. We reviewed Mr J’s medical records and obtained clinical advice to investigate this complaint component.
19. The records show Mr J was admitted to hospital on 7 January 2024. He presented with shortness of breath and a cough. On admission, he had a blood test and was prescribed oral antibiotics among other medications. This is line with GMC ‘Good Medical Practice,’ section 7d, which says clinicians should prescribe drugs or treatment which will meet the patient’s needs.
20. Our adviser said the inflammatory markers identified in the blood test, namely the white blood cell and CRP levels, were normal. These markers suggest Mr J was not suffering from an infection. Mr J’s medical records say clinicians considered Mr J’s symptoms were caused by the progression of cancer to his lungs, possibly in conjunction with his recent Covid diagnosis at the end of 2023. Our adviser said this clinical impression was reasonable. They said it reflected the blood test result and other clinical findings.
21. Our adviser said the clinical decision of whether to administer antibiotics orally or intravenously would normally vary based on the clinical context. They said it would also sometimes depend on which individual antibiotics were prescribed. They said the antibiotics received by Mr J were appropriate to prescribe orally, rather than intravenously, and it was standard clinical practice to do so. They said the Trust’s decision to prescribe Mr J oral antibiotics was clinically appropriate and in line with GMC guidance, as it met Mr J’s clinical need.
22. We have not seen evidence of failings on this issue. The Trust gave Mr J a blood test in line with GMC guidance and prescribed oral antibiotics in line with standard clinical practice. Mr J’s medical records detail the medications he was prescribed. The Trust therefore acted in line with relevant guidance and standards.
The Trust incorrectly gave Mr J a double dose of chemotherapy in March 2023, which damaged his liver and meant his chemotherapy had to be paused - not upheld
23. Mrs J says the Trust gave Mr J a double dose of chemotherapy in March 2023. She said this caused damage to his liver and meant his chemotherapy had to be paused.
24. In its response, the Trust said Mr J did not receive a double dose of chemotherapy. It says it followed standard practice in giving his first cycle at 75% of a standard dose, then increasing this to 100% for his second cycle. When Mr J experienced side effects, the Trust said he received subsequent cycles at the 75% dosage. We reviewed Mr J’s medical records and obtained clinical advice to investigate this complaint component.
25. The records show Mr J consented to chemotherapy treatment on 25 January 2023. He received his first cycle on 17 February 2023 at a 75% dose in view of his slight frailty. On 8 March, he saw a consultant oncologist. The oncologist recorded an excellent clinical response in the notes and documented that Mr J’s dosage would be increased to 100% for cycle two. He received his second cycle on 10 March 2023.
26. On 29 March 2023, Mr J saw the consultant oncologist and reported severe total body itching, dark urine and fatigue following cycle two. Following these reports of side effects and liver dysfunction, the consultant paused chemotherapy while further blood tests and scans of Mr J’s liver were completed. On 11 April Mr and Mrs J saw the oncologist again. His blood tests showed improvement and the computed tomography (CT) scan of his liver showed no biliary dilatation (abnormal widening of the bile ducts). The consultant planned to restart Mr J’s chemotherapy treatment at cycle three, with a dose reduction to reflect the 75% dosage he received in cycle one. Mr J received cycle three of his chemotherapy on 25 April 2023.
27. Our adviser explained the combinations of drugs used in chemotherapy treatment are detailed in NICE guidance NG83. Section 1.5.5 explains the combinations which can be used for first line palliative chemotherapy for metastatic oesophageal cancer, which was the type Mr J had. The records showed Mr J received capecitabine in combination with oxaliplatin (CAPOX) which is in line with guidance 1.5.5.
28. Our adviser explained each hospital trust has a chemotherapy protocol, used to determine the dosages of chemotherapy used. This is normally standardised across a geographical region or cancer alliance, in this case the Somerset, Wiltshire, Avon and Gloucestershire Cancer Alliance. These protocols use a patient’s body surface area (BSA) to calculate the dose of chemotherapy they should receive. Our adviser reviewed Mr J’s BSA and the dosages of the chemotherapy drugs he was given during each cycle and said his dosages were in line with the chemotherapy protocol.
29. Our adviser said Mr J received 75% of a standard dose for his first cycle. They said this is standard practice in someone who is less well. They said Mr J received 100% of the standard dose for cycle two, because he presented as stronger than he was before the first cycle. They said this represented a standard approach to treatment.
30. Unfortunately, Mr J experienced some side effects and liver dysfunction. Our adviser said this can be a side effect of chemotherapy, as the Trust explained when Mr J consented to chemotherapy treatment. Unfortunately, the side effects he experienced delayed his third cycle of treatment. Our adviser said the Trust could not have foreseen or avoided this. They said there is no guidance around whether an oncologist should go up to a full dose after improving with cycle one at a reduced dose, and this is generally down to individual clinician’s discretion.
31. Our adviser told us Mr J’s chemotherapy was delivered in line with guidance and the clinical decision to give him 100% of the normal dose at cycle two, following a good response to cycle one, was standard practice. They said although Mr J unfortunately experienced some side effects, this was not due to any departure from guidance and did not affect the completion of his chemotherapy treatment.
32. We have not seen evidence of failings on this issue. The Trust delivered Mr J’s chemotherapy in line with NICE guidance and the Trust’s chemotherapy protocol. It calculated his BSA and adjusted his dose accordingly. The decision to give him 100% of the normal dose at cycle two following a good response to cycle one was standard clinical practice. The side effects Mr J experienced did not impact upon his treatment. He received a full cycle of chemotherapy. The Trust therefore acted in line with relevant guidance and standards.
The Trust’s failure to communicate blood test results resulted in missed chemotherapy appointment on 21 April 2023 - not upheld
33. Mrs J says the Trust did not communicate that Mr J’s blood test results were sufficient to proceed with his chemotherapy treatment. She says this resulted in Mr J missing a planned chemotherapy appointment on 21 April 2023, which delayed his cancer treatment. In its response, the Trust said it would not routinely call patients to confirm that the appointment could go ahead and apologised for the misunderstanding. It said it rescheduled Mr J’s chemotherapy appointment promptly and his care was not compromised. We reviewed Mr J’s medical records and obtained clinical advice to investigate this complaint component.
34. Mr J’s medical records show he received his second cycle of chemotherapy on 10 March 2023. It scheduled his third cycle for 21 April 2023, following the delay caused by the side effects he experienced. Mr J did not attend this appointment, and a clinical nurse specialist contacted him the same day. Mr J believed the Trust had cancelled the appointment due to the side effects he had experienced following cycle two. He was awaiting a call from the Trust confirming that the appointment could proceed, and since he had not received one assumed the appointment was cancelled.
35. The clinical nurse specialist told Mr J the Trust would only call a patient if an appointment could not go ahead for any reason. They had therefore been expecting Mr J on 21 April. Following this miscommunication, the Trust rescheduled the appointment, and Mr J received his third cycle on 25 April 2023.
36. Our adviser said the four-day delay in arranging Mr J’s third cycle of chemotherapy would not have made any difference to his treatment. They said Mr J’s chemotherapy protocol was based on three-week intervals, meaning he should have attended for treatment every 21 days.
37. The Trust’s chemotherapy protocol confirms this, saying the cycle frequency for this type of chemotherapy is 21 days. The gap between Mr J’s second and third cycles was necessarily longer, because it was not safe to give the third cycle until he had recovered from the side effects he had experienced after the second cycle. This is in line with GMC guidance on providing and managing medicine, section 92-94, which says clinicians should ensure they follow up and review after giving medicines, particularly when the medicines have potentially serious or common side effects.
38. Our adviser said the delays experienced by Mr J, while frustrating for Mr and Mrs J, did not affect his treatment or outcomes. They said patients often opted to delay chemotherapy cycles for family events and a four-day delay would not have impacted on his care. They said Mr J’s chemotherapy was delivered in line with the Trust’s plan for his care.
39. We have not seen any evidence of failings on this issue. The Trust rescheduled the missed chemotherapy appointment promptly. The delay between cycle two and three of Mr J’s chemotherapy treatment was caused by the need to wait until Mr J’s side effects had subsided. The Trust therefore acted in line with the Cancer Alliance chemotherapy protocol and relevant guidance.
The Trust cancelled and rescheduled a chemotherapy appointment in May 2023 without informing them - not upheld
40. Mrs J says the Trust cancelled and rescheduled a chemotherapy appointment in May 2023 without informing them, which impacted on Mr J’s treatment. In its response, the Trust said its administrative staff were asked to cancel the appointment due to an oncology consultant being away from the Trust. It apologised that Mr and Mrs J were not made aware of the cancelled appointment. We reviewed Mr J’s medical records and obtained clinical advice to investigate this complaint component.
41. The records show Mr J received his cycle three chemotherapy treatment on 25 April. He attended the oncology clinic for a planned appointment with the consultant oncologist on 3 May. Unfortunately, the consultant was on sick leave, but Mr J had not been informed. The appointment was rescheduled for 10 May and he received cycle four on 16 May.
42. Our adviser said Mr J’s chemotherapy protocol was based on three-week intervals, meaning he should have attended for treatment every 21 days. They said Mr J had not needed to see the consultant as early as 3 May, because he had only received his cycle three treatment a week previously. They said the Trust delivered his fourth cycle in line with the 21-day protocol and it was not delayed.
43. We have not seen evidence of failings on this issue. The Trust apologised for the miscommunication around Mr J’s oncology clinic appointment in its response. This is line with PHSO’s Complaint Standards, which says organisations should give meaningful apologies and transparent explanations. The Trust rearranged Mr J’s clinic appointment and he received his fourth cycle in line with his 21-day protocol. It did not affect his chemotherapy treatment. The Trust therefore acted in line with relevant guidance.
The Trust incorrectly and prematurely discharged Mr J on 22 August 2023, so he had to be readmitted for a repeat blood test the following day - not upheld
44. Mrs J says the Trust prematurely discharged Mr J before his blood test results were known on 22 August 2023. She says he had to reattend for another blood test the following day. The Trust said it carried out a standard post-transfusion blood test but the haemoglobin level did not rise as expected. Mr J had to return to the hospital the following day. The Trust apologised for the inconvenience. We reviewed Mr J’s medical records and obtained clinical advice to investigate this complaint component.
45. The records show Mr J attended the hospital emergency department on 20 August 2023 with shortness of breath. He was diagnosed with an upper gastrointestinal haemorrhage, which was considered likely secondary to his known oesophageal cancer. He had tested positive for COVID-19 several weeks previously.
46. Mr J’s medical records show his clinical plan included a blood transfusion and antivirals for COVID-19. His records flagged the potential need for an endoscopy in the future if he experienced ongoing bleeding. The records also noted the need to check his haemoglobin level. The Trust did a blood test on 21 August to check this. The records show Mr J’s clinical plan was to check his haemoglobin level again prior to discharge.
47. Mr J was discharged from hospital on 22 August. His medical records from 22 August say he did not need to stay for the results of the haemoglobin level check. Later that day, the blood sciences department advised the post-transfusion haemoglobin level had not risen as expected. The Trust decided to arrange a further blood test and asked Mr J to reattend the hospital. Mr J attended for repeat bloods the following day and was discharged.
48. Overall, our adviser said Mr J received appropriate clinical care during the admission. While the decision to discharge him prior to the blood tests result was not in line with standard practice, it did not have an impact on his clinical progression.
49. We have seen the Trust made a mistake discharging Mr J prematurely before his blood test results were available. We have considered the impact of this mistake on Mr and Mrs J. We have not seen evidence it impacted on Mr J’s clinical care, although it did cause them inconvenience.
50. When something serious could have happened but did not, we consider the impact of any distress this caused the complainant rather than any potential injury. Our Severity of Injustice scale identifies a level one injustice as annoyance, frustration, worry or inconvenience typically arising from a single (one-off) incidence, where the effect is of short duration. We conclude a single incident of short duration caused the inconvenience to Mr and Mrs J. We recognise it would have been distressing in the context of Mr J’s ongoing treatment.
51. Therefore, we believe this complaint component falls at level one on our Severity of Injustice scale. The inconvenience experienced was the result of a one-off incident of short duration and had no ongoing or adverse effects. The Trust responded to Mrs J’s concerns on this point in line with our complaint standards. It acknowledged Mrs J’s concern and apologised for the inconvenience caused.
52. For these reasons, we consider the action the Trust has taken to put things right, namely an apology, is appropriate for the inconvenience caused. We do not believe a financial remedy is appropriate because the inconvenience was of short duration with no ongoing effects.
The Trust did not regularly monitor Mr J to make sure he was not distressed, did not provide him with sufficient oxygen and did not properly inform Mr J or Mrs J about his condition between 7 and 9 January 2024, when he was receiving end of life care – partly upheld
53. Mrs J says the Trust did not ensure Mr J was not distressed and should have prescribed him midazolam to help with this. She says it did not provide him with sufficient oxygen when he was receiving end of life care between 7 and 9 January 2024. She also says the Trust did not communicate correctly with her and her husband and did not make them sufficiently aware Mr J was imminently approaching the end of his life.
54. The Trust said Mr and Mrs J were involved in clinical discussions on 7, 8 and 9 January about his care and were kept updated about his prognosis. It said there was no clinical need to prescribe midazolam. It said it adjusted Mr J’s oxygen to meet his recorded oxygen saturations and apologised if it had not adequately explained that. It said its records do not show Mr J was distressed. Finally, it said there was no documentation around Mr J’s expected prognosis in terms of remaining lifespan. It said it was very difficult to put an accurate timeframe in such situations. We reviewed Mr J’s medical records and obtained clinical advice to investigate this complaint component.
55. The records show Mr J presented at A&E on 7 January 2023. He died on 9 January.
Non-prescription of midazolam
56. Mrs J says the Trust should have prescribed Mr J midazolam to relieve his pain. Mr J’s medical records show he received paracetamol on 8 and 9 September. During this period, the medication charts show the Trust prescribed Mr J morphine for his pain. The notes in the medication charts say this was for ‘severe pain.’ He also received three doses of morphine on 8 and 9 September. It prescribed Midazolam on an ‘as needed’ PRN basis. The records show this was ‘for agitation.’
57. Our adviser said this is in line with NHS guidance, which says clinicians should use the weakest available painkiller to keep a patient free from pain and escalate as necessary. It is also in line with NICE guidance on the care of dying adults, which says clinicians should match medication to the severity of pain and manage it promptly and effectively.
58. Our adviser said the notes do not suggest Mr J was in extremely severe pain and noted that he had been feeling slightly better on 8 January. They said it was standard practice Mr J was not given morphine on the day of his admission, because clinicians would usually wait a day or two before prescribing medication for long term background pain. This is line with NICE 1.5.12, which says clinicians should assess the dying person's level of pain before prescribing medication.
59. Morphine is an opioid which reduces pain. Our adviser explained midazolam is not an opioid and is not used for pain management. They told us it is generally used for the management of anxiety and seizures. The notes reflect this, where the PRN prescription of midazolam is described as ‘for agitation.’
60. Our adviser said there were no indications in the notes that Mr J was agitated or anxious and that not giving midazolam was in with guidance. We appreciate Mrs J disagrees with this and says her husband was agitated. Our adviser emphasised that it was prescribed if needed and if Mr J had shown signs of agitation or anxiety it could have been administered, but there is no record it was. This is line with NICE guidance 1.6, which says clinicians should assess what medicines the person might need to manage symptoms likely to occur during their last days of life (such as agitation, anxiety). It is also in line with NICE 1.5.26, which says a trial of a benzodiazepine (such as midazolam) should be considered to manage anxiety or agitation where observed.
61. We have not seen any evidence that the Trust’s prescription and administration of midazolam was not in line with guidance. If Mr J had shown signs of anxiety or agitation it could have been administered, but there is no record Mr J was experiencing these symptoms. Not administering midazolam was therefore in line with guidance. We acknowledge Mrs J says Mr J was distressed and agitated during this period, and do not wish to minimise her experience of this traumatic event.
Inadequate provision of nebuliser and oxygen
62. Mrs J says the Trust did not provide Mr J with sufficient oxygen or nebuliser during his admission, which caused him unnecessary distress.
63. Mr J’s medical records show he received oxygen therapy and nebuliser during his admission period from 7 – 9 January 2024. NICE BNF guidance explains the concentration of oxygen required depends on the condition being treated, and that using an inappropriate concentration of oxygen can have serious or fatal consequences. It says that short burst oxygen therapy is prescribed in a palliative care setting. NICE CKS guidance says oxygen can be prescribed either by a face mask or by nasal cannula, whichever is preferred by the patient. It also says oxygen should be prescribed at the lowest flow rate possible to produce benefit and avoid potential adverse effects.
64. Our adviser said the records show Mr J’s oxygen therapy was dictated by his two hourly observations. His oxygen therapy was titrated to reflect the oxygen saturation of his blood and prevent this becoming too elevated. The Trust tested his blood gas levels to determine the appropriateness of continued oxygen therapy and nebuliser prescribed on an ‘as needed’ basis to loosen any mucus build up. This was in line with relevant guidance.
65. Our adviser said Mr J’s advanced oesophageal cancer would likely have caused symptoms of breathlessness, because as the cancer advances it impedes more on the patient’s trachea and windpipe. They said the records show Mr J found the drying effect of oxygen therapy by face mask distressing and changed this to a nasal cannula. The records also show staff considered the use of humidified oxygen (oxygen with water added) to ease the drying effect of the oxygen therapy. On 9 January, the Trust prescribed opiates (painkillers) on a PRN basis to ease Mr J’s symptoms of breathlessness. This was also in line with guidance.
66. Our adviser said that staff should communicate to the patient and family the reasons why oxygen is set at a certain level and the dangers of elevated saturation levels. It is possible the Trust did not communicate this to Mrs J as well as it could have. We do not wish to dismiss the distress this would have caused to Mrs J.
67. We have seen evidence the Trust’s provision of nebuliser and oxygen to Mr J was in line with guidance. The records show Mr J’s oxygen was titrated (adjusted) in line with his blood saturations. Giving excessive oxygen can cause serious side effects. The Trust’s provision of oxygen was therefore in line with guidance. It is possible it did not explain this to Mr and Mrs J as well as it could have, which caused confusion and distress at a very difficult time. We will write to the Trust to draw attention to this impact, so that it can reflect on it and improve its processes when communicating with patients and their families.
Poor end of life care communication
68. Mrs J says the Trust did not properly inform her husband or her when he was imminently approaching the end of his life.
69. The records show Mr J was admitted to hospital on 7 January 2024 and died on 9 January 2024. NICE guidance on the care of dying adults is clear it can be difficult to be certain that a person is dying (1.1). On admission, Mr J was noted to be receiving palliative care in his medical records. There is no indication from the notes that Mr J was in the last days of his life. On the day of his admission, the notes show that a DNR was put in place for Mr J given his advanced stage of cancer, following discussion with Mr and Mrs J. The notes show the Trust did not believe, at that time, that Mr J was imminently dying.
70. The records show the palliative care team reviewed Mr J at several points during his hospital stay. The palliative care team discussed a plan to move Mr J to a hospice along with the suggested next steps in his care. On 9 January, the palliative care nurse specialist reviewed Mr J and advised the priority was symptom management rather than treatment, given Mr J had decided to stop anti-cancer treatment. The records say the nurse had a ‘frank discussion’ with Mr and Mrs J but are not explicit about what the expected timescales for the remainder of Mr J’s life might be.
71. The Trust referred Mr J to a hospice and made the family aware of the difficulty of securing a bed. The palliative care team documented Mr J was at the ceiling of care and that clinical observations should be stopped. This is in line with NICE guidance 1.1.4, which says to avoid undertaking investigations unless there is a clinical need. Mr J collapsed to the floor and died at 6.15pm on 9 January.
72. Mr J’s medical records suggest the Trust was of the view he was approaching the end of his life. However, the notes do not make this clear and explicit.
73. Our adviser said that palliative care clinicians appear to have communicated to some extent with Mr and Mrs J regarding their view that Mr J was approaching the end of his life. The notes are not clear whether clinicians explicitly communicated to Mr and Mrs J how long they expected this process to take.
74. NICE guidance on the care of dying adults, section 1.2, says that patients should be asked how much information they wish to have about their prognosis and about their current level of understanding that they may be nearing death. The notes do not make clear whether this was done. Section 1.2.4 of the guidance says the dying person should be provided with accurate information about their prognosis while avoiding false optimism. Section 1.2.6 of the guidance says a dying person’s prognosis should be documented in their record of care. While the notes show Mr and Mrs J were involved in frequent discussions about his care, it is not clear whether the Trust made the expected time frames for Mr J’s remaining life clear to him and Mrs J.
75. Our adviser said that while the Trust generally followed guidance in terms of guiding the conversation about Mr J’s clinical progress, the notes are not detailed enough to know whether it made it sufficiently clear to Mr and Mrs J that he was approaching the end of his life. They said a DNR was not put in place until his admission on 7 January, at which point Mr and Mrs J were told staff did not feel he was imminently dying. It is understandable that Mrs J has questions following Mr J’s death on 9 January. Our adviser said it is possible staff could have communicated better with Mr and Mrs J.
76. We have seen evidence of failings in the Trust’s communication around Mr J’s end of life care. It is not clear whether the Trust followed guidance in terms of giving Mr J accurate information about his prognosis and expected timescales for the remainder of his life, and recording this in his medical records.
77. The notes do not show the details of conversations clinicians had with Mr and Mrs J. Where the notes are explicit, on 7 January, they say staff did not believe Mr J was imminently dying. This is not in line with guidance, which says clinicians should avoid false optimism. While it can be very difficult to be certain at what point a dying person will eventually die, guidance is clear that staff should ask patients and family members about the extent of their understanding that they may be nearing death and document those conversations.
78. Elsewhere during Mr J’s admission, the records are thorough and detailed. They are not thorough and detailed regarding Mr J’s end of life care. The only point at which they are detailed is when staff told Mrs J they did not believe Mr J was imminently dying. On the balance of probabilities, the lack of detail in the records on the Trust’s communication with Mr and Mrs J as he neared the end of his life is more likely to be due to the communication not taking place as outlined in the guidance, rather than due to an oversight in the Trust’s record keeping.
79. On the balance of probabilities, we have decided the Trust did not act in line with NICE guidance when communicating with Mr and Mrs J at the end of Mr J’s life. There is no documented evidence it provided accurate information or made clear the expected time frame before Mr J’s death. If the Trust had these conversations with Mr and Mrs J, we would expect them to have been explicitly and clearly documented, which was not the case. This is in contrast with other documentation around Mr J’s care, which is clear and detailed.