Chest infection
13. The Clinical Knowledge Summary published by NICE (chest infections – adult) states doctors should investigate whether a person has a chest infection by measuring their oxygen saturation level (the amount of oxygen in the blood) and C-reactive protein (an inflammatory marker in the blood), and by undertaking a chest X-ray.
14. These guidelines say that for people over the age of 80 with at least one criterion that puts them at higher risk of complications, doctors should prescribed antibiotics to treat the chest infection. Mr A was over 80 years old and had congestive heart failure. These are high risk criteria, meaning the Trust should have prescribed antibiotics to treat his chest infection.
15. The Department of Health’s guidelines on hospital discharged state that if there are no indications of an acute illness, patients should be discharged from hospital. The clinical indicators include:
• the patient requires oxygen therapy • a NEWS2 score of above 3 • acute functional impairment that cannot be managed in the community • the patient is in the final hours of their life • the patient needs intravenous medications • the patient has had surgery or an invasive procedure within the past 24 hours.
16. On 14 May Mr A reported a five-day history of a cough, which is the main indicator of a chest infection. The Trust arranged for a chest X-ray, in line with the NICE clinical knowledge summary, which found no concerning results that could indicate a chest infection or pneumonia. His blood test results also showed his white blood cell count (an indicator of infection) was within the normal range.
17. On 17 May Mr A’s white blood cell count and C-reactive protein were elevated, indicating he may have an infection. The Trust commenced a five-day prescription for antibiotics and, when Mr A was reassessed on 22 May, his inflammatory markers had dropped significantly. His physical observations showed a low likelihood of serious illness and no indication of an infection.
18. On 24 May Mr A continued to show no clinical signs of infection. His NEWS2 score (a tool used to estimate how unwell a patient may be) was zero and there were no clinical reasons for him to remain in hospital. This is because he did not meet the Department of Health’s criteria for remaining in hospital. He was discharged later that day.
19. The evidence indicates that when Mr A was discharged from hospital on 24 May he did not have any clinical indicators of a chest infection. He had completed a course of antibiotics whilst in hospital, and his chest infection appears to have resolved after he had completed this course of treatment. Mr A was medically fit for discharge, as per the Department of Health’s guidelines, and there are no indications of service failure.
Discharge on 25 May 20. NICE guideline NG27 states that as soon as someone with complex needs, like Mr A, is admitted to hospital clinicians should start assessing their health and social care needs. These guidelines also state when a patient is discharge, a discharge summary should be sent to the patient’s GP and a copy of this should be given to the patient on the day of their discharge.
21. The Trust began assessing Mr A’s social and mobility needs from 16 May. He was referred to the inpatient therapies team and was assessed by physiotherapy and occupational therapy colleagues the following day. This assessment concluded Mr A was not yet able to be discharged as he required support at home.
22. Mr A was assessed by physiotherapy colleagues again on 19 May, who identified he required further assessment to ensure he had the right support in place at home. On 20 May the Trust undertook a full social and physical assessment. The physiotherapist planned to discharge Mr A from the inpatient therapies team and noted he would need a package of social care when discharged from hospital. The Trust referred Mr A for this package of support the same day, which included assistance with washing and dressing, toileting, and assistance mobilising in his house.
23. On 24 May Mrs A raised concerns about her husband having the correct equipment at home. She requested a recliner chair, and the physiotherapist explained this would not be helpful for Mr A. The physiotherapist noted Mr A was close to his baseline level of functioning and should be discharged home with support from carers once medically fit.
24. Prior to Mr A’s discharge on 25 May, the Trust undertook a final social and community assessment of his needs. It explored whether he needed any extra support in addition to the package of social care, and the ward’s occupational therapist advised twice daily visits for support would be sufficient. Mr A was discharged later that day with a package of social care.
25. The evidence indicates the Trust comprehensively assessed Mr A’s social and mobility support needs prior to his discharge. It commenced this assessment by referring him to the therapies team early in his admission, and it continued to assess his functioning. When the Trust identified he would need support in the community, it promptly referred him for a package of social care at home. The Trust continued to assess and review Mr A’s needs until he was discharged from hospital on 25 May. There are no indications of service failure.
26. With regards to whether the discharge summary was given to Mr and Mrs A when he was discharged, we have reached a view on this on the balance of probabilities.
27. Mrs A says the Trust did not give her the discharge summary on 25 May and that she was not aware of the important information about when to seek help. The Trust did not document it gave this to her. On balance, it appears the Trust may have overlooked providing Mr and Mrs A with a copy of the discharge paperwork.
28. Having reviewed the discharge summary, the only safety information relating to when to seek help was included in the ‘advice provided’ section of the summary. This outlined that Mr A had been told to seek help if he felt unwell, got severe blistering around his arm brace, or he started to lose functioning in the hand on the side he had fractured his arm. Whilst it would have been in line with NICE guideline NG27 to provide Mr A with a copy of the discharged summary, the evidence also indicates he had already been given the information about when to seek help.
29. On balance, it appears there was a one-off departure from NICE guideline NG27 that does not appear to have impacted on the information Mr A needed to know. This is because he had already been given this information verbally and the evidence does not indicate he lacked the mental capacity to communicate this to his wife.
30. The Trust apologised that Mrs A had not received a copy of the discharge paperwork when it discharged him from hospital. This appears to be sufficient to put right a one-off instance of poor service that had no wider clinical impact.
Pain relief 31. The GMC’s Good Medical Practice guidelines say that doctors must adequately assess a patient’s needs and arrange suitable treatment if necessary. This would include responding to a patient’s pain levels and providing relief, if appropriate.
32. On 12 June Mr A displaced his fracture when he fell at home, and he required this to be manipulated back into place by the orthopaedic team. This would likely be a painful procedure.
33. Following Mr A’s arrival at the ED at 5.17am, a one-off dose of codeine was administered at 6.09am. The Trust then prescribed Mr A’s usual painkiller – a strong opiate medication called dihydrocodeine – at 12.04pm. This was prescribed to be taken as and when required, which meant he would need to tell the staff when he required pain relief.
34. There appears to have been little documented regarding Mr A’s level of pain whilst in the ED. There is nothing documented as to when the painful fracture manipulation took place or whether pain relief had been administered for this procedure. We asked the Trust about pain relief and when the fracture was manipulated and it explained this had already taken place by the time a doctor reviewed Mr A at 9.56am and that Mr A had been prescribed codeine to manage this. Mr A arrived at the ED at 5.17am and was administered codeine at 6.09am. It is possible that this is when the fracture was manipulated back into place and the pain relief had been administered to manage this.
35. After the manipulation of the fracture, there is no record of Mr A requesting the pain relief that had been prescribed and was available on request. The nurses in the ED consistently documented that the call bell was available to Mr A so that he could request pain relief as needed.
36. Mr A’s condition deteriorated in the early afternoon, and he was transferred to the resuscitation area of the ED. When handed over to the nurse in this area at 1.20pm, Mr A requested pain relief. The nurse documented this medication was not available in this part of the ED and left to obtain the prescribed pain relief from elsewhere. The nurse then returned to the room and found Mr A unresponsive. He initially improved and then deteriorated again. He had do not attempt CPR order in place and, sadly, died before the pain relief could be administered.
37. The evidence indicates Mr A was given a strong painkiller at 6.09am. Following this, at 12.04pm the Trust prescribed a different strong painkiller to be taken as and when needed. This meant Mr A needed to ask for pain relief. There is no record he asked for pain relief until 1.20pm, and it was regularly documented that Mr A was given a call bell to request assistance should he need it.
38. It appears the Trust’s documentation of the pain relief provided could have been more robust in relation to when Mr A’s fracture was manipulated back into place. There is no record of exactly when the manipulation took place, though we know this happened before 9.56am. This makes it difficult to ascertain whether sufficient pain relief had been provided at that time.
39. Mr A was given the maximum recommended dose of codeine at approximately 6am and another dose could not be administered until 12pm, as per the prescribing guidelines outlined by the British National Formulary. On balance, therefore, it is more likely than not Mr A had been given adequate pain relief during the period when his fracture was manipulated and there are no indications of service failure.Care on 12 June 2024 40. The GMC’s Good Medical Practice guidelines say that doctors must listen to patients and be considerate to those close to them. They must also adequately assess a patient’s condition, promptly provide investigations or treatment, and only prescribe drugs when they are satisfied it will meet the patient’s needs.
41. With regards to the injection given to Mr A, a one-off dose of intravenous furosemide (a drug that helps to reduce water retention) was given at approximately 2pm. This drug is commonly prescribed for patients with heart failure, like Mr A, because heart failure can cause significant fluid retention. There is no record of an injection being given aside from this one-off dose of intravenous furosemide. Our Physician Adviser has confirmed this was an appropriate treatment for his needs.
42. Mrs A believes an injection caused her husband to deteriorate rapidly. We can only comment on the care documented in the absence of other evidence that indicates a different injection was given. Our Physician Adviser explained Mr A’s deterioration was ‘sudden and not predicted’, and it appears to have been managed appropriately. We have seen no evidence that could indicate this sudden deterioration arose from an injection.
43. Whilst it is possible a different injection was giving to Mr A without the staff documenting this happened, there were no other medications prescribed as an injection. We cannot know, even on the balance of probabilities, whether or not an injection that had not been prescribed was given to Mr A due to a lack of evidence.
44. Our Physician Adviser has also reviewed the totality of the care provided to Mr A on 12 June, and they are satisfied he appears to have received care that was appropriate to his needs. Mr A underwent investigations for his acute medical needs and appropriate treatments were prescribed to manage these. This indicates Mr A’s care aligned with the GMC’s Good Medical Practice guidelines.
45. Mrs A also says she was raising concerns about her husband’s deterioration whilst in the ED on 12 June. Whilst there is no record of these concerns being raised, we do not doubt Mrs A was likely very concerned about her husband at that time. It is possible she raised concerns, but these were not documented by the Trust.
46. What we can say is that the Trust appears to have obtained a good overall picture of Mr A’s clinical needs via the physical observations, blood tests, ECG, and X-rays. The Trust also appears to have addressed his needs with appropriate interventions. It is likely that there was nothing further the Trust could have done to manage Mr A’s acute needs, meaning that it is unlikely anything would have changed when Mrs A raised concerns.
47. On the balance of probabilities, we think it is more likely than not Mrs A raised concerns, even in the absence of these being documented. We know she consistently advocated for her husband, as evidenced in his records from previous admissions, and it seems likely she would have continued to do so on 12 June. However, there was nothing further the Trust could do for Mr A even though Mrs A was concerned about his condition. Therefore, we have seen no indications of service failure.
48. We recognise losing her husband on 12 June was devastating for Mrs A, and our decision in no way detracts from her distress. We hope our work reassures her that, overall, the care her husband received appears to align with national guidelines.