14. 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 something has gone wrong.
Anti-coagulant
15. Mr B complains his grandmother had to wait until after the weekend before she could have her gallbladder drainage procedure. He says she could have had the procedure the Friday before if a nurse had not given her anti-coagulant medication (blood thinners). Mr B says Mrs H’s condition worsened over the weekend.
16. The Trust said it had not booked Mrs H’s gallbladder drainage at the time it administered the anti-coagulant.
17. The Trust explained due to Mrs H’s age, reduced mobility and further comorbidities (other health conditions) the anti-coagulant was necessary to reduce the risk of venous thromboembolism (VTE). VTE is a potentially life threatening blood clot in the vein.
18. The records show on the first day of considering the gall bladder procedure ‘the radiology nurses confirmed there was not a slot available’.
19. The next day there is a note to say Mrs H was awaiting the drainage procedure, the date and time had not been confirmed, and the drainage was being arranged by the surgical team.
20. The following day, a doctor made a note they had discussed with Interventional Radiology (IR) nurses and they may have a slot available later that afternoon to do the drainage procedure. It was noted Mrs H had the anticoagulant that morning and it was planned to discuss with another doctor later in the day.
21. Our adviser explained there is a high risk attached to placing a gallbladder drain following administration of anticoagulant.
22. Later that day we saw in the notes the surgical team re-explored the option for the drainage procedure and were advised by the consultant radiologist to repeat a CT scan to see if there were any changes since her last one.
23. Our adviser explained the placement of ultrasound guided drainage carries a risk and so if the CT scan showed that antibiotic treatment had been adequate, invasive intervention could potentially be avoided.
24. As the CT scan showed a slight increase in fluid on a Friday, the Trust then planned the drainage procedure for the upcoming Monday.
25. From what we have seen the Trust had not confirmed it would do Mrs H’s gallbladder drainage on the Friday, it was still considering how to treat Mrs H and conducting investigative tests.
26. It is important to note at the time Mrs H had the anti-coagulant medication (in the morning); the medical team were not aware of the CT scan findings.
27. The RPS guidance advocates that medicines are administered in accordance with a prescription.
28. We consider the nurses acted in line with this in administering the anti-coagulant in line with Mrs H’s prescription. For this reason, we have not seen indications of a failing.
NG tube
29. Naso gastric (NG) tubes are thin, soft tubes inserted up a patients nose and fed down the throat into the stomach.
30. Mr B says the Trust repeatedly failed to insert an NG tube, causing Mrs H distress and discomfort. Mr B says no other insertion methods were considered. He also says the watch and wait approach was not sufficiently proactive enough.
31. The Trust did not think it did anything wrong. It said when the tube fell out, staff made attempts to reinsert it.
32. Our adviser explained the NG tube was inserted to manage pressure from the stomach which would accrue due to the problems in Mrs H’s bowels. This pressure would cause discomfort, vomiting and there is a chance of aspiration of fluids into the lungs.
33. Our adviser explained it is established clinical practice to place a nasogastric tube when there is suspicion that the stomach or the small bowel is not functioning adequately.
34. The records show the Trust inserted the NG tube when Mrs H had vomited bile. When the tube fell out the following day, attempts were made at reinsertion but were unsuccessful. The plan was to monitor to see if Mrs H vomited and if she did to reinsert the tube.
35. The records show the NG tube fell out and had to be reinserted on numerous occasions over the following few days. On one occasion the tube had not been fitted correctly, it was later corrected.
36. Two days before Mrs H died, the plan was to insert the NG tube to drain stomach contents. Initially Mrs H refused the NG tube and insertion with lidocaine spray (for numbing) was offered. It seems Mrs H was agreeable to trying again but later she removed her consent for the NG tube to be fitted.
37. From then onwards the records say if Mrs H vomits then the NG tube was to be revisited.
38. Our adviser said on review of the medical notes, the team had followed appropriate process and procedures while placing the nasogastric tube but unfortunately due to patient inability to tolerate the procedure, this had to be abandoned.
39. Our adviser says other alternative methods to place the nasogastric tube were not appropriate, for example under sedation or anaesthetic.
40. From what we have seen Mrs H needed the NG tube to relieve pressure in her stomach which caused vomiting. Unfortunately placing an NG tube is an uncomfortable process and not always easily tolerated by patients.
41. NMC Code says nurses should:
‘balance the need to act in the best interests of people at all times with the requirement to respect a person’s right to accept or refuse treatment’
and
‘respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate.’
42. The nurses were acting on the advice of surgical staff. The tube was needed to relieve pressure in Mrs H’s stomach which caused the vomiting. When Mrs H advised she no longer consented to the NG tube, the Trust stopped. We consider staff acted in line with NMC code.
43. We do not doubt the process of inserting the NG was distressing and we are sorry Mrs H had to go through it. Without the tube the fluid in Mrs H’s stomach built up and caused vomiting which would also cause discomfort.
44. We consider the Trust did what it could to weigh up the risks and benefits here. Sadly, it seems discomfort was unavoidable in this situation whether it came from the NG tube or from fluid build up. We have not seen indications of a failing.
Gallbladder drainage delay
45. Mr B says Mrs H’s health declined over the weekend whilst she waited for her gallbladder drainage procedure. He complains the Trust did not consider transfer to another facility to have the procedure.
46. The Trust explained the service which would need to complete the gallbladder drainage (interventional services) was not available over the weekend.
47. The Trust says Mrs H was closely monitored and it was not felt that she needed to be transferred. The Trust explained Mrs H was a complex case receiving acute care and it would have been clinically unsafe to transfer to another hospital.
48. As Mrs H had sepsis, our adviser explained NICE NG51 guidelines were applicable here. Mrs H was observed using the National Early Warning Score (NEWS) scoring system which is a requirement of NICE NG51.
49. NEWS was developed by the Royal College of Physicians in 2012 to standardise the process of recording, scoring and responding to changes in routinely measured physiological parameters in acutely ill patients.
50. A score is allocated to a patient’s vital signs, physiological measurements, which are recorded in routine practice when patients are being monitored in hospital. The measurements are taken regularly for example, every two hours. Six physiological parameters form the basis of the scoring system:
• respiration rate • oxygen saturation • systolic blood pressure • pulse rate • level of consciousness or new confusion • temperature.
51. A score is allocated to each parameter as they are measured, with the magnitude of the score reflecting how extremely the parameter varies from the norm. Simply put, the higher a patient’s NEWS score, the sicker they are. The scoring system is used as an early warning system to help identify when a patient needs specialist intervention.
52. We looked at the NEWS scores over the weekend and saw the scores were consistently low. There were no indications of deterioration.
53. Our adviser explained Mrs H had multiple comorbidities and she was being treated for sepsis due to cholecystitis and a gallbladder perforation (hole). Transfer to another Trust posed risks and the clinical team would need to justify taking the risk to facilitate the transfer.
54. Our adviser explained as Mrs H’s NEWS remained low there was no requirement for emergency intervention or transfer.
55. We do not dispute Mr B’s account that from his perspective Mrs H was getting worse which must have been distressing to see. We recognise Mrs H was a very sick patient who was waiting for a procedure to provide her with some relief and help her to recover.
56. We have looked to see if Mrs H’s condition meant clinicians should have considered transfer to another hospital or emergency intervention and we found it did not. The Trust was closely monitoring Mrs H in line with guidelines. NEWS did not indicate signs of deterioration therefore we have not seen indications of a failing.
Monitoring and communication
57. Mr B complains the Trust did not communicate the severity of Mrs H’s condition leaving them unprepared for her sudden death. He says because she was not appropriately monitored the hospital staff were not aware her condition was worsening.
58. The Trust said it closely monitored Mrs H. It said a patient can unexpectedly decline and Mrs H’s death was unexpected and sudden. The Trust apologised for any distress caused.
59. GMC guidelines for good medial practice advocate that clinical teams should be considerate and compassionate to those close to a patient and be sensitive and responsive when giving them support and information.
60. In the records we saw regular updates with the family including the Trust asking family to translate especially since English was not Mrs H’s first language.
61. On one occasion the Trust called a member of Mrs H’s family to discuss her ‘ceiling of care’. This is a term often heard in intensive care and palliative care. It refers to the maximum level of care a patient is set to receive, it is often a sensitive discussion to have. The family member advised they wished to ‘take things a day at time’.
62. As we previously explained NEWS is the system used to monitor signs of deterioration. The Trust recorded Mrs H’s NEWS multiple times each day. Her scores remained low indicating she was at low risk of deterioration.
63. We asked our adviser if they could identify any instances where Mrs H’s condition had been misrepresented and our adviser could not find any such instances. They consider the family was appropriately updated.
64. We have cross referenced Mrs H’s observations (NEWS score) with the clinical notes and records of conversations and we do not see her status was misrepresented in any way. We consider the Trust acted in line with GMC guidance.
65. The records show Mrs H suddenly declined. Sadly, it is not always possible for doctors to predict when a patient will decline. We consider Mrs H’s condition was monitored appropriately with her status and planned treatment communicated to her family. We were sorry to see her condition suddenly worsened and appreciate it was completely unexpected and an enormous shock to her family.
66. From what we have seen the Trust frequently monitored Mrs H and communicated with the family. We did not find any indications of a failing.
Nutrition and hydration
67. Mr B says Mrs H was not given adequate nutrition or hydration which contributed her decline.
68. The Trust explained patients can lose their appetite when unwell. The Trust explained it took measures to ensure she remained hydrated.
69. The records show in Mrs H’s initial stays she did try to eat but was feeling nauseous. As time went on Mrs H was nil by mouth which means she was not to have any foods orally. This was because her bowel problems meant she could not move food along the digestive tract.
70. NICE CG32 says healthcare professionals should consider delivering nutrition through the veins in people who are malnourished or at risk of malnutrition.
71. The Trust’s medical team considered total parenteral nutrition (TPN) but felt the risks associated outweighed the benefit. TPN is a method of providing nutrition directly into the bloodstream through a vein. Infections can occur with this method of feeding.
72. Our adviser agreed with the Trust’s medical team. They said providing TPN in a patient such as Mrs H would be risky and challenging given her comorbidities and sepsis.
73. Our adviser concluded Mrs H’s deterioration was due to multiple factors including her pre-admission conditions, complications from the sepsis and gallbladder infection. Our adviser did not attribute Mrs H’s deterioration to a lack of nutrition.
74. The records show Mrs H was given replacement intravenous fluids which would have ensured adequate hydration.
75. We understand why Mrs H’s family would be concerned she was not being given nutrition. The Trust acted in line with NICE CG32 to consider other methods to supply nutrition. We have not seen indications of a failing.
76. Whilst we have not found indications something went wrong, that is not to say Mr B and the family did not have an extremely difficult time. Our decision is not intended to diminish this in any way.
77. We thank Mr B for bringing the complaint and sharing their experiences.