Oxygen and nebulisers 14. Ms T says staff did not give Mrs L enough oxygen during her admission. She says someone rang her on 28 January to get to hospital urgently as her mother was struggling to breathe. When she got there, her mother had no oxygen on and believes she had been left overnight without oxygen.
15. She also says she asked staff to give her mother nebulisers several times and believes they should have provided them sooner.
16. The Trust said it does not believe earlier use of saline nebulisers would have significantly altered the course of Mrs L’s illness. It also added that salbutamol nebulisers would not have been appropriate as Mrs L did not have any wheezing.
17. The records show staff recorded Mrs L’s oxygen saturations as 96% on oxygen at 8.47pm when she was first admitted.
18. BNF says oxygen is probably the most common drug used in medical emergencies. It should be prescribed initially to achieve a normal or near–normal oxygen saturation; in most patients a normal oxygen saturation should be 94–98%.
19. We can see nursing staff were regularly observing Mrs L’s oxygen saturations, and they were regularly recorded in the 90s. There is evidence that when Mrs L’s oxygen saturations dropped, staff intervened and provided her with oxygen via a nasal cannula or mask.
20. For example, the records show on 28 January at 5.33am Mrs L’s oxygen saturation level was 92%. At 10.39am it was 98%, therefore the nurse recorded that they had weaned her off oxygen to monitor her observations. By the next review at 12.16pm, her oxygen saturations had dropped to 75% so staff put her back on oxygen. The nursing staff reviewed Mrs L again at 3.30pm and her oxygen saturation level had increased to 92%.
21. Our adviser says some people are at risk of developing hypercapnic respiratory failure (too much carbon dioxide in the blood) if too much oxygen is given. The records show Mrs L was identified as being at risk of this based on a blood gas test results from a previous admission. Therefore, she was managed with slightly lower oxygen levels than is standard.
22. Guidance from RCP says:
‘For patients confirmed to have hypercapnic respiratory failure on blood gas analysis on either a prior or their current hospital admission, and requiring supplemental oxygen, we recommend (i) a prescribed oxygen saturation target range of 88–92%, and (ii) that the dedicated SpO2 scoring scale (Scale 2) on the NEWS2 chart should be used to record and score the oxygen saturation for the NEWS.’
23. The records show staff monitored Mrs L throughout her admission and adjusted her oxygen in line with RCP guidance. There were times where staff removed the oxygen when Mrs L’s oxygen levels were within target whilst breathing room air.
24. There is a nursing note from 28 January at 3.37am that Mrs L was ‘non-compliant to her oxygen, fitted back frequently’. Our adviser said this can happen when a person is very unwell and confused/delirious, and they may repeatedly remove their oxygen mask or nasal cannula.
25. The records show staff gave Mrs L saline nebulisers on 29 January.
26. Nebulisers are not part of the recommended treatment options under NICE guidance for pneumonia, which is what staff diagnosed Mrs L with. Nebulisers can be used as symptomatic relief, are fairly low risk but are still a medication that has to be prescribed.
27. NICE guidance for ‘Palliative care – cough’ does support the use of saline nebulisers to ease a cough. As Mrs L was deteriorating at this time, it was in line with guidance to provide nebulisers for symptom relief on 29 January.
28. Our adviser said nebulisers seem to have been used thoughtfully later in Mrs L’s admission, but there no evidence they should have been used earlier.
29. We recognise it was distressing for Ms T to find Mrs L without oxygen when she had been receiving this regularly and for staff to not have given Mrs L nebulisers sooner when she asked.
30. We have seen no indication of a failing here, the Trust regularly observed and recorded Mrs L’s oxygen saturations and acted in line with the relevant guidance when providing her with oxygen. The Trust adjusted her oxygen use when her saturations were within the target range and when they fell below.
31. It was also not necessary for the Trust to have provided Mrs L nebulisers sooner as they are not a recommended treatment under NICE guidance for pneumonia.
32. We hope this is reassuring for Ms T.
Fluid input and output
33. Ms T complains staff were not monitoring Mrs L’s input and output. She said when she was checking her mother’s catheter, nothing was coming out and she never saw anyone empty it.
34. The Trust has been unable to find a fluid balance chart and the hydration charts it found, were incomplete.
35. The Trust said Mrs L was receiving intravenous (IV) fluids and staff should have completed accurate balance charts. It apologised this was not done.
36. There are regular notes from nursing staff about Mrs L’s catheter draining urine between 24 and 28 January. We can see nursing notes from 29 January which say only small volumes of urine were visible in Mrs L’s catheter.
37. The records show Ms T raised concerns to nursing staff about her mother’s input and output on 29 January and this was escalated to a doctor. We can also see a physician reviewed Mrs L on 29 January at 6.40pm and noted Mrs L had poor urine output.
38. It is impossible to know how much fluid Mrs L was taking in and how much fluid output she had due to the lack of records. We therefore considered what other information is available to help us understand whether staff took appropriate action overall.
39. Our adviser said input and output form part of someone’s overall fluid status. Fluid status is also made up of body fluid content, where in the body fluid is contained, whether there is too much or too little, and someone’s kidney function.
40. There is evidence the doctors were clearly assessing Mrs L’s overall fluid status during daily reviews.
41. There is also clear evidence of consideration of her fluid status and decision making around the quantity of IV fluids she should have, comments about her urine colour within the catheter, her blood kidney function tests, what medications should be given, and which should be withheld.
42. The Trust assessed and considered Mrs L’s condition which was in line with GMC guidance:
‘In providing clinical care you must: a) adequately assess a patient’s condition(s), taking account of their history, including i. symptoms ii. relevant psychological, spiritual, social, economic, and cultural factors iii. the patient’s views, needs, and values.’
43. The Trust has acknowledged an issue with its record keeping and has apologised to Ms T as part of the complaint response. It said concerns have been raised to the ward manager and there is ongoing training and education with staff about how this should be undertaken.
44. Our Principles of Good Complaint Handling say that to put things right organisations should provide an apology, explanation, and an acknowledgement of responsibility. We say organisations should take remedial action, which may include revising procedures, policies or guidance to prevent the same thing happening again, or training or supervising staff.
45. We are reassured that the Trust has acknowledged and apologised for the poor record keeping and has taken learning to prevent recurrence in line with our Principles of Good Complaint Handling.
46. As, overall, we have seen no indications of failings in the Trust actions regarding Mrs L’s fluid status, we will not investigate this further.
Antibiotics 47. Turning now to Ms T’s complaint about staff were only giving her mother antibiotics every 12 hours, in the morning and at night instead of every six to eight hours.
48. The Trust said antibiotics were administered every 12 hours due to Mrs L’s poor renal (kidney) function.
49. The records show staff reviewed Mrs L on admission when they documented that her creatinine clearance (CrCl) had been 16 mL/min. Creatinine clearance is a test used to assess kidney function by measuring how well creatinine, a waste product, is filtered from the blood into the urine.
50. BNF guidance says normal dosing for antibiotics is every eight hours, but this should be adjusted to 12 hourly if CrCl is below 20mL/min.
51. BNF guidance also explains if someone has reduced kidney function, which Mrs L did have, to adjust the dosage to 12 hourly.
52. As Mrs L’s CrCl was below 20mL/min, the Trust adjusted the time between giving antibiotics intentionally and in line with guidance.
Regular medications 53. Ms T says staff took her mother off a lot of her medications due to her having an acute kidney injury (AKI). She understands that some medications were temporarily removed until her kidney function improved.
54. However, Ms T explains her mother was on around 15 tablets each morning before she went into hospital. She says staff took her off important drugs for her heart and if her mother did not take her water pills, she would not pass urine.
55. The Trust explained due to Mrs L having an AKI, her medications were amended and reviewed.
56. It said bumetanide, ramipril and eplerenone were stopped as they can worsen the kidney injury, and she received IV fluids with caution. Bumetanide and eplerenone are both diuretics (also called 'water pills' that increase urine production in the kidneys, promoting the removal of salt and fluid from the body) and ramipril is an ACE inhibitor (medications primarily used to treat high blood pressure and heart failure).
57. The Trust noted minimal improvement in her kidney function during admission.
58. The Trust considered the amendments to Mrs L’s medications were appropriate for the acute conditions she was diagnosed with.
59. The medication charts in the records show a number of Mrs L’s medications were stopped. The records show staff stopped the medications intentionally and wrote notes to justify why each one was stopped or held. Staff also had planned to restart the medications if her condition improved.
60. Our adviser said there was good reason for the Trust to stop the medications it did.
61. RCP’s ‘acute care toolkit’ explains diuretics and ACE inhibitors can cause renal impairment.
62. As Mrs L’s renal function was affected, the Trust stopped these medications in line with guidance.
63. We understand Mrs L not receiving her regular medications caused Ms T to worry about the implications this could have.
64. We are satisfied the Trust acted in line with guidance when stopping medications that could cause further damage to her renal function, which was already affected. This includes medications that she was regularly taking for her heart and her water pills. We hope this information is reassuring to Ms T.