Northern Care Alliance
Barium meal follow-up
22. A barium meal visualises how well someone can swallow food. It also tracks how long the food takes to travel through their digestive system. The results of this test can identify certain problems, like an obstruction typical of Mr P’s SMAS.
23. Mrs C says the barium meal Mr P had in May 2021 showed food took ten minutes longer to pass through her brother’s digestive system than it should have done. She complains Northern Care Alliance did not organise a follow up at the time to monitor or address this.
24. Nutrition support guidance sets out how doctors should have assessed Mr P’s feeding problems. It says doctors should give patients a swallow contrast study (like a barium meal) when they struggle to take in food.
25. Nutrition support guidance goes on to explain specialists in the community should follow-up patients whose barium meal shows problems. These specialists should then continually monitor the patient’s nutritional needs and provide appropriate treatment.
26. Feeding guidelines set out when PEG feeding is appropriate. It says PEG feeding is usually the preferred option when feeding directly into the stomach for longer than four weeks.
27. Northern Care Alliance gave Mr P a barium meal on 26 May. It explained doctors were asked to review the results at the time but said it could find no record of why they did not add Mr P to the follow-up waiting list.
28. Our surgeon adviser explained Mr P reported weighing 50kg in a telephone consultation in April. This was a concerning loss of weight considering he weighed 67kg in January. This led to the barium meal showing a delay how long Mr P took to digest food.
29. Our gastroenterology adviser explained the results of this study meant there should have been follow-up from the community gastroenterology team. The team would have monitored Mr P’s weight and nutritional intake in the community. Whilst the Trust sent the referral, it did not provide this follow-up.
30. In line with guidance, the Trust should have followed up the results of the barium meal. It did not do so and this was a failing. We have therefore looked at the impact flowing from this and what has been done to put things right.
31. Mrs C told us her brother did not receive appropriate nutritional support with PEG feeding. She says this has caused her and her family significant distress. We recognise how much these events have affected her and the prolonged distress she has told us about.
32. Northern Care Alliance identified it did not add Mr P to the follow-up waiting list and did a rapid review of his care. It concluded the lack of an outpatient follow-up for his SMAS was not responsible for his death but did not find any other impacts.
33. Our gastroenterology adviser explained if the Trust had followed up the barium meal then it probably would have given Mr P a PEG. They said this would have more than likely resulted in better feeding for him.
34. Mr P did have a PEG fitted at Tameside on 16 July. However, this was done following an emergency hospital admission because of his aspiration pneumonia. It was decided Mr P’s progressively poor swallow was the underlying cause of this pneumonia.
35. We consider there was an opportunity to start PEG feeding sooner. Mr P did eventually get a PEG fitted but it could have possibly happened two-months earlier, in line with Guidelines for enteral feeding in adult hospital patients.
36. On the balance of probabilities, it seems if Mr P had the PEG feeding in place then he would have avoided the emergency hospital admission at Tameside. We recognise the distress this likely poor care has brought to Mrs C. We understand how long she has felt this for and why it is such an important issue for her.
37. It is clear these events have been understandably distressing for Mrs C and her family.
38. Mrs C says that as an outcome to her complaint she would like Northern Care Alliance to acknowledge any failings and apologise for them. We therefore considered what Northern Care Alliance has done in response to Mrs C’s complaint.
39. To do this, we compared Northern Care Alliance’s response to our Principles. These set out when organisations provide an apology they identify and acknowledge what went wrong. They should take responsibility and express sincere regret for the impact of their actions.
40. The Trust’s complaint response to Mrs C does not acknowledge the potentially avoidable ED visit for the PEG. It has also been unable to identify why the failing happened and whether it has happened again.
41. We have made some recommendations for Northern Care Alliance to put this right.
Tameside
ED care
42. Initial Assessment of Emergency Department Patients says a senior clinician should see patients on arrival. They should perform a rapid clinical assessment and start appropriate investigations and treatment.
43. Our ED adviser explained there is no national guidance on how soon a medical inpatient team should assess a patient after referral from ED. They said local standards mean it will likely happen within approximately two hours.
44. An ambulance took Mr P to a hospital at Tameside. He arrived in the ED at 10.23am on 8 September. He had been short of breath for two days, had little energy and signs of an infection.
45. A nurse triaged Mr P and an ED doctor visited him about one hour after admission. They took a history from his mother over the phone and asked for a chest X-ray. They suspected Mr P had sepsis. Sepsis is when the body’s immune system attacks itself in response to an infection.
46. Staff gave Mr P some antibiotics directly into his vein (IV). They referred him to the medical inpatient team for further management at 2.29pm.
47. Staff monitored Mr P in the ED and his condition fluctuated, which delayed investigations and treatment. The medical inpatient team assessed him at 9.30pm, around seven hours after the referral.
48. Our ED adviser explained the doctor’s initial response to Mr P’s condition happened promptly. Although doctors later decided Mr P did not have sepsis, they reasonably suspected he had it when he arrived in ED. Doctors began appropriate tests and treatment for this and referred him to the inpatient team.
49. Our ED adviser explained assessment by the medical inpatient team happened seven hours after the ED doctor referred Mr P. They explained this was a significant delay, and meant it took the inpatient team until 10pm to respond to Mr P’s deterioration.
50. However, our ED adviser said it is unlikely earlier treatment would have changed the sad outcome for Mr P.
51. We have found the inpatient medical team took too long to review Mr P. This meant further investigations like an abdominal CT scan did not happen promptly. It also resulted in delays to treatments such as anti-sickness tablets or an NG tube.
52. We consider there were missed opportunities to make Mr P more comfortable by providing symptomatic relief with anti-sickness tablets or an NG tube. It is likely this treatment would have avoided some of the discomfort he experienced at the end of his life.
53. Having discussed this with Mrs C, we understand the distress this knowledge caused is still ongoing for her despite private counselling. She says their mother is traumatised by the events and cries every day because of what happened.
54. Tameside prepared a serious incident report of what happened. It found there were significant delays with specialty teams reviewing Mr P. It considered his death would still have happened if the reviews had taken place when they should have done.
55. Tameside provided a detailed explanation of what happened to Mr P in hospital. It acknowledged how upsetting the events have been for Mrs C and her family. It also produced an action plan to identify missed opportunities for earlier transfer and avoid the same problem happening again.
56. However, Tameside has not specifically apologised for Mrs C’s distress arising from the fact that Mr P’s symptoms could have been controlled better. We have made a recommendation with this in mind.
Timing of updating Mr P’s family
57. Mrs C complains staff did not warn her or her family about Mr P’s condition or deterioration as soon as they should have done. Mrs C feels family could have been with Mr P for the entire duration of his hospital stay if they had done so. She says their mother arrived just ten minutes before Mr P died.
58. NEWS should be used for initial assessment of acute illness and for continuous monitoring of a patient’s well-being throughout their stay in hospital. Recording NEWS regularly can identify trends in the patient’s condition. This can provide an early warning of potential deterioration and trigger the appropriate response.
59. NEWS guidance says if the patient’s condition scores seven or more then the nurse must immediately inform the relevant medical team. There should then be an ‘urgent or emergency response’ from staff with critical care skills.
60. The Code says nurses should accurately identify and assess when a patient’s health gets worse. They should make a timely referral to another practitioner when the patient needs care or treatment beyond the limits of their competence. Nurses should also share information with families about the health, care and ongoing treatment of loved ones.
61. The Trust’s complaint response explained staff contacted their mother at 5am on 9 September. They told her about her son’s condition and he was not suitable for resuscitation. It added doctors planned to update their mother with his treatment plan when it could. Sadly, Mr P died before this conversation could take place.
62. The family’s first point of contact during an unexpected deterioration was the nursing team. Nursing staff are not qualified to advise on the course of a patient’s medical condition, or the extent of care. The medical team is responsible for sharing this clinical information with nurses who then communicate it to the family.
63. Mr P’s NEWS show his condition deteriorated significantly on two occasions – at 6pm on 8 September and 2.22am on 9 September. On both occasions the nurses escalated this to the doctors promptly. Once the doctors had reviewed Mr P the nurses updated their mother. These updates came at 9.30pm on 8 September and 5am on 9 September.
64. Our nursing adviser said nursing staff contacted the family and provided appropriate updates in line with their expertise. They said the nurses escalated concerns about Mr P’s condition to the right colleagues promptly. They then shared any updates with the family as soon as possible.
65. We have found no failings with how long it took staff to inform Mr P’s family.
66. This does not take away from the distress Mrs C and their mother have experienced. We understand how upsetting it was for their mother to only spent time with Mr P at the very end of his life.