Infection and sepsis treatment 22. Mrs A says the Trust failed to appropriately treat Mr B for an infection and sepsis throughout his admission, failing to take into consideration his existing neurological condition during this treatment.
23. The NICE NG51 guidance outlines that clinicians should assess people with a suspected infection to identify: • the possible source of infection • factors that increase the risk of sepsis • any indications of clinical concern, such as new-onset abnormalities of behaviour, circulation or respiration.
24. It says clinicians should carry out appropriate investigations to find the source of the infection and take microbiological and blood samples. They should give a broad-spectrum antimicrobials (substances that inhibit or kill microorganisms such as antibiotics to target and treat bacteria), if antibiotics have not already been given, within one hour of identifying the patient meets any high-risk criteria.
25. The NICE NG51 guidance goes onto explain for patients with a suspected infection clinicians should take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available. For patients with suspected sepsis clinicians should take blood cultures before antibiotics are given.
26. The Trust’s sepsis protocol explains clinicians should monitor a patient’s urine input and output, take blood cultures, check their serum lactate (the amount of lactic acid in the blood) levels, provide intravenous (IV) fluids, provide IV antibiotics and give oxygen if their oxygen saturations fall below 94%.
27. The clinical records show Mr B presented to the ED on 18 May with a high temperature, altered conscious level and signs of organ dysfunction (acute kidney injury) although his blood pressure and lactate levels remained within normal limits (normal range for blood pressure is below 120/80 mm Hg and lactate is 0.6 to 1.8 mmol/L).
28. The ED records show Mr B has persistent high temperature throughout the day. During his time in the ED Mr B was observed regularly. His Glasgow Coma Score (a score used to assess level of consciousness) reduced. He was examined at 3.17pm and was referred to the medical team.
29. The medical team carried out an assessment at approximately 7pm, at which point the Trust felt he had sepsis of unknown origin. It started the sepsis protocol and took his blood for testing. At this point the Trust prescribed and administered Mr B with the antibiotics Gentamicin and Tazocin.
30. The evidence shows the initial management of Mr B was appropriate and in line with the NICE NG51 guidance on carrying out appropriate investigations by sending his blood for testing and administering antibiotics to treat sepsis.
31. The clinical records show the blood tests taken during his time within the ED grew two types of bacteria, Streptococcus Salivarius and Aerococcus viridans. The Trust then referred Mr B’s management to a microbiologist on 19 May to review his treatment.
32. On 20 May Mr B was transferred to the ICU for further treatment as he was experiencing seizures, a low GCS, confusion and fever. He was sedated and intubated and treated for sepsis and seizure management. He had a microbiologist review and Mr B’s antibiotics were changed to an eight-day course of ceftriaxone (an antibiotic), and the anti-viral Acyclovir was added into his treatment plan, as doctors suspected he might have encephalitis, which is an infection of either the lining of the brain or the brain tissue itself.
33. The Trust also arranged for Mr B to have a lumbar puncture and samples of cerebrospinal fluid (CSF) being sent for microbiology examination. The records show the CSF came back as negative for infection. On 21 May Mr B’s blood culture was negative for infection and the Trust felt his sepsis had resolved.
34. The clinical records show between 22 and 23 May the clinical team reviewed Mr B again and continued to try to identify a source a potential infection, carrying out a further echocardiogram. The Trust still felt Mr B could have encephalitis and sought input from a neurologist given his condition. The Trust also arranged for an MRI of Mr B’s brain.
35. Between 23 and 26 May the Trust continued Mr B on the acyclovir and ceftriaxone medication. On 27 May Mr B’s MRI scan results suggested he did not have encephalitis. Given this the Trust stopped Mr B’s acyclovir. On 28 May Mr B’s ceftriaxone was stopped as he had completed the 8-day course prescribed.
36. Between 29 May and 2 June, Mr B’s condition improved in the ITU and he was deemed ‘wardable’ (fit for transfer back to a general ward). On 2 June Mr B was transferred from the ICU back to a general ward. Mr B’s condition suddenly deteriorated on 3 June, and he sadly died.
37. Overall, we can see between 18 May and 3 June the Trust has treated Mr B for suspected sepsis and encephalitis with antiviral treatment, which was changed at different points throughout his admission, following review of his blood tests and discussions with a microbiologist. This is in line with the NICE NG51 guidance, and our clinical advice supports this view.
38. Our critical care adviser explains largely the Trust’s overall treatment of Mr B for potential infection during this period was appropriate. Our critical care adviser has identified there was a delay in the Trust initially administering antibiotics to Mr B in the ED on 18 May, this is because he had a reduced GCS throughout the day and a high temperature.
39. The antibiotics should have been given within an hour of Mr B having any high-risk criteria for sepsis.
40. The clinical records suggest Mr B was identified as having a persistent high temperature and reduced GCS during the assessment at 3.17pm. The evidence suggests Mr B should have been started on the antibiotics within one hour of this assessment (by 4.17pm). The antibiotics were only given at approximately 7pm. Meaning there was a delay of just under three hours in administering antibiotics. This is contrary to the NICE NG51 guidance, and is a failure.
41. Having identified a delay, we considered whether this had any impact on Mr B. As we explain above, our critical care adviser explains Mr B’s overall treatment of infection and its antiviral usage was appropriate. Our critical care adviser considers while there was an initial delay, they do not consider earlier antibiotics will have changed the overall outcome for Mr B. We can see the evidence shows Mr B’s test results on 21 May showed he was clear of infection. Based on this, we consider the delay in antibiotics did not have any subsequent impact on Mr B.
42. We do consider the knowledge of this delay would cause Mrs A distress. We therefore recommend the Trust apologises to Mrs A for the delay in administering antibiotics and acknowledges the distress the knowledge of this is likely to cause.
43. From speaking to Mrs A it is clear how worrying this issue is for her and her family. We understand how important it was for them to know Mr A was properly treated for any infection and sepsis during his admission. We hope our findings provide them with the information they require in respect of this issue.
Transfer from HDU 44. Mrs A says the Trust inappropriately transferred Mr B from the HDU on 2 June, as he was not fit to be cared for on a general ward.
45. Our critical care adviser further explains there is no formal guidance as to when a patient should be deemed fit for discharge from a critical care setting. They explain decision to discharge a patient is based on clinical judgement of the patient’s condition.
46. The FICM guidance outline patients who no longer require critical care must be discharged without delay within four hours of the decision and this must occur between 7.00am and 9.59pm. It explains all patients should be reviewed by the critical care outreach team following discharge from the ICU to a more general ward setting.
47. The NICE QS158 guidance explains there should be a formal handover of care from critical care to a general ward, including: • a summary of the critical care stay, including diagnosis and treatment • a monitoring and investigation plan • a plan for ongoing treatment • an agreed individualised rehabilitation programme.
48. The clinical records show on 1 June 2023 the Trust carried out a full review of Mr B and felt he was suitable for discharge from the critical care ward on 1 June 2023. At this time we can see Mr B no longer was on a ventilator and was able to maintain his own airway, without the need for any additional oxygen treatment. It was felt he could be nursed in an upright position. He was stable from a cardiovascular perspective, meaning his heart rate, blood pressure and other vital signs were stable and not fluctuating, and he was not receiving any additional support for this.
49. Our critical care adviser explains at this point, the decision to transfer Mr B from a critical care setting was appropriate. They explain the evidence shows Mr B’s condition and observations were appropriate until his sudden deterioration on 3 June. There is no evidence to suggest the clinical decision to discharge Mr B from the critical care setting to a general ward was inappropriate, and our clinical advice supports this view.
50. During the discharge process, we can see the Trust involved different clinicians in the decision to discharge Mr B. This included the critical care consultant, the matron of the receiving ward and a dietitian. The Trust created a discharge document which included a clear summary as to what treatment he received during the critical care admission. It included the ongoing treatment he required from the receiving ward and the need for one-to-one care, given his condition. It identified his ongoing feeding and therapy requirements.
51. The Trust also arranged for Mr B to be seen by the critical care outreach team the day after his discharge. Overall, we are satisfied the Trust’s carried out an appropriate handover of care between the critical care and receiving ward, in line with both the NICE QS158 and FICM guidance.
52. In its final response, we can see the Trust has acknowledged Mr B was discharged from the critical care ward outside of the recommended hours of between 7.00am and 9.59pm. The evidence shows he was transferred onto the ward at 12.10am. This is contrary to the FICM guidance, and this is a failure.
53. We sought clinical advice to establish if the time of discharge had any clinical impact on Mr B. As we explain above, we can see the day after the discharge from critical care, Mr B’s condition was reviewed by the critical care outreach team. Our critical care adviser has reviewed Mr B’s clinical records from the time of his discharge from critical care until his sudden deterioration on 3 June and explains his observations were normal, and there is no evidence to suggest there was any impact in respect of the inappropriate time of discharge. Taking this into consideration, we consider reassuringly, there was no impact on Mr B being transferred from the critical card ward at an inappropriate time.
54. As an outcome of bringing her complaint, Mrs A is seeking an explanation of what happened, an apology and service improvements.
55. The complaint standards outline how we expect an organisation to give a fair and accountable response that sets out what happened and whether mistakes were made, offering fair remedies to put things right. They should take action to make sure learning is identified and used to improve services.
56. In its response we can see the Trust acknowledged Mr B was transferred at 12.10am, it explained this was outside of the recommendations and was due an urgent need for a bed in critical care for another patient. It has acknowledged this fell short of the service expected and explained it collates data at the end of the month for out of hours transfers to raise any incidents. The Trust has apologised for the issues experienced and the subsequent impact this had on Mr B’s family.
57. We are pleased to see the Trust has taken this concern seriously. We are satisfied the Trust has acted in line with the complaint standards by clearly setting out what happened during the transfer from critical care and the reasons why Mr B was moved outside of the recommended hours. It has apologised for the issue and distress caused and taken data to learn from the incident.
58. Taking this into consideration, we do not think it is proportionate for us to make any further recommendations in respect of this issue and consider the Trust has appropriately remedied this issue. We have not identified there was any clinical impact to Mr B and we do not think any further service improvements are required in relation to this issue.
59. Throughout our investigation it was clear from speaking to Mrs A how important this issue was for her. We know she and her family had significant concerns about Mr B’s fitness for transfer from the HDU. We are sorry to hear how much distress this issue continues to cause her. We hope our findings there was no clinical impact to Mr B provide reassurances over the transfer of Mr B.
Care between 2 and 3 June 60. Mrs A says the Trust failed to provide Mr B with appropriate care between 2 June until his death on 3 June by not appropriately treating his deteriorating condition. She says the Trust failed to provide one-to-one nursing care, appropriate repositioning and monitoring at this time. She says the Trust inappropriately restrained him during this time and failed to provide sufficient hydration and nutrition, ignoring concerns raised by the family about him removing his feeding tube.
61. For ease of understanding, we have split this into separate sections.
One-to-one nursing 62. The NQB guidance explains patients are categorised using a decision tool according to their requirements into different levels of care. The tool uses a formula to calculate how many care hours per patient day (CHPPD) are required, and rates their level of care required, as follows: • Level 0: General Ward Care: Patients who require minimal assistance and are generally independent in their care.
• Level 1a: Increased Acuity: Patients who require increased monitoring and observation due to a change in the You heir condition or increased risk.
• Level 1b: Increased Dependency: Patients who require more assistance with their daily living activities due to their condition or limitations.
• Level 2: Unstable, Detailed Observation: Patients who require close monitoring, frequent assessments, and complex interventions due to unstable conditions.
• Level 3: Intensive Care: Patients who require continuous monitoring, advanced interventions, and highly specialized care.
63. The clinical records show on 1 June the Trust felt Mr B was fit for transfer from the critical care unit to a general ward for ongoing care. At 3.10pm Mr B’s condition was discussed with the receiving ward matron, who felt he needed one-to-one care. This did not happen, which has left Mrs A understandably concerned her father-in-law did not receive the right level of nursing during this period.
64. We have requested clinical advice to establish if Mr B needed one-to-one care between 2 June and 3 June based on his condition during this period, and if the Trust met his care requirements.
65. On 2 June we can see Mr B’s condition was noted to be unremarkable, he did not require continuous monitoring, any form of specific advanced interventions or specialised care in any way. Our nursing adviser explains at this time Mr B’s care needs were likely at level 1b, his overall dependency on nursing staff was increased and he required more assistance than normal with his daily living activities due to his condition at the time. Based on this, he did not require one-to-one nursing at this time. There is no evidence to suggest the Trust was not meeting his care requirements on 2 June.
66. On 3 June, Mr B’s care needs increased, and his condition acutely deteriorated. It was felt he was unstable and required closer monitoring and more frequent assessments. His care needs continued to deteriorate on 3 June to the point where he required constant monitoring and more specialised care. Our nursing adviser explains at this point, Mr B’s care needs had likely increased to between level 2 and level 3.
67. The clinical records show on 3 June the Trust increased his care needs, he also had increased personnel in attendance at his bedside treating him, had input from the critical care outreach teams and the resuscitation teams. There is no evidence to suggest the Trust was not meeting his care requirements on 3 June.
68. Based on the evidence we are satisfied the Trust appropriately escalated Mr B at the right time to needing one-to-one nursing care on 3 June. Overall, we consider the Trust provided the appropriate level of nursing in line with the NQB guidance, and our clinical advice supports this view.
69. We understand why Mrs A remains unhappy Mr B did not always receive one-to-one care. She explains this was based on the conversations Mr B’s family had with the receiving ward in respect of Mr B needing one-to-one care. This again was one of the most significant parts of Mrs A’s complaint. We understand why she has concerns given the discussions Mr B’s family had about the necessity for one-to-one nursing, given this was not provided.
70. We understand the conflicting information about his care needs is likely to have increased concerns about the level of care he received, at what was already a very difficult time. We hope our findings in respect of the level of care provided between 2 and 3 June provide Mrs A with reassurances the Trust provided the right amount of nursing care to Mr B during this period.
Repositioning 71. The NICE CG179 guidance outlines that clinicians should carry out a risk assessment on adults to identify if they are at risk of skin damage, using a recognised scale (such as the Waterlow score) to assess pressure ulcer risk. For patients who have been assessed as being at high risk of developing a pressure ulcer (such as Mr B) they should develop an individualised care plan. They should encouraged patients to change their position frequently and at least every four hours. If they are unable to reposition themselves, they should offer help to do so, using appropriate equipment if needed. They should document the frequency of repositioning required.
72. The NMC code explains nurses should keep clear and accurate records relevant to their practice,completing all records at the time or as soon as possible after the event. Records should be clear, accurate and factual. The NMC code explains good record keeping is essential for delivering safe and effective care, providing a clear account of interactions, decisions made, and care provided which is crucial for continuity of care.
73. The clinical records show prior to Mr B’s transfer to the ward on 2 June, he was deemed to be at high risk of developing pressure damage and had a small blister of 2cmx2cm on his neck, which was felt to have developed because of friction.
74. The evidence shows the Trust uses a pre-printed SSKIN assessment and planning documentation to create an individual care plan for patients. This is a five-step care bundle used to prevent pressure ulcers. The acronym stands for surface, skin inspection, keep moving, incontinence/moisture, and nutrition/hydration.
75. The clinical records show on 2 June the Trust carried out a Waterlow risk assessment on Mr B to calculate his overall risk for skin damage. The Waterlow score was 17, which falls within the ‘high risk’ category. This means more intensive preventative measures were required to prevent further skin breakdown and with suggested two-hourly repositioning. The clinical records show this was added onto the wrong section of the SSKIN assessment.
76. The evidence shows the Trust failed to complete the rest of the SSKIN assessment and did not identify the plan of care it was to follow for Mr B during his time on the ward. Based on this there is no evidence to show the Trust created an individualised care plan for Mr B, and this is contrary to the NICE CG179 guidance. We consider this is a failing, and our clinical advice supports this view.
77. We have reviewed whether the Trust repositioned Mr B appropriately, based on the Waterlow score of 17, which as stated above suggests repositioning every two hours. The clinical records show the Trust repositioned Mr B between two and four hours until 9.00pm on 2 June. Our nursing adviser explains overnight between 9.00pm and 9.00am on 3 June the standard of record keeping is weak, meaning it is not possible to say with any certainty as to what level of repositioning Mr B received. We can see on 3 June at 9.00am the Trust reviewed Mr B again, documenting a Waterlow score of 17, and the Trust repositioned him appropriately from 9.00am until his sudden deterioration at 11.05am. This is contrary to the NMC code on keeping clear, accurate records to ensure continuity of care.
78. Overall, the evidence suggests, on balance, the Trust has failed to appropriately reposition Mr B between 2 and 3 June based on his requirements at the time. We know the Trust did not always ensure he was repositioned every two hours on 2 June and it is not possible to say with any certainty what amount of repositioning was provided overnight from 9.00pm on 2 June until 9.00am on 3 June. This is contrary to the NICE CG179 guidance and is a failing. Our clinical advice supports this view.
79. Having identified a failing in respect of the Trust’s repositioning, we will now consider what impact, if any, this had on Mr B. Mrs A considers the failure to reposition Mr B between 2 and 3 June caused his overall condition to deteriorate.
80. We requested clinical advice to establish if there was any impact caused by these failings had on Mr B. Our nursing adviser explains Mr B was unwell during his admission and importantly was identified as being at high-risk of developing pressure damage to his skin. Therefore, even if the Trust provided the correct level of skin care, there was the potential of Mr B still developing pressure damage. Due to the standard of record keeping here, we will never know if he received sufficient repositioning.
81. Our nursing adviser explains the omissions we have identified in changing a patient’s position to prevent skin breakdown do not carry the risk of deterioration in cardiovascular or respiratory function. Reassuringly our work suggests the omissions in repositioning Mr B did not contribute to his overall condition deteriorating, as Mrs A says.
82. The failure to appropriately reposition Mr B, could have caused his skin to deteriorate further and cause him a level of discomfort. Due to the standard of the Trust’s record keeping in respect of the skin care and the lack of clear records between 9.00pm on 2 June and 9.00am on 3 June means we will never be able to say, even on balance, what impact, if any, this failure had.
83. While we have not identified any clinical impact from these failings, we consider the fact Mrs A will never know what impact this failing had is in itself an injustice. The overall poor standard of record keeping here means we are unable to assure Mrs A on whether there was an impact of this failing or not. This is in itself significant. We understand the impact this will have on Mrs C and her family, about never truly knowing what the impact would be of this.
84. Taking this into consideration, we recommend the Trust apologises for the failings we have identified, acknowledging the distress this issue has caused Mrs A and Mr B.
85. We also recommend the Trust creates an action plan to describe what it has done or will do to improve the standard of record keeping in the future. The action plan should identify the reasons for the failings, where possible. It should explain the learning the Trust has taken from these issues, what it will do differently in future, who is responsible and timescales for each action, and how it will monitor these. The Trust should provide a copy of this action plan to Mrs A.
Monitoring 86. The NEWS2 guidance explains NEWS is a numerical score calculated from the patients’ observations which in turn determine resultant actions and frequency of observations by clinicians. The overall NEWS is scored as low (a score of zero to four), medium (a score of five or six) or high (a score of seven and over). Specifically for monitoring, a low score, requires monitoring every 12 hours for patients scoring zero, and every four to six hours for a score of between one and four, unless more or less frequent monitoring is deemed necessary by a clinician. A medium score of between four and five requires monitoring every hour, and a high score requires continuous monitoring.
87. The clinical records show the Trust carried out regular observations of Mr B on 2 June and calculated his NEWS on each occasion. The Trust reviewed Mr B at 9am when his score was zero, at 1pm his score was zero, at 4.30pm he was reviewed by the critical care team and his score was two, he was checked again at 5pm when his score reduced to zero, at 8pm his score was zero and at 8.30pm his score was two. He was reviewed at this time, and it was decided to continue on his current management with a further review of his condition the following day.
88. On 3 June again the Trust carried out regular observations on Mr B. We can see the Trust reviewed Mr B at 4.55am when his score was one at 11.20am his score was two, this was repeated at 11.45am and his score subsequently increased to nine. The clinical records show this increase was due to Mr B’s respiratory rate and his blood pressure scores, increasing the overall NEWS. After this increase the evidence shows the Trust referred him to the critical care outreach team who requested his observations be changed to match his respective NEWS of nine, with continuous monitoring. Sadly the evidence shows after this his condition continued to deteriorate, and Mr B unfortunately died shortly after.
89. We again extend our sincere condolences for Mr B’s death. We understand how important this issue remains to be for the family.
90. Overall, the Trust carried out observations in line with the NEWS2 guidance. We can see when Mr B’s NEWS increased he was appropriately escalated to the critical care outreach team and reviewed by the medical teams. This is in line with the NEWS2 guidance on escalating an increasing NEWS. We consider there are no failings in respect of the Trust’s monitoring of Mr B between 2 and 3 June, and our clinical advice supports this view.
91. We understand the concerns Mrs A has in respect of the observations carried out on Mr B. We are sorry to hear how concerned they are Mr B did not have the right level of observations before his death. We hope our findings provide reassurances over the observations carried out.
Restraint 92. Mrs A says the Trust inappropriately restrained Mr B between 2 and 3 June.
93. The MCA provides a legal framework for making decisions on behalf of individuals who may lack the capacity to make decisions for themselves. Restraint is definded as any method used to limit a person’s freedom or movements and can only be applied under specific conditions: • Necessity: Restraint is permitted only if there is a real risk of harm to the individual or others, and less intrusive methods have been considered and ruled out • Proportionality: The level of restraint must be proportionate to the risk of harm. This means that the minimum amount of restraint necessary should be applied, and it should be for the shortest time possible • Best Interests: Any decision to use restraint must be made in the best interests of the person lacking capacity. This includes considering their past and present wishes and feelings, as well as the views of other relevant people.
94. The Deprivation of Liberty Safeguards (DoLS) are a legal framework within the Mental Capacity Act 2005 that provides protections for vulnerable individuals in care homes and hospitals who lack the capacity to consent to their care and treatment, and whose care arrangements may amount to a deprivation of their liberty. These safeguards ensure that any restrictions on a person's freedom are necessary, in their best interests, and subject to legal oversight.
95. The clinical records show the Trust made a DOLS application on 20 May, which expired on 26 May and a subsequent extension to the DOLS that expired on 2 June 2023. This was because Mr B was deemed to not have capacity to make decisions by himself as he was confused and not engaging in conversation. Our nursing adviser explains the Trust made a DOLS application with full knowledge of Mr B’s family as it was felt he required ongoing care that he could not consent to. Overall the evidence shows the Trust followed the MCA 2005 by creating a live DoLS with Mr B’s family, and our clinical advice supports this view.
96. The clinical records show following the DoLS, the Trust then used mittens on 2 June to prevent Mr B from removing his nasogastric tube to enable his nutrition to continue as planned.
97. The Trust used soft mittens to cover Mr B’s hands. The mittens prevent patients from pulling out any lines or tubes that are being used to give them medication, fluids or nutrition. Our nursing adviser explains the aim of the use of safety hand mittens is to protect the patient from self-injury or from pulling out or dislodging essential medical equipment e.g. cannula, catheter, intravenous lines, feeding tubes etc.
98. The use of safety hand mittens is a form of physical restraint and the relevant legislation surrounding consent, mental capacity and human rights must be upheld to ensure staff are lawfully using safety hand mittens when required in the patients’ best interests. The evidence shows the Trust did this. We consider there are no failings in respect of the decision to use mittens on Mr B on 2 June.
99. We understand how critical it was to ensure restraint was used appropriately during Mr B’s admission and the concerns his family have over this. Mrs A has described how upset the family were at witnessing this, we recognise how significant of a concern this is, and are sorry to hear how upsetting it was to see. We hope our findings reassure Mrs A the restraint was used appropriately.
Hydration and Nutrition 100. Mrs A says the Trust failed to provide sufficient hydration and nutrition to Mr B between 2 and 3 June, ignoring concerns raised by the family about him removing his feeding tube.
101. The NICE GG32 guidance explains nutritional support should be considered in people in risk of malnutrition who have eaten little or nothing for more than five days. Nutritional monitoring for patients with enteral tubes (such as a nasogastric tube) should be completed by daily fluid balance charts (a chart which monitors the fluid in against the fluid out) to ensure a patient is not becoming over or under hydrated. Patients should be supported by a multidisciplinary team to receive coordinated care.
102. During his time in the ICU, Mr B was intubated and fed by nasogastric tube on a low sodium feed plan at 60ml/hr.
103. On 2 June Mr B’s nutrition and hydration were assessed. It was identified Mr B should remain nil-by-mouth with a nasogastric tube in place for feeding. The Trust administered intravenous (IV) fluids to support his nutrition, referred him to nutritional support and arranged for the completion of fluid balance charts to monitor his intake. Mr B was referred by a dietitian who increased his low sodium feed plan to 125ml/hr while he was on the ward.
104. The clinical records show between 2 and 3 June the Trust administered IV fluids and kept regular fluid balance charts to monitor his intake and to ensure he was not becoming either over or under hydrated.
105. Our nursing adviser explains this was appropriate in Mr B’s condition given his acute kidney injury at the time of his admission. They explain his fluid was appropriately balanced during this period in line with Mr B’s clinical need and to prevent any issues with his kidney function.
106. Overall, we consider between 2 and 3 June the Trust provided sufficient nutritional support to Mr B, and our clinical advice supports this view. We recognise how important it was for Mrs A and her family to know Mr B received appropriate hydration and nutrition at such a critical time. We hope our findings provide reassurances over the level of care provided.
Complaint handling 107. Mrs A says the Trust took too long to investigate her complaint, provided insufficient updates and failed to respond to requests for updates during the investigation. She says the Trust failed to prepare for the resolution meeting by not including relevant members of staff it said would attend and took five months to send a follow-up response letter following the resolution meeting. She says the final response contains lots of inaccuracies and is lacking in detail.
108. The Trust’s complaints policy explains it aims to ensure all investigations are completed in a timely and appropriate manner and it aims to ensure a response is issued within 60 working days from receipt of the complaint letter. It says if a response will not be sent within the 60 working day timescale, updates should be provided to the complainant to explain the progress of the investigation and will include an apology, a full reason for the delay and, if possible, a date by which the final response can be expected. It says the final response should include an apology (if applicable), a response to each concern raised, and any action taken from the complaint.
109. For investigations involving a meeting, the Trust’s complaints policy says any follow-up complaint points from the meeting should be responded to within the same timescales allowed for the investigation (60 working days). It says the lead investigator should brief the attendees of the meeting before the meeting takes place.
110. The NHS complaint regulations outline how a response must be sent within six months of a complaint being received. If they cannot provide a response within this period they must write to the complainant to explain why and send the response as soon as is reasonably practical after this period.
111. The complaint standards explain we expect an organisation to be thorough and fair during an investigation, providing regular updates during the investigation. They should give fair and accountable responses, giving a clear, balanced account of what happened based on established facts. Each account compares what happened with what should have happened. It clearly references any relevant legislation, standards, policies or guidance, based on objective criteria. We expect organisations to be open and accountable, acknowledging when things go wrong and taking action to prevent the same thing from happening again.
112. The Trust has provided a copy of its complaint file for Mrs A’s complaint. We have carefully considered the information contained within the complaint file. We can see the Trust received Mrs A’s complaint on 21 June 2023. The Trust’s complaints file shows the Trust’s initial timescale for completion of its investigation was 14 September 2023. The Trust’s final response was dated 4 April 2024 and sent on 17 April 2024 by email. Local resolution therefore took approximately nine months and three weeks to complete. This far exceeded the 60-working day (eight week) timescale set by the Trust to investigate and the NHS complaint regulations timescale of six months to respond.
113. NHS complaint regulations say the organisation investigating a complaint should ‘Investigate in a manner appropriate to resolve it speedily and efficiently’. The regulations say the organisation should send the complaint response 'within the relevant period', which it defines as 'the period of 6 months commencing on the day on which the complaint was received'.
114. The time between the Trust receiving Mrs A’s complaint in June 2023 and sending its response in April 2024 was nine months and three weeks. The Trust identified this being a lengthy process for which it has apologised. During this period, we would have expected the Trust to have kept in contact with Mrs A to update her on the progress of the investigation.
115. The records show the Trust only provided an update after Mr B’s son contacted the Trust to chase for an update. The Trust and Mrs A exchanged emails between September and November to arrange a complaint meeting. The Trust met with Mr B’s family on 1 December 2023 and it made no further contact with Mrs A and her family until the Trust sent its response on 17 April 2024 by email.
116. Some time is expected in order that an appropriately thorough investigation is carried out. We understand complaints can be complex and it might not always be possible for the Trust to meet the timescales set to respond, in this event, we would expect the Trust to provide Mrs A with regular updates about the progress of its investigation. The evidence shows while the Trust were in contact with Mr B’s family between September and December 2023 to arrange the meeting, there were large gaps when the Trust failed provide any updates on the progress of its investigation at all. Specifically, we can see no contact between December 2023 and April 2024.
117. We consider the Trust has exceeded the six-month timescale set by NHS complaint regulations. We also find the Trust failed to provide appropriate updates between December 2023 and April 2024 to update Mrs A on the progress of its investigation. This is contrary to the Trust’s complaints policy, NHS complaint regulations and the complaint standards on providing meaningful updates on the progress of the investigation, and we are likely to find this a failing.
118. Mrs A also complains about the failure by the Trust by not including clinicians who cared for Mr B in the complaint meeting. The Trust’s complaint file shows before the meeting, the investigator did contact the responsible departments involved in the care being complained about to seek their input. The Trust identified who it felt would be beneficial to attend the meeting and its investigator also sent the specific questions raised in the initial complaint to the attendees before the meeting itself.
119. We are satisfied the Trust has followed its complaints policy here by briefing the people involved in a complaint before the meeting took place. Mrs A feels they were not prepared for the meeting, but we have seen no evidence of this. We consider there were no failings in respect of the people involved in the complaint meeting.
120. Finally, we have considered the standard of the Trust’s complaint response to ensure it addressed all the concerns raised by Mrs A. Mrs A feels the response contains a lot of inaccuracies and is lacking in detail.
121. We can see as part of the investigation the Trust identified a total of 16 questions raised by Mr B’s family as part of the initial complaint. The evidence suggests these points were discussed at the meeting and the response letter dated 4 April 2024 does address each point in turn. The Trust has in part addressed points together, this is not an unreasonable approach to take. The response does contain instances of the Trust outlining the relevant policy guidance describing what should happen for different elements of care and comparing this against what did happen.
122. We have identified some concerns in respect of the overall standard and accuracy of the Trust’s final response. From reviewing Mrs A’s complaint, a key element was whether Mr B required one to one nursing, and the reason why this was not provided, despite the nurse explaining to Mr B’s family this would be provided between 2 and 3 June.
123. The response does not answer whether one to one nursing care was actually necessary for Mr B and what was done to mitigate the fact that it was not provided, it just apologises this was not provided as agreed. By exploring this further, we think the Trust could have sufficiently answered this aspect of Mrs A’s complaint.
124. We have looked at her concerns about observations. The Trust does, in part, outline what should happen in respect of the frequency of observations by referring to the relevant NEWS guidance. However, the information within the response relating to the timing of the observations does not correlate with the clinical records provided and several timings are inaccurate.
125. Our nursing adviser has reviewed this aspect of the response further and considers more information could have been provided to Mr B’s family that there was no indication to escalate to the medical team until his acute deterioration on 3 June shortly before his death. Again, by exploring this further, we think the Trust could have done more to answer this aspect of Mrs A’s complaint.
126. Overall, we consider the Trust’s response does not sufficiently answer all the key concerns raised by Mrs A and does contain inaccuracies. Our clinical advice supports this view. This is contrary to our complaint standards which says an organisation should give fair, balanced and accountable response, comparing what happened with what should have happened. As well as the Trust’s complaints policy which says a response should address each concern raised.
127. Having identified a failing in respect of the time taken to investigate, and the standard of the response we have considered what impact this may have had and if we feel the Trust needs to take further action to remedy this.
128. In her complaint to us, Mrs A explains the poor complaint handling compounded the distress of the family at what was already a very difficult time, which caused a loss of faith in the Trust. It is clear how deeply the loss of Mr B impacted his family and how important it was for the Trust to ensure the complaints investigation went some way to resolve this. We accept the long period of time taken by the Trust to investigate the complaint, and the standard of the final response, after waiting this long, is likely to have added to the distress at what was already a very difficult time.
129. As an outcome of bringing her complaint to our service, Mrs A is seeking an acknowledgement of failings, apology and service improvements. We can see in the final response the Trust has acknowledged the time taken to investigate the complaint and apologised for this. The Trust has also identified the failings are likely to have caused distress to Mr B’s family. We are reassured to see the Trust has taken this issue seriously.
130. Mrs A explained how the standard of complaint handling compounded the distress at what was already a difficult time. We understand how important it was after Mr B’s death for the Trust to get the complaint handling right. We know it did not do this in parts and understand how disappointing this must be for Mrs A and her family.
131. While the Trust has acknowledged the delay in responding, it has not yet taken action to remedy the lack of meaningful updates between December 2023 and April 2024 or the overall standard of its response letter. We therefore recommend the Trust acknowledges the failure and subsequent impact these issues caused Mrs A and apologises for this.
132. We also recommend the Trust creates an action plan to describe what it has done or will do to improve complaint handling in the future. The action plan should identify the reasons for the failings, where possible. It should explain the learning the Trust has taken from these issues, what it will do differently in future, who is responsible and timescales for each action, and how it will monitor these. The Trust should provide a copy of this action plan to Mrs A.