Croydon Health Services NHS Trust

5. Mr U complains the Trust did not put in place an effective secretion management plan for Mrs V between September and October 2023 and did not re-refer Mrs V to the chest physiotherapy team, despite this being advised in Mrs V’s discharge notes of 24 October. Mr U also complains the Trust placed Mrs V in a side room and did not respond to her call bell on 26 October.

6. Mr U says the Trust’s failings caused Mrs V repeated episodes of distress and suffering, and ultimately her death. Mr U says this has caused profound and lasting impact on her family. Mr U has also told us of the lasting impact this has had on his own wellbeing. He says this is a direct result of his mother’s death.

7. Mr U seeks an acknowledgement of failings and an apology from the Trust. He would also like the Trust to make service improvements and pay a financial remedy.

8. The following is intended to be a summary of events to help set Mr U’s complaint in context. We have limited the information to that which is relevant to our consideration.

9. Mrs V was in her early sixties at the time of the events Mr U complains about. She had multiple sclerosis (MS), a condition where the immune system attacks the protective coating around nerves in the brain and spinal cord.

10. Mrs V was first admitted to hospital in May 2023 with a pressure ulcer. While she was in hospital, she was diagnosed with osteomyelitis, an infection in a bone, usually caused by bacteria. Mrs V was discharged at the beginning of July but unfortunately, she deteriorated and was readmitted to hospital later that month. She remained in hospital until her sad death.

11. In September, Mrs V unfortunately contracted hospital acquired pneumonia. Mrs V’s MS meant that she struggled to effectively clear secretions by coughing. When this happened, Mrs V tended to desaturate, meaning there was a sudden and rapid drop in the level of oxygen in her blood. Mrs V was referred to the Trust’s chest physiotherapy team for support.

12. In October, the Trust attempted nasopharyngeal airway insertion (a soft, flexible tube inserted through the nostril to help keep the upper airway open) to manage Mrs V’s secretions. When this was unsuccessful, the Trust performed oropharyngeal suction (a procedure that uses gentle pressure to help keep the airway clear) instead.

13. Very sadly, Mrs V went into respiratory failure and died on 26 October.

Secretion management plan

17. 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 that something has gone wrong.

18. The joint ACPRC/BTS guidance describes the role of physiotherapy for patients who can breathe on their own but need support to clear secretions from their airways. It says the main goals for chest physiotherapy are to manage breathlessness, control symptoms, keep people moving, and help them clear secretions from their lungs.

19. Secretions are the mucus or phlegm that the lungs and airways naturally produce. In some illnesses they can become thicker, stickier, or harder to clear, which can make breathing more difficult and increase the risk of infection.

20. The guideline explains physiotherapists should consider a range of methods, including exercise plans, techniques to clear secretions, positions, and breathing exercises to make breathing easier.

21. Our adviser highlighted that Mrs V’s postmortem showed she had oedema in her right lung. Lung oedema from heart failure happens when the heart becomes too weak to pump blood effectively, causing fluid to back up into the lungs instead of moving through the body as it should. This extra fluid fills the tiny air spaces in the lungs, making it hard to breathe. We understand from our adviser that unfortunately, neither chest physiotherapy or suctioning can help in this situation.

22. The joint ACPRC/BTS guideline reflects that chest physiotherapy techniques cannot treat fluid that has collected in the lungs as a result of pneumonia or heart failure. Our clinical adviser explained Mrs V’s secretions were not primarily caused by mucus in her airways. They said they were more likely related to heart failure. We understand from our adviser that chest physiotherapy cannot be expected to improve an underlying condition like this.

23. The records show Mrs V was referred to physiotherapy and assessed on 21 September. The notes from the physiotherapy team’s assessment shows it did not accept the referral. It said Mrs V could clear her own secretions and knew the best way to do this. It also seems she felt she did not need support from the physiotherapy team because she had been ‘managing her [condition] since childhood’ and was experienced in caring for herself.

24. We can see the physiotherapy team assessed Mrs V again on 24 October, two days before she died. The physiotherapist found her to be capable of coughing and clearing her secretions. The notes indicate Mrs V declined support with coughing and suctioning. The physiotherapist discharged Mrs V but said could be re-referred if she deteriorated or struggled to clear her secretions.

25. Our adviser said based on the physiotherapy assessments, and taking into account Mrs V’s needs and the likely cause of her secretions, there was no support the physiotherapy team could realistically offer between 21 September and her sad death. They said the physiotherapy team’s assessment and decision not to treat Mrs V was made in line with the joint ACPRC/BTS guidelines.

26. We can see from the records that when Mrs V was unable to clear her secretions by herself, nurses performed suctioning. We could not identify any gaps in the Trust’s monitoring of Mrs V’s suctioning needs or desaturation episodes. Our adviser said on the occasions when Mrs V desaturated, the Trust intervened and managed Mrs V’s secretions effectively.

27. We know Mr U was also concerned that the Trust did not re-refer Mrs V to the chest physiotherapy team after 24 October, despite the team stating that she could be re-referred. As we have explained above, there was no realistic role for physiotherapy. Our adviser added that the only intervention Mrs V required was occasional suctioning. They explained this is basic secretion management which nurses would be expected to perform. They said there would not be a role for a chest physiotherapy team.

28. While we recognise Mr U’s view that the Trust did not have an overall plan to deal with Mrs V’s secretions, we do not see that it could have done more in this situation. As we have seen above, Mrs V was able to clear her own secretions, although we acknowledge this became more difficult for her as her condition worsened. When she needed assistance, the Trust performed suctioning in line with guidance.

29. We understand how distressing it would have been for Mr U to witness Mrs V struggling with breathing and secretions. Based on the evidence we have looked at, there is no indication that additional physiotherapy or a different secretion management plan would have been likely to improve Mrs V’s condition.

Call bell and side room

30. We looked at the Trust’s internal guidance on its use of side rooms. This says side rooms should be used when available for patients with neutropenia. Neutropenia happens when the body doesn’t have enough neutrophils, which are white blood cells that help fight off infections.

31. We understand from our adviser that neutropenic patients may need to be isolated because their immune system is weak. They are at risk of developing serious infections if they come into contact with sources of bacteria and viruses.

32. The Trust transferred Mrs V to a side room on 15 October. An entry from this date confirms she had neutropenia. Based on this, we are satisfied the Trust acted in line with guidance when it moved Mrs V into a side room. We have seen no indication that being in a side room meant Mrs V went without the care she needed.

33. Mr U said Mrs V sent a text message saying she was ‘struggling to breathe’ just before midnight on 25 October. He said at this time, Mrs V would have pressed her call bell, but it was not within her reach. Mr U said an entry in Mrs V’s medical records just after midnight, stating she was ‘well’, ‘not in pain’, with her call bell within reach, conflicts with what she said in the text message.

34. In its response to Mr U’s complaint, the Trust said the time in the record would not necessarily reflect the exact time a nurse or healthcare assistant (HCA) would have been to check on her. It said this is because the nurses and HCAs complete the records after they have checked on the patients. We can understand Mr U’s view that Mrs V’s records and the text message, despite coinciding with each other, give potentially differing accounts of how she was at that time. We think the Trust has given a reasonable explanation as to why this would have been.

35. The Trust also said a nurse took ‘immediate action’ when Mrs V said she had difficulty breathing just after 1am. It said the nurse could not recall whether she had gone to check on Mrs V because she had pressed her call bell or had noticed changes in her monitoring equipment. It said there was no delay in Mrs V getting the care she needed at the time.

36. We looked at the call bell record. This shows the call bell in Mrs V’s side room was pressed and answered at 22:23, 23:24, and 23:27 on 25 October, and at 00:41 on 26 October. We have no reason to believe this record is inaccurate. This tells us a call bell was available and working in Mrs V’s side room during the period Mr U complained about.

37. Mrs V’s records show she went into respiratory distress just after 01:00. We acknowledge there is an indication from the text message that Mrs V was ‘struggling to breathe’ before this. However, we have seen no indication she went without the care she needed. We understand from our adviser Mrs V’s deterioration in the early hours of 26 October was sudden and sadly unavoidable.

38. Based on the evidence available to us, we have seen no indication that anything went wrong here. We acknowledge Mr U’s concerns about the side room and call bell and we understand that he would have wanted the Trust to attend to Mrs V as soon as she needed. We hope we have been able to provide him some reassurance.

1. We thank Mr U for his complaint about the care the Trust provided his mother, Mrs V. We recognise how important the complaint is to him and the effort he has made to share his experience with us. We offer our sincere condolences to Mr U and Mrs V’s family for their sad loss.

2. We have carefully considered Mr U’s concerns about the way the Trust managed Mrs V’s secretions. We recognise on occasions Mrs V struggled to clear her airways and we think at these times, the Trust provided her effective treatment with suctioning.

3. Based on the evidence we have looked at, we do not think there was a role for the Trust’s chest physiotherapy team between September and Mrs V’s sad death. For this reason, we have seen no indication the Trust should have re-referred her after 24 October.

4. We consider the Trust acted in line with its internal guidance when it transferred Mrs V to a side room. Furthermore, the evidence indicates the Trust responded to Mrs V’s call bell as it should have. We have seen no indication that Mrs V went without the care she needed.