The Trust unnecessarily carried out a biopsy on Mrs J
18. 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 indications something has gone wrong.
19. Mrs Q says the Trust carried out a biopsy of Mrs J’s left groin whilst she was nearing end of life. Mrs Q says that this was unnecessary and caused Mrs J unnecessary pain and discomfort.
20. The records show Mrs J was referred for a biopsy on 14 May. The procedure was carried out on 16 May. Mrs J did not demonstrate any capacity to consent, despite the presence of an interpreter, so Mrs Q consented to the procedure.
21. GMC ‘Good Medical Practice’ guidance says clinicians should propose treatment or investigations based on an assessment of the patient. They say clinicians should propose treatment based on the best available evidence.
22. GMC ‘Professional Standards: Decision Making and Consent’ say where there is doubt around a patient’s capacity to give consent for a procedure, clinicians should act in patient’s best interests alongside discussion with their family where appropriate.
23. Our adviser said Mrs J was being treated with antibiotics prior to being referred for the biopsy, but had shown little positive response to treatment. They said the referring clinician had concerns over whether Mrs J was suffering from tuberculosis, and referred Mrs J for a biopsy, to determine the correct treatment plan. Our adviser said this would have prevented further complications and possibly surgery if Mrs J had been suffering from tuberculosis.
24. Our adviser said this was clinically appropriate, as the results of the biopsy would have affected the treatment plan for Mrs J. They said the records showed that the Trust documented it would refer Mrs J to palliative care if she did not positively respond to treatment. They said this was in line with GMC ‘Good Medical Practice’ guidance.
25. Our adviser said the Trust’s decision to seek consent for the procedure from Mrs Q, after Mrs J did not demonstrate capacity, was in line with GMC guidance on decision making and consent.
26. In summary, our adviser said the Trust carried out the biopsy on Mrs J and sought consent from Mrs Q in line with guidance.
27. Having reviewed the evidence, we are satisfied the Trust’s decision to carry out a biopsy on Mrs J was in line with guidance. We are satisfied the Trust sought consent first from Mrs J herself, and then from Mrs Q before deciding to proceed. We will therefore not be looking at this part of the complaint further.
The Trust did not communicate to family that Mrs J was on the end-of-life pathway
28. Mrs Q says the Trust did not communicate to Mrs J’s family that she was nearing the end of her life and did not advise them that Mrs J’s nutrition and medication had been stopped. She said it was a shock to her when Mrs J died.
29. The records show Mrs J was observed by a clinician the day after her biopsy, who documented Mrs J was struggling to swallow and appeared drowsy. They documented that she would be observed for 24 hours and would be referred to palliative care if there was no improvement.
30. The records show Trust staff made family members aware of Mrs J’s deterioration and her escalation to palliative care. At this point, Mrs J’s family requested chaplaincy support.
31. GMC ‘Professional Standards’ guidance on end-of-life care says clinicians must consider the benefits and risks of treatment for patients nearing the end of their life. They must consider whether further treatment which may prolong a patient’s life is in their interests, and if it may be preferable to change from active treatment to management of a patient’s symptoms and keeping them comfortable.
32. The guidance says clinicians should acknowledge the role and responsibilities of those close to the patient and ensure their needs for support are met as far as possible. It says those close to a patient may want information about their condition, and clinicians should assume, if a patient lacks capacity to make a decision about sharing information, they would want those closest to them to be kept informed of relevant information.
33. Our adviser said the decision on when to refer a patient to palliative care was a matter of clinical judgement. They said from the records it was clear Mrs J was rapidly deteriorating and had not responded to treatment with antibiotics. They said the Trust discussed Mrs J’s options for further treatment with the microbiology team, and clinicians decided to move Mrs J to palliative care. They said this was in line with GMC guidance on end-of-life care.
34. Our adviser said the records show Trust staff discussed Mrs J’s treatment and referral to palliative care, with her family on 17 May. The records show the Trust gave the family supportive advice and that the family requested chaplaincy support. They said Mrs J’s deterioration was fast and the Trust had discussed next steps with the family at the appropriate time. They said because Mrs J had been receiving treatment up to this point, it would not have been possible to inform the family any sooner. They said this was in line with GMC guidance on treatment and care at the end of life.
35. In summary, our adviser said the Trust referred Mrs J to palliative care and communicated this decision to her family in line with relevant guidance.
36. Having reviewed the evidence, we are satisfied the Trust referred Mrs J to palliative care and communicated this decision to her family in line with relevant guidance. We will therefore not be looking at this part of the complaint further.
The Trust did not provide Mrs J with a face-to-face interpreter
37. Mrs Q says the Trust did not provide Mrs J with a face-to-face interpreter, despite Mrs J having difficulty communicating over a telephone line.
38. In its final response, the Trust apologised for the communication difficulties Mrs J experienced due to the language barrier. It said it had provided staff who could speak Punjabi where possible, provided an interpreter where requested and gave permission for family members to be present outside of usual visiting hours. It said it had drawn up an action plan with Mrs Q to minimise communication difficulties.
39. The records show the Trust provided a telephone interpreter for Mrs J, who sought to gain consent for her biopsy. In her complaint, Mrs J said the telephone interpreter could not communicate with Mrs Q as she was in and out of consciousness. Due to these difficulties, Mrs J gave consent for the biopsy procedure on her mother’s behalf.
40. GMC ‘Good Medical Practice’ says clinicians must treat patients fairly and not discriminate against them. It says clinicians must follow the law relevant to their work. It says clinicians must take steps to meet patient’s language and communication needs, so they can make informed decisions about their care. It says the steps taken should be proportionate to the circumstances, including the patient’s needs, the urgency of the situation and the availability of resources.
41. Department of Health and Social Care guidance says where language is a problem in discussing health matters, a professional interpreter should always be offered, rather than using family or friends to interpret. The guidance says this ensures accuracy and impartiality, minimises the risk of misrepresentation of clinical information and reduces the emotional load on family members.
42. The Equality Act says service providers must make reasonable adjustments to prevent people being disadvantaged. It says information should be provided in an accessible format as a reasonable adjustment. This may include interpretation or translation.
43. The Health and Care Act says NHS organisations must consider the need to reduce health inequalities in terms of access to healthcare, experience and outcomes when making decisions.
44. We understand Mrs Q’s experience with the telephone interpreter was frustrating and necessitated her giving consent for Mrs J’s biopsy. From the records, we consider the Trust acted in line with legislation and guidance when it provided a telephone interpreter prior to Mrs J’s biopsy. Legislation and guidance does not specify that face-to-face interpreters should be provided. We consider the Trust’s decision to use a telephone interpreter was appropriate, given Mrs J’s condition and the clinical need to perform her biopsy.
45. Following the biopsy, the records show Mrs J deteriorated rapidly over the following days. We consider the Trust took appropriate and empathetic steps in seeking to minimise the impact of any communication difficulties on Mrs Q and Mrs J. It offered an interpreter in line with guidance, collaborated with Mrs Q to produce an action plan and allowed Mrs J’s family to remain with her outside of visiting hours. We consider this in line with relevant guidance and legislation. We will therefore not be looking at this part of the complaint further.
46. We thank Mrs Q for taking the time and effort to bring her complaint to our attention. We recognise this was a very difficult and distressing period for her. We hope our explanation provides reassurance that the care and treatment her mother received was in line with guidance and legislation. We wish Mrs Q the best for the future.