Cambridge University Hospitals NHS Foundation Trust

4. Miss Y complains about aspects of care and treatment her grandmother, Mrs E, received from the Trust in April 2022. Specifically, Miss Y complains the Trust failed to recognise Mrs E’s deterioration, inform her of this and relax visiting restrictions.

5. Miss Y says this meant she could not be with Mrs E before she died. She says this caused her distress.

6. By bringing this complaint to us Miss Y would like the Trust to acknowledge the failings, take responsibility, apologise and put in place service improvements to prevent this happening to other patients. Miss Y would also like a financial remedy for the impact of the failings.

7. Mrs E was 85 years old at the time of events. She had chronic obstructive pulmonary disease (COPD – a group of lung conditions that cause breathing difficulties) which she received oxygen at home for.

8. In 2019, a doctor informed Mrs E her recent scan results showed a lung nodule that was suspicious for lung cancer.

9. On 19 April 2022, the Trust admitted Mrs E with breathlessness. On admission, the Trust conducted a chest X-ray which indicated the lung nodules had grown.

10. On 21 April, Mrs E reported left sided chest pain and was experiencing breathlessness, so the Trust requested a CT scan.

11. On 22 April, the Trust conducted the CT scan which showed a clot causing strain on her heart. The Trust said it also showed the nodules had grown, were cancerous, and she had additional large lymph nodes throughout her lungs which had spread to her bones.

12. On this day, the doctor referred Mrs E to the palliative care team. The palliative care team reviewed her on 24 and 25 April.

13. On 26 April, Mrs E sadly died.

17. Miss Y complains the Trust failed to recognise Mrs E’s deterioration, inform her of this and relax visiting restrictions.

18. The Trust said Mrs E deteriorated very rapidly just after midnight on 26 April and unfortunately there was no time to contact Miss Y or family at the time this was happening.

19. The records show staff contacted Mrs E’s family at 12.49am on 26 April, after she had passed away.

20. NICE CG103 helps us understand what should happen. This states all over 65s admitted to hospital should have an assessment of their cognition for example with an abbreviated mental test score or other similar tool.

21. An abbreviated mental test score is a quick assessment tool designed to evaluate cognitive function, particularly in elderly patients. It consists of ten questions that assess various cognitive areas including orientation, memory and attention.

22. Each correct answer scores one point. A total score of six or less indicates potential cognitive impairment, such as dementia or delirium.

23. These initial assessments help staff to establish the patient’s cognitive baseline on admission. A cognitive baseline represents a person’s typical level of cognitive function and awareness, which helps to detect changes in cognitive function over time.

24. The guidance says disorientation and/or confusion is an indication of delirium.

25. If delirium is suspected, the guidance says a further clinical assessment should be conducted, based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or a Confusion Assessment Method to confirm the diagnosis of delirium.

26. The guidance also states changes in behaviour can be reported by the patient, a carer or relative.

27. We reviewed Mrs E’s medical records with the help of our clinical adviser to understand what did happen.

28. Based on the records available, we cannot see the Trust assessed Mrs E’s cognition on admission. As she was over 65 at the time, the Trust should have conducted this assessment, in line with the NICE guidance above.

29. The records show on 25 April, the medical team responsible for Mrs E’s care changed.

30. At around midday on this day, the ward round states Mrs E was disorientated to time and place and did not know why she was there. The doctor noted Mrs E’s delirium and said they were unsure of her cognitive baseline.

31. From the clinical advice, we understand if the Trust had conducted a cognitive assessment on Mrs E’s admission, this would have provided a baseline for any other clinical teams providing her care and treatment.

32. In line with the NICE guidance above, when doctors noted Mrs E was disorientated on 25 April, they should have assessed her for delirium.

33. This assessment should have involved staff contacting her family to confirm her cognitive baseline. The records available do not indicate the Trust did this.

34. Our adviser explained delirium is an urgent medical condition and indicates a patient is deteriorating.

35. In response to our provisional views, the Trust noted that delirium is a multifaceted condition and does not always mean a person is in their last moments of life.

36. We discussed these comments further with our clinical adviser. We understand, although delirium does not predict death it is a sign of deterioration, and this is why it is incorporated in the national early warning scores (NEWS).

37. NEWS is a clinical tool used to detect early signs of deterioration in patients, allowing for timely medical intervention. The scores range from zero to seven or more. The lower the score, the lower the risk of deterioration.

38. Our adviser explained if the patient has new-onset confusion, disorientation and/or agitation, this should score a three on the NEWS system.

39. We also understand from the clinical advice, delirium is serious and indicates one of the body’s organs (the brain) is shutting down and so it is a significant sign of deterioration.

40. Therefore, if the Trust had acted in line with the NICE guidance, the clinical team could have confirmed delirium more rapidly. This likely would have resulted in the Trust identifying Mrs E’s deterioration sooner on 25 April.

41. For this reason, we find this is a failing.

42. Miss Y also complains the Trust did not inform family of Mrs E’s deterioration or relax visiting restrictions when she deteriorated.

43. As we have investigated Miss Y’s complaint, we have seen the Trust did not identify Mrs E’s delirium indicating deterioration. We have considered Miss Y’s concern the Trust did not inform her of this or relax visiting restrictions in response to the deterioration, within the impact section below. This is because these issues seem to be closely linked to what happened with the Trust not identifying the delirium and deterioration.

Impact

44. We found failings in the Trust not identifying Mrs E’s deterioration sooner.

45. As part of this concern, Miss Y also complains the Trust failed to inform family of Mrs E’s deterioration and relax visiting restrictions in response to this.

46. Miss Y told us during her grandmother’s admission only one nominated family member was allowed to visit for one to two hours per day, unless agreed otherwise with ward staff. This is consistent with the visiting guidance on the Trust’s website in late February 2022.

47. We have carefully considered the impact of this and discussed this with our clinical adviser.

48. If the Trust had recognised Mrs E delirium and deterioration sooner, we consider this should have prompted earlier communication between the Trust and Mrs E’s family about her deterioration. This is in line with GMC guidance which states doctors must be considerate of those close to a patient.

49. In response to our provisional views, the Trust highlighted the records on 25 April at 5.40pm indicate a nurse informed Mrs E’s sons about the delirium. The Trust also said Mrs E was receiving ongoing treatment, so it did not consider relaxing visiting restrictions.

50. This note indicates the nurse gave a general update to Mrs E’s sons when they visited in the evening. It states ‘Confusion/Delirium/Hallucination’.

51. Whilst this is letting the family know about the delirium, we cannot see the Trust communicated the significance of this and that this was a potential indicator of deterioration, to the family. This is not in line with GMC guidance referred to above.

52. Additionally, the Trust’s visiting policies indicate staff should adopt a compassionate approach for end-of-life care visiting. Had the Trust identified the deterioration earlier, this compassionate approach should have included relaxing visiting restrictions for the family sooner.

53. Miss Y says these concerns meant she could not be with Mrs E before she died. She says this caused her distress.

54. We fully recognise the emotional impact to Miss Y because she could not be with her grandmother before she sadly died. We recognise this would have added to her distress at an already very upsetting time.

55. We cannot say with certainty if the Trust had recognised Mrs E’s delirium and deterioration sooner, Miss Y definitely would have visited Mrs E before she died.

56. However, we consider the failings caused Miss Y a lost opportunity to be informed about her grandmother’s deterioration, and to visit her before she died.

57. We cannot see the Trust has acknowledged or undertaken any action to remedy this impact. As such, we have made recommendations below.

1. We have carefully considered Miss Y’s complaint about Cambridge University Hospitals NHS Foundation Trust (the Trust). We were very sorry to learn about her concerns and for the loss of her grandmother, Mrs E. We recognise this has been a very upsetting time for Miss Y.

2. We have found failings in the Trust not identifying Mrs E’s deterioration. These failings caused Miss Y a lost opportunity to be informed about her grandmother’s deterioration, to be with her before she died and avoidable distress.

3. Therefore, we uphold Miss Y’s complaint. Our recommendations are set out at the end of the report.

58. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.

59. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

60. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found

61. Through investigating this complaint, we found:

• the Trust failed to recognise Mrs E’s deterioration sooner. We consider this caused Miss Y a missed opportunity to be informed about her grandmother’s deterioration and to visit before she died.

What the organisation should do

62. By bringing this complaint to us Miss Y would like the Trust to acknowledge the failings, take responsibility, apologise and put in place service improvements to prevent this happening to other patients. Miss Y would also like a financial remedy for the impact of the failings.

63. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

64. The Trust should write to Miss Y to:

• acknowledge and apologise for the failing we have found and the linked impact of this • send a copy of this letter to us within one month of this report.

65. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

66. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice (SOI) scale.

67. Level three on our SOI scale involves a moderate impact (for example, in terms of distress, worry, inconvenience) but has lasted for significant period of time. It may also involve cases where a higher impact injustice has been suffered for a short period.

68. Level three bereavement cases also includes where poor communication with the patient’s family results in significant worry or distress.

69. We consider Miss Y’s case sits within low level three. Whilst the events happened over a short period (25 to 26 April), the injustice Miss Y has experienced because of the failings is ongoing and significantly aggravated the already distressing event of losing a loved one.

70. Therefore, following this review, we recommend the Trust:

• pay Miss Y £600 in recognition of the failings causing her a lost opportunity to be informed about her grandmother’s delirium and deterioration and to visit her before she died.

• send us evidence it has done this within three months of our final report.

71. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.

72. We recommend the Trust:

• reflect on the learning it can take from the failings and impact identified in this report and from Miss Y’s experience • share how it plans to learn from this with us, Miss Y, the CQC and NHS Improvement within three months of our final report.

73. We recognise these events have been very distressing for Miss Y, following the loss of her grandmother. We hope our investigation will be helpful towards resolving her concerns.

74. This concludes our report.