Pneumonia diagnosis
36. Mr L says the Trust incorrectly diagnosed Mrs L with aspiration pneumonia. He says her high temperature could have been due to her history of labial abscesses, especially as her chest X-ray on admission was clear.
37. GMC guidelines say when diagnosing patients, clinicians must adequately assess them, taking account of their history, and arrange suitable investigations and treatment where necessary.
38. As explained in paragraph 35, there was no national guidance in place at the time of these events around diagnosing aspiration pneumonia. Our adviser has explained the BTS guidelines set out what was common practice at the time and have since become the national guidance.
39. BTS guidelines say when diagnosing aspiration pneumonia, clinicians should consider the patient’s history of risk factors. It lists many risk factors including stroke and prolonged supine position (lay flat). It advises the following investigations:
• an assessment of oxygenation • chest X-ray • blood tests (including a full blood count, urea and electrolytes (salts), and liver function tests including albumin and CRP) • blood or sputum cultures.
40. BTS guidelines also say a diagnosis of aspiration pneumonia is more likely if the patient has:
• crackles or loud harsh breathing sounds and an increased heart rate • an abnormal white blood cell count • a temperature above 37.5 • low oxygen saturations.
41. The records show the Trust reviewed Mrs L’s history. Mrs L’s history included a stroke and right sided muscle weakness. This meant Mrs L was positioned at a 30 degree angle for prolonged periods and so was not sat upright. This increased Mrs L’s risk factors, according to BTS guidelines.
42. The Trust examined Mrs L including her blood oxygenation at every assessment, and it arranged a chest X-ray and blood tests (including a full blood count, urea and electrolytes, albumin and CRP) and took her blood cultures.
43. Mrs L showed signs that would increase the likelihood of a diagnosis of aspiration pneumonia, as set out in the BTS guidance. She had an increased heart rate, a raised white blood cell count and CRP, her temperature was over 37.5 at 38.6 and her oxygen saturations were low. Mrs L had crackles in her chest, and she was also chesty and required suctioning, experiencing respiratory distress, an increased respiratory rate, and decreased oxygen saturations.
44. Our consultant adviser said based on the Trust’s consideration of Mrs L’s history and its examinations there was ample evidence to suggest Mrs L had aspiration pneumonia.
45. We have found the Trust’s diagnosis of aspiration pneumonia was in line with the GMC guidance. We can see the Trust undertook the investigations set out in the BTS guidance, and the findings from these are consistent with aspiration pneumonia. The tests set out in the guidance were standard clinical practice at the time and so we consider the Trust acted within GMC guidelines. It considered Mrs L’s history and carried out suitable investigations to diagnose Mrs L.
46. We recognise Mr L’s concern Mrs L’s first X-ray was clear. It is understandable why this has left him worried the diagnosis might be wrong.
47. BTS guidelines say chest X-rays fail to detect aspiration pneumonia in up to 25% of cases. Our adviser explained this is because a chest infection can occur without any visible changes on the X-ray, or changes can take time to develop. Our adviser said aspiration pneumonia is diagnosed based on the patient’s history, examination and investigation findings, putting the whole picture together.
48. The second X-ray showed slight shadowing at the top and middle of both Mrs L’s lungs. Our adviser says this was most likely to be an infection from aspiration pneumonia rather than a viral infection, in the context of Mrs L being sedentary.
49. We also recognise Mr L’s concern the Trust did not consider other causes for Mrs L’s condition, particularly her history of labial abscesses.
50. The records show the Trust did consider other reasons for infection. It referred Mrs L to gastroenterology to consider a flare up of her Crohn’s disease. It also arranged an MRI scan of her pelvis given her recurrent labial abscesses, although Mrs L died before this took place.
51. We also note the Trust carried out regular examinations of this area, during personal care. It recorded a fistula and pressure to her sacrum. It did not document any indication of labial abscesses. Based on this, we think it would have documented Mrs L had labial abscesses, if they were there.
52. It is understandable Mr L is concerned the Trust incorrectly diagnosed Mrs L with aspiration pneumonia, in light of her clear X-ray and recurrent abscesses. We have found the Trust acted in line with the relevant guidelines when it diagnosed Mrs L with aspiration pneumonia.
Nutrition
53. Mr L says the Trust did not provide Mrs L with the appropriate nutrition. He says the Trust did not feed Mrs L for around 60 hours.
54. GMC guidelines say clinicians must promptly provide treatment where necessary. They must provide effective treatment based on the best available evidence and take all possible steps to alleviate pain and distress. Our adviser said Mrs L had a well-established feeding regimen which the Trust should have prescribed on admission without dietician input.
55. As set out in paragraph 19, 21, 23 and 24, the Trust referred Mrs L to dietetics on day two and she did not receive her feeding regimen until the evening of day three.
56. There was a period of around 60 hours where the Trust did not provide her with the appropriate feed, until a dietician saw her. Although it appears the Trust gave Mrs L two 125ml Ensures on her third day of admission, our adviser says this was not enough to meet her calorific intake or provide complete nutrition.
57. We have found the Trust’s decision to not prescribe Mrs L her usual feeding regimen is a failing. We have found the Trust should have prescribed Mrs L her feeding regimen on admission to provide her with prompt and effective treatment and alleviate her distress, in line with GMC guidelines.
58. We have next considered the Trust’s decision to not provide Mrs L with her feed overnight. As set out in paragraph 24, the Trust was aware Mrs L had a well-established feeding regimen which included overnight feeding.
59. The Trust does not have a formal written policy on overnight feeding but said it avoids this. It explained this is due to a number of reasons, which include:
• the difficulty of ensuring patients remain in safe positions • the noise of the pumps • the need for a four hour break when feeding into the stomach and • the risk of tubes dislodging which can lead to aspiration.
60. It said there was an incident over 10 years ago where a patient was fed overnight, aspirated and died. It then became practice for the Trust not to provide overnight feed. It said it can and does provide overnight feed if it deems it safe and appropriate for individual patients.
61. Our consultant adviser said a policy or rule of not feeding patients through an established PEG overnight is not commonplace as it can have a negative effect. They said although there is no national guidance on this, it is usual practice to continue feeding patients overnight. They also said it is reasonable following an incident to generally avoid overnight feeding, making exceptions on an individual patient basis.
62. Although the Trust recognised Mrs L had an overnight feeding regimen, it decided not to continue this unless the ward manager decided otherwise acknowledging the risks. There is no evidence the Trust discussed or considered Mrs L’s individual case or the risks of stopping her overnight feed in line with its established practice.
63. We have found the Trust should have done this in line with its own established practice and in line with GMC guidelines to provide effective treatment based on all the evidence.
64. We have found the Trust failed to provide feed to Mrs L and consider the risks of overnight feeding, in line with the relevant guidelines and the Trust’s established practice. We recognise the distress this caused to Mr L as he tried to ensure she received the correct feed during her admission. We have considered the impact of this towards the end of this report.
Hydration
65. Mr L also complains the Trust failed to provide Mrs L with sufficient fluids.
66. NICE fluid guidelines say clinicians should provide IV fluids to patients who cannot meet their fluid or electrolyte needs orally. They should consider whether IV fluids are needed to maintain normal hydration or to replace fluids already lost.
67. The NICE fluid guidelines also say clinicians should assess how much fluid a patient needs through considering their history and through clinical examination. This should include: pulse, blood pressure, capillary refill time, jugular vein pressure, presence of pulmonary or peripheral oedema (fluid in the lungs, or ankles and feet) and presence of postural hypotension (becoming dizzy on standing).
68. Capillary refill time is measured by pressing on the nail bed and then counting the time taken for the tissue to regain its normal colour, and it helps assess peripheral perfusion and dehydration. Jugular vein pressure can also provide an insight into the patient’s fluid status.
69. Our adviser says fluid status is also assessed by looking at the dryness of the mucous membranes lining the inside of the mouth.
70. When the acute medial team assessed Mrs L, it decided she should be nil by mouth, meaning she could not meet her fluid needs orally. As the Trust had not set up Mrs L’s PEG feed, this meant she could not meet her fluid needs this way either.
71. We have found at this point the Trust should have provided Mrs L with IV fluids. It should have considered whether she needed these to maintain normal hydration or to replace fluid loss on admission, in line with NICE fluid guidelines. Instead, the records show the Trust started Mrs L on IV fluids the following morning.
72. The records show the Trust noted Mrs L’s pulse and blood pressure. A blood test showed she had low albumin. Albumin is a protein that keeps fluid in the blood vessels. Low albumin causes fluid to leak into the tissues, causing oedema. The Trust noted Mrs L had no peripheral oedema (the swelling of lower legs or hands).
73. We think the Trust should also have checked Mrs L’s capillary refill time, JV pressure and presence of pulmonary oedema in line with NICE guidelines. We do not think the Trust should have checked Mrs L for postural hypotension, given her limited mobility. We also think it should have checked her mucous membranes in line with what our adviser told us.
74. Our consultant adviser said a patient with Mrs L’s level of albumin would be expected to have some oedema. No oedema was a sign of dehydration. Mrs L also had a high temperature which is a risk factor for dehydration. Her blood pressure was low, also indicating dehydration. Based on this, our adviser says it is likely Mrs L was dehydrated on admission.
75. NICE guidelines say patients should have an IV fluid management plan which includes details of their fluid and electrolyte prescription over the next 24 hours. This should also contain an assessment and monitoring plan. Initially, an expert should review this daily.
76. There is no evidence the Trust implemented an IV management plan in line with NICE guidelines. We think if it had, it would have detailed Mrs L’s fluid and electrolyte prescription over the next 24 hours and an assessment and monitoring plan. There is no evidence to show it did this.
77. NICE guidelines say clinicians should assess a patient’s fluid and electrolyte needs within every ward review. Initially, this should include at least daily reassessments of the patient’s laboratory values (full blood count, urea, creatine and electrolytes), fluid status and fluid balance charts.
78. To monitor a patient’s fluid status clinicians should monitor the patient’s NEWS score and their fluid balance charts. NEWS is a tool to assess how severe a patient’s illness is by checking their respiratory rate, oxygen saturation, temperature, blood pressure, heart rate and level of consciousness.
79. Our adviser says clinicians should also regularly assess dehydration using the tests outlined in paragraphs 67 to 69.
80. The records show the Trust did not assess and manage Mrs L’s fluid and electrolyte needs within every ward review. While it did take laboratory tests of her urea and electrolytes and took her NEWS observations, it did not assess her fluid status by checking for dehydration through testing her capillary refill time, mucous membranes, and pulmonary oedema. Our adviser says the Trust should have done these assessments regularly since laboratory tests are a late sign of dehydration.
81. The Trust checked Mrs L’s JV pressure once, on her fifth day of admission. Our adviser says the fact this was normal shows Mrs L was not overloaded with fluid. However, it is not possible to tell from JV pressure alone whether she was dehydrated, as this is only part of a fluid assessment.
82. The Trust checked Mrs L’s mucus membranes once, on her fourth day of admission. These were dry, indicating she was dehydrated.
83. The documentation shows the Trust did not complete Mrs L’s fluid balance charts fully. These show Mrs L received no fluid during her time in ED and immediately following her admission. The Trust documented 100ml on her second day of admission, but Mr L says she received 400ml later that day. There is no documented intake for her third day, but nursing notes show she received some IV fluids during the afternoon. The Trust documented Mrs L received 2000ml on her fourth day and there is no documented fluid intake for her fifth day of admission.
84. We think the lack of documentation means the Trust would not have been able to adequately monitor Mrs L’s fluid status.
85. The Trust did not properly assess Mrs L’s fluid status or properly document her fluid input and output. It is therefore difficult to know how much fluid she should have received and how much she was actually given.
86. Our adviser says a patient of Mrs L’s weight would generally require around 2 to 2.5l per day. However, as it is likely Mrs L was dehydrated on admission, our adviser estimates she would have needed around 3 to 3.5l per day.
87. The records show Mrs L received 1.5l or less under this estimated daily requirement. Our adviser says this would have most likely caused Mrs L to become further dehydrated during her admission.
88. We have found the Trust failed to assess Mrs L’s fluid needs in line with the relevant guidelines both on admission and throughout her admission. We have also found it failed to implement an IV fluid management plan to meet Mrs L’s fluid and electrolyte needs.
89. We acknowledge how concerning it was for Mr L to know Mrs L was not being given fluids. We have considered the impact of these failings towards the end of this report.
Oxygen
90. Mr L says the Trust gave Mrs L too much oxygen during her admission, as her oxygen saturation was 100%.
91. BTS oxygen guidelines say clinicians should measure a patient’s target oxygen levels on admission and start them on oxygen therapy if needed. This should be set at the correct flow range to achieve the patient’s target range. If their oxygen goes above or below their target range, clinicians should adjust the flow to put them back into this range.
92. Once the patient can stay within their target range without oxygen, it should be stopped and if necessary restarted at the lowest concentration that previously maintained the patient’s target range.
93. The Trust set Mrs L’s target range at 94-98%. Our adviser said this was an appropriate target for a patient with Mrs L’s clinical history.
94. At the start of Mrs L’s admission, the Trust began oxygen therapy until her oxygen saturation rose to 98%. Her oxygen saturation remained within her target range when she was breathing room air. On her second day of admission, when her saturations dropped to 90%, the Trust restarted her oxygen at 1L/min. This was the lowest concentration to maintain Mrs L’s oxygen saturation in her target range. This was in line with BTS oxygen guidelines.
95. When the Trust increased the oxygen flow to 3l/min, Mrs L’s oxygen saturation rose to 99%. She remained on 3l/min for the rest of the day, and her saturation stayed between 99 and 100%. Early the next morning the Trust increased the flow rate to 4l/min and Mrs L’s saturations stayed at 100%.
96. We have found the Trust did not act within BTS oxygen guidelines when Mrs L’s saturation rose to 99%. We think the Trust should have adjusted the oxygen flow to return Mrs L’s saturation to within her target range of 94-98%, in line with BTS oxygen guidelines.
97. We acknowledge how worrying this was for Mr L to see. We have considered the impact this failing had towards the end of this report.
Hyoscine
98. Mr L says the Trust should not have given Mrs L hyoscine. He says Mrs L was taking amantadine for her seizures where hyoscine is not recommended. He also says Mrs L’s breathing was normally noisy and she did not have respiratory secretions. Because of these reasons, Mr L says Mrs L did not need hyoscine.
99. NICE care guidelines advise clinicians to consider giving hyoscine to patients who are experiencing respiratory secretions and becoming distressed.
100. The records show Mrs L sounded ‘chesty’ and ‘bubbly’ on the morning of her second day. We acknowledge here Mr L has said Mrs L’s breathing was normally noisy. The Trust documented Mrs L was becoming agitated, had secretions and appeared to be in pain. It provided her with painkillers for the pain and suctioned her when needed.
101. Later that day, Mrs L still had secretions and the Trust prescribed hyoscine to be given to her as needed. The Trust administered hyoscine over the next three days, and the records show it successfully reduced Mrs L’s secretions.
102. We acknowledge Mr L’s concern hyoscine is not recommended for patients taking amantadine. Our adviser said hyoscine is listed as having interactions with amantadine, not because it is dangerous but because can cause effects such as a dry mouth, dry eyes, constipation and faster heartbeat.
103. Our adviser said the Trust’s decision to provide Mrs L with hyoscine was appropriate considering her presentation. They said in this situation, the benefits of giving Mrs L hyoscine would have outweighed the risks. They said a patient with excessive secretions can aspirate these, worsening a chest infection and causing distress.
104. They also said Mrs L was very frail and her prognosis uncertain. They said Mrs L was at significant risk of deterioration and sadly, of dying. They said it was also important to make sure Mrs L comfortable. This is in line with NICE care guidelines as the records show Mrs L’s respiratory secretions were causing her distress.
105. We appreciate Mr L’s concern the Trust should not have provided Mrs L with hyoscine, given it is listed as interacting with a medication Mrs L was taking. We have found the Trust acted within guidelines when it prescribed Mrs L with hyoscine to manage her respiratory secretions.
Stoma care
106. Mr L says the Trust did not change Mrs L’s stoma bag and it was bursting on her third day of her admission. He has provided an image of this.
107. The NMC code says nurses must uphold a patient’s dignity by delivering the fundamentals of care. This includes bladder and bowel care and making sure patients are kept in clean and hygienic conditions. ACSN guidelines say a stoma bag should be changed every 1-3 days.
108. The records show the Trust emptied Mrs L’s stoma at 2.13am and 7.27am on her second day of admission. It checked her stoma at 10.50am and 11.10am on this day also.
109. Following this, the Trust did not check Mrs L’s stoma until 2.18am of her third day of admission. It emptied it the same evening. There is no evidence the Trust checked Mrs L’s stoma on her fourth day of admission. It was checked at 4.09am, 5.45am, 10.16am and 3.43pm on her fifth day of admission. There is no evidence of Mrs L’s stoma being changed at all during her admission.
110. Considering the image Mr L provided from Mrs L’s third day of admission, we have found Mrs L’s stoma should have been checked more regularly, in line with the NMC code. We also found the Trust should have changed Mrs L’s stoma bag at least once during her admission, in line with ASCN guidelines.
111. We acknowledge it would have been distressing for Mr L to have witnessed Mrs L’s stoma bag not being emptied or changed. We have considered the impact this failing had below.
Impact
112. We have found the Trust failed to administer oxygen in line with guidance. We have found it gave Mrs L too much oxygen. We recognise Mr L’s concern this is one of the issues that caused Mrs L’s death.
113. Our adviser said this issue did not cause Mrs L any negative clinical impact. They said if a patient is over oxygenated to the stage where this supresses their breathing, their carbon dioxide level rises. This causes the patient’s blood pH to fall into the acidic range. The Trust carried out a blood test which showed Mrs L’s pH was at the normal level.
114. We have found the Trust’s failure to administer oxygen to Mrs L in line with guidance did not impact on Mrs L’s clinical condition and therefore, her death. We do however acknowledge this has caused Mr L worry and distress.
115. We have found the Trust failed to attend to Mrs L’s stoma bag as it should have. Mr L told us how Mrs L was in discomfort in the final days of her life, and he feels the full stoma was probably the cause of her pain.
116. Our nursing adviser said a full stoma is unlikely to cause pain. A full stoma could be uncomfortable if a patient can feel their stoma is full, and it can cause worry if they are concerned it could leak.
117. We have found the Trust’s failure to check and change Mrs L’s stoma often enough likely caused her a small degree of concern if she was worried it would leak. Again, we acknowledge this has caused Mr L worry and distress to witness.
118. Next, we have considered the impact of the Trust’s failure to provide Mrs L with nutrition and fluids in line with the relevant guidance, as set out earlier in this report.
119. Our consultant adviser said dehydration and malnutrition can lead to a reduced ability to fight infection. They said the absence of adequate nutrition and hydration will have had some form of negative effect.
120. However, they said this would not have hit the threshold of contributing to Mrs L’s death. This is because Mrs L had a significant number of comorbidities and was suffering from an overwhelming infection.
121. Our adviser said Mrs L’s comorbidities would have independently affected her prognosis. Mrs L had a stoke in 2026 and was wheelchair bound with right sided muscle weakness. She also had Crohn’s disease which was treated with Humira. This is a medication that supresses specific parts of the immune system to reduce inflammation caused by Crohn’s disease. This meant Mrs L was immunosuppressed and so would have had reduced capacity to fight off infection.
122. The Trust was also concerned Mrs L’s PEG site presented a possible source of infection. On admission, Mrs L’s white blood cell count was 20 and this rose to 25 the following day. On admission Mrs L’s CRP was 103 and this had increased to 185 the following day and to 205 the day after this. Our adviser said the Trust was providing optimal medical management for the infection. Despite this, Mrs L continued to deteriorate.
123. Our adviser said Mrs L’s prognosis was very poor and she was deteriorating despite the Trust providing optimal medical management of her infection. They said due to this, and Mrs L’s significant comorbidities, it is unlikely Mrs L would have survived even if the Trust had provided nutrition and hydration in line with guidance.
124. We acknowledge Mr L’s concern the Trust’s failure to provide adequate nutrition, hydration and oxygen caused Mrs L’s death. We recognise Mr L went to great lengths to try and ensure the Trust provided the appropriate care during her admission.
125. We have found the failings in Mrs L’s nutritional and fluid care did not impact on her death. It is sadly unlikely Mrs L would have survived, even with optimum nutrition and hydration.
126. We acknowledge this has caused Mr L worry about whether the outcome could have been different for Mrs L. It has caused him significant distress at what was already a difficult and distressing time.
127. In summary, we have not found the Trust’s failings impacted on Mrs L’s clinical condition. We have found the failings we have identified have caused Mr L worry and distress. Mr L witnessed these failings and is understandably worried about whether the outcome could have been different if the failings in Mrs L’s care had not occurred. This added to his distress at an already difficult time. We have set out our recommendations to address this below.