Mr D’s mobility care plan
20. In her complaint, Mrs C told us staff simply noted Mr D had reduced mobility. They then made a generic mobility care plan not personalised to him.
21. She said staff noted he had a chesty cough and pneumonia. She added immobility can make this condition worse. When staff are responsible for a less mobile patient with respiratory conditions, a key action they should take is repositioning the patient, even if this is just turning them in bed. She said staff gave no consideration to such measures through an assessment of Mr D’s individual circumstances.
22. In its complaint process, the Trust said nursing staff put a reduced mobility care plan in place for Mr D. The instructions they noted within it were only the generic instructions listed in the Trust’s care plan template document. Staff did not personalise the plan by considering Mr D’s specific mobility needs or what they should do to manage such needs. The Trust said it expected staff to make personalised care plans.
23. We found staff did not act in line with guidelines on this matter.
24. Section 1.3 in NICE Guideline 138 says staff need to tailor services to respond to the needs, preferences, and values of each patient. Staff should individualise care and treatment as much as possible, having considered the risks and benefits to each patient.
25. Specific to mobility and patient handling, the Mobility Goal Setting says staff should have two types of moving and handling risk assessments. This includes:
• generic risk assessments covering workplace needs, balancing the safety of staff with the needs, safety, and rights of patients • individual risk assessments, which consider each patient’s specific moving and handling needs.
26. From Mr D’s care records, we saw the same documentation Mrs C and the Trust described. That is, the generic plans staff put in place regarding Mr D’s mobility. We did not see any assessments staff made specifically to consider his mobility needs, and what plans they needed to make to manage them. Our nurse said they expected to see a personalised mobility assessment with personalised goals for Mr D.
27. Having considered the above, we agree with the Trust’s conclusions. Staff did not devise a personalised mobility care plan for Mr D, and they should have. This is not in line with the guidelines we referred to in paragraph 24 and 25.
28. In terms of what should have happened had staff devised a personalised plan, our nurse advised what this should have looked like. They explained what difference this is likely to have made regarding how and when Mr D mobilised.
29. In his care records, staff noted Mr D had poor mobility when they admitted him to hospital. They also recognised he had poor bed mobility, which meant he struggled to reposition himself in bed. To address these challenges, our nurse said they would have expected staff to plan actions like:
• ensuring he had assistance to sit out of his bed for increasing periods of time • assisting him to reposition himself regularly when he was in bed.
30. We saw this went beyond the actions from the Trust’s generic mobility care plan. This plan said staff should encourage Mr D to mobilise out of bed and assist him if necessary. It gave similar instructions about repositioning in bed, and that staff should encourage him to do this every two to four hours.
31. With the generic plans staff had in place for Mr D, his care records show staff did not offer assistance for him to sit out of bed, other than the morning of 19 April 2022 when he declined this. They gave him assistance to reposition in bed at:
• 6.27am on 18 April (staff turned him onto his back) • 3.33am on 20 April (staff rolled him to deliver personal care) • 12.31am on 21 April (staff rolled him to deliver personal care) • 2.48pm on 21 April (staff helped him change position in bed) • 10.55pm on 21 April (staff helped him change position in bed) • 2.53am on 22 April (staff turned him onto his left side).
32. Had staff planned and documented specific personalised goals, in particular about getting Mr D out of bed, our nurse said staff are likely to have seen these instructions. Having done so, it is likely they would have followed them. This meant it was more likely staff would have given Mr D opportunities to mobilise more. This included supporting him out of bed, rather than simply encouraging him to do this, as the generic plan suggested.
33. Having considered the above, we concluded a personalised care plan made in line with guidelines would have directed staff to give Mr D more opportunities to mobilise.
34. With these instructions in place, we consider it more likely than not staff would have taken greater and more consistent action during his admission to mobilise him. This means they missed opportunities they otherwise would have taken had they acted in line with guidelines to ensure Mr D mobilised more.
35. We carefully considered what impact this had on Mr D, including the impact Mrs C described. Had staff mobilised him more, we did not find this influenced his pneumonia, or the lack of mobilisation contributed to it worsening and his death.
36. Our physician identified research about the impact of mobilising patients with pneumonia and whether this enhances their survival chances. This includes the Early Mobilisation Study, the Physical Therapy Intervention Trial, and the Chest Physiotherapy Review.
37. We relied on our physician’s interpretation of this research. This is because it contains complex clinical and statistical information. For example, about the results of clinical trials. This also applies to other research studies we have referred to later in paragraphs 62 and 154.
38. Our physician said the Early Mobilisation Study and the Physical Therapy Intervention Trial do not conclude mobilising patients with pneumonia enhances their survival rates. The Early Mobilisation Study and Chest Physiotherapy Review found some limited evidence mobilisation may slightly shorten the hospital stays of patients who survive. However, there is little evidence it improves mortality rates in patients with pneumonia.
39. Having considered this research, our physician said more mobilisation or even chest physiotherapy would not have increased Mr D’s chances of survival.
40. As the above evidence does not suggest further mobilisation would have impacted on Mr D’s pneumonia worsening, we did not see the course of events would have been different had staff acted in line with guidelines. This means we saw no link between the failings we found and the impact Mrs C describes on Mr D, or any other negative impact.
41. We recognise our findings may be difficult for Mrs C to reconcile. We hope they help in bringing her closure about the significance of the Trust’s omissions.
42. We may make recommendations an organisation acts to prevent a recurrence of any failings we see. This includes when we see no impact linked to the failings. We also appreciate Mrs C seeks service improvements, for the benefit of the Trust’s future patients. Therefore, we considered whether the Trust has taken action to avoid repeating the failings we saw.
43. To prevent the same things happening again, our Principles for Remedy say organisations can:
• revise procedures • train or supervise their staff • do any combination of these things.
44. Although recognising the same omissions we have seen, the Trust did not explain any action it took to prevent them happening again during its complaint process. On this basis, we saw there is action it should take to improve on this matter. In paragraph 172, we explain the recommendations we made to the Trust to achieve this.
Monitoring Mr D’s food intake and his dietician referral
45. In her complaint, Mrs C explained Mr D normally had a good appetite. The Trust’s staff did not ask him or his family what was normal for him. When staff saw he did not eat much of his meals, this meant they did not appreciate this was a concerning change.
46. Mrs C said staff did no risk assessment concerning Mr D’s nutrition when they first admitted him to hospital. Had staff done so, and kept reviewing his nutritional intake, they may have detected changes and loss of appetite. She added one of the Trust’s doctors suggested a dietician referral. However, staff did not complete this referral.
47. In its complaint process, the Trust said it expects staff to do assessments regarding a patient’s malnutrition risk within six hours of admitting them to hospital. It acknowledged this did not happen in Mr D’s case, or that staff completed any malnutrition risk assessment.
48. The Trust said its staff recorded limited information about his dietary intake. They initiated no care plan for his poor intake. On 20 April, they had noted he ate little of his lunch. They saw he also only had the dessert of his evening meal after declining the main meals staff offered.
49. On 21 April, noting his poor appetite, a doctor suggested referring Mr D to the Trust’s dieticians for further support. The Trust saw no evidence staff completed this referral or made colleagues at Hospital B, where staff transferred him to later, aware of this need. This fell short of what the Trust expected.
50. We found the Trust did not act in line with guidelines on this issue.
51. Section 1.2 in NICE Guideline 32 says staff should screen hospital patients at the point they admit them for malnutrition and the risk of malnutrition. NICE Guideline 32 recommends staff use the Malnutrition Universal Screening Tool (MUST). Screening should assess:
• the patient’s body mass index (BMI) • whether there has been any unintentional weight loss, how much, and when this happened • whether there has been, or whether it is likely the patient has unintentionally reduced nutrient intake.
52. If this assessment indicates a patient is malnourished or at risk of malnourishment, staff should consider providing nutrition support.
53. Section 1.3 in NICE Guideline 32 sets out the thresholds which define when a patient is malnourished or at risk of this. For example, staff should consider a patient malnourished if they have a BMI of less than 18.5kg/m2. Section 1.4 says staff skilled and trained in nutritional support (dieticians) should prescribe nutritional support.
54. As the Trust acknowledged, and Mr D’s records confirm, staff did not do a malnutrition screening assessment at all during his admission. Our nurse said they would expect staff to do one soon after admitting him to hospital. On this basis, we agree with the Trust’s conclusion staff failed to do this when they should have.
55. Our nurse said, had staff done a malnutrition assessment, this would have provided staff with information on whether they needed to refer Mr D for nutrition support with dieticians. It would also direct them on what action they needed to take, and how often, in monitoring his dietary intake. For example, how often they needed to complete food charts and retake Mr D’s weight.
56. Our nurse added, because staff did no assessment, it did not direct them to take such actions and complete this documentation. We saw Mr D’s records illustrate this because staff did not complete charts about his food intake other than for one 24-hour period from the evening of 22 April to teatime on 23 April.
57. Staff noted concerns about Mr D’s food intake. Therefore, our nurse said staff should have made a dietician referral for nutritional support and completed regular food charts. We saw section 1.3 in NICE Guideline 32 says where a patient has been eating little or nothing staff should take this action.
58. As the Trust recognised in its complaint process, despite concerns about Mr D’s dietary intake, staff failed to make such a referral or complete documentation like this. As NICE Guideline 32 says staff should have taken this action, we agree with the Trust’s conclusions staff did not do what they should have on this matter.
59. This means we can see they missed opportunities to monitor Mr D’s food intake more closely. They also missed the opportunity to provide nutrition support through a dietician referral to try and address his reducing dietary intake.
60. Had staff took these opportunities, our nurse explained Mr D’s nutrition support was likely to consist of dieticians prescribing him supplement drinks. It would also include dietary adaptations to increase his calorie and nutrient intake through fortified foods and additional snacks.
61. Had staff acted in line with guidelines and provided this support, we did not see this was likely to have helped Mr D’s condition or change the outcome for him.
62. Our physician identified the Nutritional Support Evaluation and the Malnourishment Systemic Review. These studies considered whether nutritional support improves the survival chances of hospital patients who are malnourished or at risk of malnourishment.
63. As we highlighted in paragraph 57, Mr D’s records indicate he had reduced food intake. This met criteria from NICE Guideline 32 meaning he was at risk of malnourishment.
64. Our physician said these studies respectively indicate an 18% and 25% decrease in the chances of dying for patients classified as high risk for malnutrition according to their MUST score, if they receive nutritional support relative to those who do not. On this basis, nutritional support may have enhanced Mr D’s survival chances.
65. However, they added this does not take account of his individual circumstances. This would also include the outcome of any dietician referral, and whether Mr D adhered to the dietician’s recommendations. Our physician noted Mr D often declined the main meals staff offered him. A considerable part of benefitting from the dietician referral and the nutritional support they prescribed would have been dependent on him engaging with it.
66. From Mr D’s records, we saw instances of him not taking in food and refusing alternatives to main meals offered by staff. This was around the time the doctor suggested a dietician referral. On 20 April, staff noted he refused alternatives to meals they offered. On 21 April, they noted he continued to have poor oral intake of nutrition.
67. Given the recurring evidence of Mr D refusing nutrition, we consider it more likely than not he would have refused the support our nurse said dieticians were likely to recommend.
68. On this basis, he would not have experienced the benefits our physician described through the nutritional support staff may have provided. This means we did not see the course of events would have been different had staff acted in line with guidelines. For this reason, we could not link the failings we saw to the impact Mrs C describes on Mr D, or any other negative impact.
69. In line with the approach we described in paragraph 42, we considered whether the Trust has taken action to avoid repeating these failings. Having done so, we saw it has acted in line with our Principles for Remedy to improve.
70. Noting the same failings we saw, the Trust explained what it did to improve in its complaint process. It applied to NHS England’s Commissioning for Quality and Innovation Scheme.
71. This is a scheme NHS organisations can apply to. The CQUIN Guidance sets out certain quality indicators and metrics, and what staff need to do to meet them. The scheme aims to drive improvements in the organisations which apply. If the organisation meets certain quality targets, it receives financial rewards from the scheme.
72. One of the quality indicators (CQUIN14), which the Trust explained it started striving for, is around malnutrition screening. To meet the quality standard and potentially achieve rewards, organisations should screen 70% to 90% of patients for malnutrition using a recognised tool like MUST.
73. To work towards achieving this quality indicator, the Trust introduced audits to check staff complete MUST assessments when admitting patients and keep them under review. We appreciate this tool sets out when staff should refer patients to dieticians based on what they see when they review patients. It is also a tool recommended in NICE Guideline 32.
74. So, the Trust has introduced procedures to try and prevent the same oversights in Mr D’s care happening again. That is, audits to check compliance with assessing and monitoring dietary intake. The audits check actions staff should take like referring patients to dieticians when they see poor dietary intake. We saw how this may reduce the chance of staff repeating the failings we found in Mr D’s nutritional support.
75. As this is in line with actions explained in our Principles for Remedy, there is nothing more we would expect the Trust to do.
76. We recognise Mrs C, understandably, is concerned about the lack of nutrition support staff gave Mr D. We hope our findings help bring her closure about what influence these omissions had on his death. We hope the Trust’s later actions assure her it has learnt lessons from what happened and taken steps to improve.
Monitoring general signs of deterioration
77. In her complaint to us, Mrs C referred to the Trust’s Physiological Observations Policy. She said this policy emphasises the need for staff to recognise the ‘soft signs’ of deterioration in a patient.
78. She said staff poorly considered Mr D’s normal appetite levels, ability to feed himself, his energy levels, and his continence. She said staff assumed low function in these factors were his norm, when in fact they were recent developments. Had staff asked about his history, this may have helped staff appreciate these changes, which she also felt staff should have seen through observing change alone.
79. She considered this would have added to the other signs of deterioration which became evident later. For example, Mr D’s deteriorating National Early Warning Scores (NEWS). As staff did not monitor general signs of deterioration, Mrs C considers they missed opportunities to detect deterioration and act on it earlier.
80. In its complaint process, the Trust said Mr D’s records show no evidence he received or required assistance from staff to eat. That said, staff did notice he had a poor appetite by 21 April. For this reason, one of the Trust’s doctors recommended referring him to the Trust’s dieticians. However, the Trust acknowledged nursing staff did not do this.
81. It added staff recorded instances of faecal and urinary incontinence. However, staff did not discuss whether this was a new or existing condition for him. Staff likely believed this was an ongoing issue because he was wearing his own absorbent pads. The Trust said staff should have discussed this with Mr D. They did not demonstrate appropriate professional curiosity about his continence.
82. We found the Trust did not act in line with guidelines on this issue.
83. Section 13.1 of the NMC Code says, in preserving patient safety, nursing staff should observe and assess signs of normal or worsening physical and mental health in patients under their care. Our nurse explained this can include whether the patient has:
• worse than normal lethargy or withdrawal • worsening anxiety, agitation, apprehension, or whether they are just not themselves • gone off their food, lost their appetite, or reduced their fluid intake • reduced levels of urinary continence, new diarrhoea, vomiting, or dehydration • become less mobile or coordinated • suddenly found their regular medications more or less effective • raised concerns themselves, or their family or catering staff think they are less well than normal.
84. The Trust’s Physiological Observation Policy also lists factors like the above, that its staff should look out for. This may help staff in spotting deterioration before clinical assessments reveal such changes.
85. Section 2 in the NMC Code says nursing staff must:
• work in partnership with people to make sure they deliver care effectively • recognise and respect the contribution people can make to their own health and wellbeing.
86. We saw the Trust said Mr D demonstrated factors from the list in paragraph 83. Despite this, staff did not assess whether these were new or existing issues and consider their significance further. On this basis, we agree with the conclusions we explained the Trust made in paragraph 81.
87. Despite documenting Mr D became doubly incontinent and stopped taking on food himself, our nurse said staff showed little concern about this. They would have expected nursing staff to consider whether this evidence was a sign of deterioration, including asking Mr D or his family about his normal continence and appetite.
88. Given the changes they saw from his records, our nurse would have expected nursing staff to escalate this to senior medical colleagues in a timely manner. We note sections 13.2 and 13.3 in the NMC Code says nurses should act like this in response to such changes.
89. As the evidence shows they did not do so, we found staff did not monitor and act on Mr D’s ‘soft signs’ of deterioration in line with the guidelines we have referred to.
90. We explain the impact this had from paragraph 142. It is important to explain our findings on whether staff got things wrong on the next two issues Mrs C raises first.
Frequency of physical observations
91. In her complaint, Mrs C told us the Trust’s Physiological Observations Policy explained how often its staff should monitor and record a patient’s NEWS. If staff begin to record higher NEWS, she said staff need to increase the frequency of their observations.
92. She cited examples where she considered staff did not monitor and record Mr D’s NEWS as frequently as they should. All these instances occurred during his stay at Hospital B.
93. In its complaint process, the Trust said its policy instructed its staff to observe and record a patient’s NEWS twice daily 12 hours apart. Depending on the NEWS staff record, staff need to increase the frequency in which they record NEWS. While Mr D was at Hospital A, the Trust said staff performed these observations in line with its policy.
94. The Trust acknowledged staff at Hospital B did not act in line with its policy following Mr D’s transfer there. It recognised there were instances when staff did not repeat NEWS within the timescales its policy indicates.
95. To explain, NEWS is a tool staff use to assess a patient's breathing rate, oxygen saturation level, blood pressure, heart rate, level of consciousness, and temperature. Staff give each parameter a score between zero and three. A score of zero means the parameter is normal. Higher scores indicate the patient is more unwell.
96. Staff add up scores for each parameter to give a total score. They should add two to this score if they need to give a patient supplemental oxygen. A higher overall score means the patient is more unwell and at a higher risk of deterioration.
97. We found the Trust did not act in line with guidelines on this issue.
98. We appreciate the Trust said it did not act in line with its policy. That said, the Trust’s Physiological Observations Policy is not in line with relevant national guidelines about observing patients. That is, the NEWS Guidance. As our nurse said this guideline is relevant, and it is a national policy, we considered whether staff acted in line with the NEWS Guidance.
99. Regarding the frequency in which staff should do observations and record NEWS again following the previous result, the NEWS Guidance says staff do so:
• every 12 hours if they record NEWS of zero • every four to six hours if they record NEWS of one to four • every hour if they record NEWS of five or more • continuously if they record NEWS of seven or more.
100. The Trust’s Physiological Observations Policy sets out different frequencies to the NEWS Guidance in which staff should repeat observations based on previously recorded NEWS.
101. While Mr D was at Hospital B from 22 April, staff did not always adhere to the requirements from the NEWS Guidance. The timings we set out below in staff doing observations show why.
102. At 9.30am, Mr D’s NEWS charts show staff recorded NEWS of one. Staff continued to record NEWS of one throughout the day. They did not record these observations every six hours as they should have. After 9.30am, staff next recorded NEWS at 5.30pm.
103. When staff next recorded NEWS, at 7.15pm, they recorded NEWS of five. Staff did not check this again within an hour. They next recorded NEWS at 3.10am on 23 April, again recording NEWS of five. They did check this again ten minutes later, and recorded Mr D’s NEWS lowered to three.
104. Around 6am, staff recorded NEWS of seven. They did other observations around the time, and his NEWS lowered to three. At 7.50am, staff recorded NEWS of four.
105. At 1.10pm, staff recorded NEWS of six. They recorded NEWS of five at 3pm and 4.15pm. At 4.30pm they recorded NEWS of four. Staff did their next check at 7.59pm, recording NEWS of five. The next time they recorded NEWS was at 12.40am on 24 April. Staff recorded NEWS of 12. At this point, paramedics had arrived, just prior to transferring Mr D to Hospital C.
106. We explain our findings about the impact of staff not adhering to the NEWS Guidance from paragraph 142. It is important to first explain our findings on whether staff got things wrong regarding the decisions they made against escalating Mr D’s care.
Decisions on escalating Mr D’s care
107. In her complaint, Mrs C told us staff decided against a transfer for Mr D early in the morning on 23 April. She said his NEWS, including low blood pressure, indicated sepsis risk and severe myelodysplasia. These were reasons to escalate his care at the time.
108. She noted the Trust told her Mr D declined a transfer later in the day. She questioned whether staff gave him enough information to appreciate the severity of his condition and his need for a transfer. Unless they gave such information, she said he was unlikely to be keen on a transfer. Staff had already transferred him between hospitals the day before.
109. She said there were reasons, which staff may not have explained to Mr D, which justified a transfer to an acute care setting at the time. Therefore, staff should have decided to escalate his care to this type of setting, and they failed to.
110. In its complaint process, the Trust said its staff escalated the concerns they had based on Mr D’s NEWS the morning of 23 April. Staff sought a clinical review for him by calling the Ambulance Service and asking paramedics to see Mr D.
111. The Ambulance Service’s staff then assessed him. These staff decided whether to transfer him to an acute care setting. The Trust obtained comments from the Ambulance Service during its complaint process to respond on this matter.
112. The Ambulance Service said its paramedics obtained a clinical history about Mr D since his attendance at the ED on 17 April. They considered the blood pressure issues the Trust’s staff recorded earlier, in Mr D’s NEWS, had resolved when they checked it. They considered there were no signs indicating the presence of severe illness like sepsis.
113. As he was a patient being supported in a community hospital ward, they decided he did not need a transfer to a more acute care setting. The Ambulance Service considered this was an appropriate decision.
114. Later in the Trust’s response, it said Mr D deteriorated and became clinically unwell later. On this basis, its staff considered he needed a transfer at that time. Staff called the Ambulance Service and paramedics attended again. Paramedics then transferred him to an acute care setting, at Hospital C, to escalate his treatment given his deterioration.
115. Regarding the decision the Ambulance Service’s staff made, we found they reached it in line with relevant national guidelines. We explain this first, before considering the Trust’s later decisions about transferring Mr D after paramedics left.
116. The JRCALC Guidelines say, in assessing a patient, paramedic staff should:
• obtain their history • pay particular attention to concerns expressed by the patient, family, or carers • consider potential infection causes.
117. Staff should also take NEWS observations and record an overall score. A score equal to or greater than five highlights a sick patient who needs urgent clinical review. Staff should consider the NEWS Guidance. The JRCALC Guidelines say NEWS scores do not represent a diagnosis, only a patient at risk. Having taken observations, paramedics should use their own judgement about what to do based on them.
118. The Ambulance Service’s records show its paramedics obtained a history about Mr D. They noted how he came to be a patient at the Trust. This followed his fall at home, visit to and discharge from the ED. They noted the purpose of his admission at the Trust, which was for rehabilitation following his fall. They noted he was receiving medication for a urinary tract infection too.
119. They recorded more recent events. That was, the Trust’s staff called the Ambulance Service because Mr D had low blood pressure. In the 999 call, staff said they had given him intravenous (IV) fluids, but these fluids made no difference to his blood pressure.
120. As part of their review, paramedics spoke to the staff at the Trust providing his care at the time. They reviewed the records the Trust’s staff made too.
121. Through this process, they established the Trust had not in fact given Mr D IV fluids, only oral ones. They noted his blood pressure was not as low as the Trust’s staff reported in the call. They saw one low blood pressure reading. His other readings were higher. Paramedics then performed their own examinations on Mr D, including recording his NEWS.
122. At the time the Trust’s staff called 999 around 6am, they recorded NEWS of seven. Based on the observations the Ambulance Service’s paramedics recorded when they arrived later, they recorded his NEWS were five.
123. Considering the above, we saw paramedics gathered the information the JRCALC Guidelines recommend in assessing a patient. Our paramedic also said their assessment was in line with what they would expect to see. On this basis, we found the Ambulance Service’s staff assessed Mr D in line with guidelines.
124. The NEWS Guidance says where a patient has NEWS of seven or more, this meets the threshold for an emergency response. In these circumstances, staff should consider transferring a patient’s care to a higher-dependency care facility containing staff with critical care competencies.
125. Had the Ambulance Service’s assessment indicated Mr D met this criteria, our paramedic would have expected to see an immediate transfer. That is, to a hospital with higher-dependency facilities like Hospital C. However, this was not the case when paramedics assessed him.
126. The NEWS Guidance says where a patient has NEWS of five or six, staff should ensure the patient goes to a clinical care setting with monitoring facilities. The setting should have clinicians with competencies to care for acutely ill patients.
127. Paramedics enquired about actions the Trust would take to monitor Mr D and the staffing it had in place for the day ahead. They noted the Trust’s staff confirmed they had a GP in the unit.
128. We appreciate our paramedic said the Ambulance Service’s paramedics might still have advised on a transfer for Mr D. However, as we explained in paragraph 117, paramedics should use their own judgement on what to do in such situations based on their assessment.
129. Through their enquiries, we saw paramedics were able to satisfy themselves a GP was present. Our paramedic noted this was a suitable type of senior clinician. As Mr D was in a hospital, it had monitoring facilities too.
130. So, based on their assessments, the Ambulance Service’s staff established the care setting requirements set out in the NEWS Guidance for a patient scoring NEWS of five was in place at the Trust. Considering this, they decided Mr D could remain at the Trust and they did not transfer him.
131. As paramedics reached this decision in the way the JRCALC Guidance recommends, and he was in a care setting the NEWS Guidance says is sufficient, we saw no failing in the Ambulance Service deciding against a transfer.
132. After the Ambulance Service’s staff left, we saw the Trust’s staff acted in line with guidelines regarding decisions they made not to transfer Mr D to an acute care setting.
133. One of the Trust’s specialist nurse practitioners reviewed Mr D during the morning of 23 April. One of its GPs reviewed him twice during the afternoon. Their last review took place at 4.39pm.
134. During this period, his NEWS fluctuated between four and six. His low blood pressure contributed to his scores.
135. In the GP’s reviews, Mr D’s records show they discussed his blood pressure with him, and his wishes in respect to any potential escalation in his care. They agreed Mr D wanted escalation in his care if needed.
136. The GP noted his blood pressure was low, but this was usual for him. The GP planned fluids to try and improve this, while also withholding diuretic medications he normally took. Mr D did not want any escalation in his care at that point, and to try the fluids. He was also already taking antibiotics staff had prescribed him to manage signs of a chest infection they had seen.
137. Our GP adviser said this was a suitable plan in the circumstances to try and address these issues. According to his NEWS, our GP adviser also said he was in an appropriate setting and assessed by suitable clinicians. As we noted in paragraph 129, the Trust’s hospital had the monitoring facilities and type of staff the NEWS Guidance recommends based on Mr D’s NEWS at these times.
138. The NEWS Guidance also says, based on scoring NEWS of five and six, staff needed to keep monitoring his NEWS hourly. As part of their plan and decision, the GP instructed nursing staff to monitor his NEWS hourly before finishing their shift. They explained colleagues should consider escalating to an acute care facility if later scores raised concerns.
139. As all the above was in line with the guidance we refer to, and our GP adviser saw evidence to support the plan staff made, we saw no faults in their decision not to transfer Mr D. This means we found no failing in the active decisions staff made not to escalate his care to an acute care setting.
140. The issue was that after the GP’s review at 4.39pm, staff did not do the monitoring they instructed. We go on to explore the impact of this, which ties in with the failings we explained in paragraphs 77 to 106, in the next section of our report.
141. We recognise Mrs C is concerned about decisions staff made against transferring Mr D. We hope our findings go some way in providing her closure on this matter, and they assure her we gave this issue careful consideration.
The impact of the failings we found in paragraphs 77 to 106, and whether the Trust has addressed this
142. We considered the impact of the failings we found on these matters together. Mrs C says they led to the same impact. That is, firstly, these omissions meant staff missed opportunities to identify deterioration and escalate Mr D’s care to an acute care setting earlier for treatment.
143. Prior to the evening of 23 April, had staff acted in line with guidelines regarding these tasks, we did not see this would have changed the course of events.
144. During his admission at the Trust, our GP adviser said Mr D’s records indicated the trajectory of his illness worsened over time. This was despite the fluctuation in his NEWS. We saw staff consistently recorded NEWS between zero and two prior to 22 April. After that, they recorded higher scores of five amongst lower scores down to one. That was until 6am on 23 April, when they recorded seven.
145. Had staff done more monitoring, our GP adviser said staff may have recorded a score of seven slightly earlier than they did on 23 April. Had this happened, they said this was likely to trigger a similar response to those we have already explained. That is, in calling for paramedics to assess him, or the Trust’s GPs during the day shift. As Mr D had these assessments later anyway, our GP said it is unlikely earlier assessments like this would have resulted in a different outcome.
146. So, we did not see these omissions meant staff missed opportunities to escalate Mr D’s care up to and including the afternoon of 23 April. As we explained in paragraphs 107 to 141, staff made decisions not to transfer him and escalate his care in line with guidelines up to this point.
147. After the GP’s review at 4.39pm and instructions for nurses to check Mr D’s NEWS hourly, we found staff missed an opportunity to escalate his care earlier because they did not monitor him frequently enough.
148. Nursing staff only recorded NEWS at 7.59pm (score five) prior to doing them again at 12.40am on 24 April, when they recorded NEWS of 12. Our GP adviser said, had staff checked his NEWS hourly, they likely would have recorded a score triggering an urgent review (seven or more) where they called an ambulance. They added this was likely to have resulted in staff transferring him to Hospital C sooner.
149. Given Mr D’s NEWS rose to 12 by 12.40am, we consider it likely staff may have found rising NEWS above seven in the almost five-hour period since his previous observations, based on the trajectory of his illness described by our GP adviser. This supports what our GP adviser said that monitoring in line with the NEWS Guidance likely would have enabled staff to transfer his care a few hours earlier.
150. We consider these omissions resulted in a delay in the Trust’s staff escalating his care to an acute care setting. This appears to be up to around three hours.
151. The Ambulance Service’s records show the Trust’s staff called 999 at 10.41pm on 23 April about escalation in Mr D’s care. The Trust’s records show staff did this because of concerns they had about him becoming unresponsive. This happened before the next NEWS they recorded around two hours later, which, based on the score, required an emergency review and consideration of a transfer to an acute care setting.
152. Regarding the impact of the delay on Mr D’s survival chances, we did not find this meant he lost the chance to have treatment earlier that may have saved or prolonged his life.
153. Our physician said Mr D was in septic shock at the time of the delay. This happened in response to his infection. Sepsis is a life-threatening condition which damages vital organs and leads to organ failure.
154. Our physician said administering antibiotics at an early stage to a patient with sepsis improves survival rates. They explained the Septic Shock Study estimates, following the onset of low blood pressure associated with the condition, a patient is 7.6% more likely to die with every one-hour delay in giving antibiotics after this point. They added this conclusion is based on a patient having not received antibiotics before staff diagnose them with sepsis.
155. They said Mr D’s circumstances were different. The Trust’s staff had already been giving him broadspectrum antibiotics (co-amoxiclav) for two days. This is the typical antibiotic hospital staff would give a patient if they arrived with an initial diagnosis of sepsis or infection.
156. By the afternoon of 23 April, Mr D was unwell and deteriorating despite receiving antibiotics. Our physician said this indicated his survival chances were already compromised given his lack of response to initial antibiotic treatment.
157. Consequently, identifying an effective antibiotic and other treatment options he would respond to posed a significant challenge to any staff treating him. This would have been the case without the delay, even had staff at Hospital C seen him around three hours earlier.
158. When he did arrive at Hospital C, our physician said staff tried different antibiotics (Tazocin). Mr D did not respond positively. We can see this reflected in his records. On this basis, our physician said it is difficult to assert with any certainty he would have responded positively had he received alternative antibiotics a few hours earlier.
159. Weighing this advice and evidence, we consider escalating his care around three hours earlier is unlikely to have made a difference regarding his survival. This is a relatively brief period in which hospital staff may have given him an alternative antibiotic he showed no response to when they did provide this treatment. Despite this treatment, Mr D still died soon after.
160. On this basis, we did not find the course of events would have been different had staff acted in line with guidelines on this matter. For this reason, we could not link the failings we found to the impact Mrs C describes on Mr D, or any other negative impact.
161. Like we have on the previous issues, we considered whether the Trust has taken action to avoid repeating these failings. Having done so, we saw it has acted in line with our Principles for Remedy to improve.
162. In paragraphs 69 to 76, we already explained the improvements the Trust made around considering poor appetite and arranging nutrition support for patients.
163. Regarding other ‘soft signs’ of deterioration, the Trust explained its clinical team lead acted on this with staff. In emails, team meetings, and individual discussions with staff, they reminded them of the importance of asking further questions on factors like low levels of continence and documenting this. This was with a view of staff gathering information on a patient’s normal level of function to assess for any deterioration.
164. We also saw the Trust asked senior nurses to complete audits to assess whether staff were adhering to these standards of care. As these are forms of training and procedures to help staff improve on this matter, this action is in line with our Principles for Remedy.
165. Regarding the frequency in which staff do physical observations, the Trust’s clinical team lead reminded staff of the importance of doing observations in line with the Trust’s Physiological Observations Policy.
166. They introduced monthly audits to check whether staff recorded NEWS at the frequency the policy says they should. The Trust also introduced the BRIGID app in its care areas. This is a system where staff can record NEWS on electronic devices. The app will prompt staff on when they need to escalate care and repeat observations based on the latest NEWS they input.
167. We consider these training, procedural, and resourcing measures will help staff to take patient observations and consider escalating their care when they should. In particular, the electronic prompts staff now receive are failsafe measures which were not in place during Mr D’s care. Therefore, we consider the measures make it less likely staff will make the same omissions which they did in his care.
168. We recognise we explained the Trust’s Physiological Observations Policy does not align with the NEWS Guidance. However, it directs staff to repeat NEWS observations more frequently than the NEWS Guidance. This means, by implementing the above measures based on its own policy, the Trust now goes beyond the expected level of care set out in national guidelines.
169. Considering all the above, the Trust has taken training and procedural actions that reduce the chance of staff failing to observe patients as frequently as they should. As this is improvement action in line with our Principles for Remedy, we did not see further action we would expect the Trust to take.
170. We recognise why Mrs C has concerns the Trust’s lack of monitoring explains Mr D’s death. We hope our findings help provide her closure on the significance of the Trust’s omissions in respect to his death.
171. We appreciate an important goal in raising her complaint is for the Trust to improve. We hope our explanations help assure her the Trust has made improvements, and how they may prevent staff repeating the same mistakes. We also hope the recommendations we explain below assure her the Trust can learn further lessons and improve.