Sandwell and West Birmingham Hospitals NHS Trust (P-001015)

  • 1.	Our decision is that we uphold this complaint. We have found some aspects of care and treatment the Trust provided were in line with the relevant guidance. However, we have found the Trust should have assessed the risk of Mrs B developing delirium, observed Mrs B every four hours and provided 1 to 1 care for her whilst on ward D26. We have also found the Trust’s complaint handling was maladministrative.
    
    2.	The evidence suggests that despite a risk assessment not being done, the Trust treated Mrs B’s delirium appropriately in line with applicable guidance and a risk assessment would not have altered her management. 
    
    3.	Had the Trust observed Mrs B as frequently as it should have, it is possible, though we cannot say likely, her decline would have been noticed. However, had 1 to 1 care been provided as it should have, it is likely Mrs B’s cardiac arrest would have been observed within one or two minutes. If this had happened, we consider it likely Mrs B would have been resuscitated without suffering the irreversible brain damage that led to her death. We have therefore concluded it is more likely than not that the failings we have identified led to her death. Given the severity of this apparent injustice we uphold Mrs A’s complaint.
    
    4.	Finally, we found that there were failings in complaint handling that led to Mrs A not fully understanding what happened to her mother and questioning for over three years whether any other treatment could have been provided which would have led to a different outcome. 
    
  • 5.	Mrs A complains about aspects of the care and treatment provided to her late mother, Mrs B, by Sandwell and West Birmingham Hospitals NHS Trust (the Trust) in March 2016. Specifically, she complains about: 
    •	the lack of understanding and subsequent care about her mother’s mental health issues
    •	the use of CPAP hood as this caused agitation (CPAP – a machine which applies mild air pressure on a continuous basis to keep the airways open)
    •	the failure to ensure her mother’s medication was administered as soon as possible which led to Trust staff using sedation to keep her manageable
    •	the fact that her mother was moved from the intensive care unit (ICU) to a ward too soon
    •	the lack of mouth care when her mother was sedated, and the lack of dignity shown to her mother
    •	the fact that her mother was not provided with focused (1 to 1) care on the ward
    •	the fact that the staff did not notice her mother had a cardiac arrest for 15 minutes which led to her developing brain damage
    •	the fact that end of life care was not put in place or discussed with the family
    •	the lack of communication with the family whilst on the ward. 
    
    6.	Mrs A questions whether the shock from the lack of regular medication and the new sedative caused Mrs B’s cardiac arrest and subsequent death, and she believes if better care and treatment had been provided then her mother’s death could have been avoided. Mrs A says the family have been left emotionally distraught by the sudden death and they are struggling to cope with their loss as no one can explain why her mother had a cardiac arrest. 
    
    7.	Mrs A also complains about the way in which the Trust handled her complaint. She complains the Trust took too long to respond to her complaint and the response did not adequately address all her concerns. Mrs A says this caused her additional distress and frustration at a time when she was grieving. 
    
    8.	As an outcome to her complaint, Mrs A would like an acknowledgement of failings and an apology, a financial remedy and service improvements.
    
  • 9.	Mrs B attended the accident and emergency (A&E) department at City Hospital (part of the Trust) via ambulance on 8 March 2016. She had been experiencing shortness of breath for a few days previously. The doctors arranged a chest X-ray which confirmed the diagnosis of inflammation of the lungs. 
    
    10.	The doctors admitted Mrs B to ICU and prescribed antibiotics and CPAP. 
    
    11.	By 17 March Mrs B’s respiratory state had much improved, and the ICU consultants had successfully weaned her off medicines for respiratory support to enable her to breathe by herself and maintain her oxygen levels. Therefore, the ICU consultants considered Mrs B to be medically stable on 17 March and discharged her from the ICU to ward D26. 
    
    12.	On 19 March Mrs B suffered a cardiac arrest. The doctors successfully resuscitated her and transferred her back to the ICU. The doctors arranged an electroencephalogram (EEG – an electrical brain wave test) which showed severe hypoxic encephalopathy (irreversible brain damage). A neurology assessment also confirmed a vegetative state and that recovery was unlikely. The ICU consultant decided to withdraw critical care support. Mrs B died on 23 March 2016 at 11pm. The cause of death was recorded as severe hypoxic brain injury and cardio-respiratory arrest. 
    
    Mrs A’s complaint to the Trust 
    
    13.	Mrs A made her initial complaint to the Trust on 6 July 2016. The Trust arranged a meeting with Mrs A to discuss the complaint which took place on 22 November 2016. The Trust sent Mrs A a CD recording of the meeting thereafter. 
    
    14.	Mrs A approached us in March 2017 as she was unhappy with the response she had received from the Trust. However, as the Trust had not given Mrs A a full written response, we wrote to the Trust in June 2017 asking it to provide this. 
    
    15.	The Trust provided Mrs A with its written response on 26 July 2018. The Trust also wrote to Mrs A on 4 October 2018 to apologise for the way in which it handled her complaint, especially the time it took it provide the response. The Trust again wrote to Mrs A on 3 December 2018 with a cheque for £150 to compensate her for its handling of her complaint. 
    
    16.	Mrs A also wrote to the Chief Executive on 9 April 2018 requesting a face to face meeting with him. She contacted the Trust again to chase this meeting in August 2018 and then in November 2018. This Trust did not arrange this meeting or provide an explanation to Mrs A as to why this did not occur. 
    
    17.	Mrs A was still unhappy with the response from the Trust and brought her complaint to us in December 2018.
    
  • 18.	We use related or relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. We have considered evidence from Mrs A, and the Trust. This includes Mrs B’s relevant medical records from the Trust. We also reviewed the complaints correspondence. 
     
    19.	In this case, we have taken advice from a physician with over 30 years’ experience in acute and general internal medicine, and a nurse with a breadth of experience in primary and acute care settings. Where written standards do not exist, our advisers have confirmed this is the case and outlined what would be good clinical care and treatment (the Ombudsman’s clinical standard). 
     
    20.	The General Medical Council (the GMC) published ‘Good Medical Practice’ in 2013. It says good clinical care must include carrying out adequate assessments, which include taking account of the patient’s history and examining them if necessary. It also includes providing or arranging investigations or treatment if needed and referring a patient to another practitioner when this is in their best interests. 
     
    21.	In 2015 the Nursing and Midwifery Council (the NMC) published ‘The code: standards of professional conduct and behaviour for nurses and midwives’ (the NMC Code). This says nurses must treat patients as individuals and uphold their dignity. To do this they have to treat people with kindness, respect and compassion. Nurses should deliver the fundamentals of care effectively. Nurses must also keep clear and accurate records. They should complete records as soon as possible after the event. 
     
    22.	We also considered the following guidance: 
    
    •	National Institute of Health and Care Excellence (NICE) ‘Violence and aggression: short-term management in mental health, health and community settings’ (2015) 
    
    •	Royal College of Physicians ‘National Early Warning Score (NEWS) Standardising the assessment of acute illness severity in the NHS’ (2012) 
    
    •	NICE ‘Delirium: prevention, diagnosis and management’ (2010) 
    
    •	British Thoracic Society (BTS) Guideline for the use of non-invasive ventilation in acute respiratory failure (2002) 
    
    •	NICE ‘Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes’ (2015) 
    
    •	Resuscitation Council UK ‘Adult basic life support and automated external defibrillation’ (2015)
    
    •	Resuscitation Council UK ‘In-hospital resuscitation’ (2015) 
    
    •	Resuscitation Council UK ‘Quality standards for cardiopulmonary resuscitation practice and training’ (2013)
    
    •	Survey of 3765 cardiopulmonary resuscitations in British Hospitals (the BRESUS study) – Tunstall-Pedoe, H; BMJ 1992 (304) 1347-51
    
    •	Cardiac Arrest and cardiopulmonary outcomes reports: Jacobs, I et al; Resuscitation (2004) 233-249 
    
    •	Management of Brain Injury after Resuscitation from Cardiac Arrest, Geocadin RG et al; Neurol. Clin 2008, Vol 26(2)
    
    •	Brain injury and Cardiac Arrest, Geocadin, R.G; Neurol. Clin 2006; Vol 24, pages 369-459
    
    •	NICE ‘Care of dying adults in the last days of life’ (2015) 
    
    •	The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009
    
    •	PHSO’s Principles of Good Complaint Handling.
    
  • Treatment for mental health issues
    
    23.	Mrs A complains there was a lack of understanding and subsequent care about her mother’s mental health issues during this admission. She said the doctors should have completed a risk assessment due to her mother suffering bipolar disorder. She also complains the Trust applied for a deprivation of liberty (DoL) order for her mother. 
    
    24.	When Mrs B attended the Trust on 8 March she was suffering with acute breathlessness. This was due to flu causing severe inflammation of the lung tissue affecting both her lungs. This in turn caused impaired oxygen absorption which caused respiratory failure. The low oxygen levels (hypoxia) caused Mrs B to be confused and agitated. 
    
    25.	Our physician adviser said this is a severe illness and the doctors carefully monitored Mrs B whilst on the ICU and provided appropriate treatment for her respiratory failure. 
    
    26.	Mrs B had long-standing mental illness with known bipolar disorder or schizo-affective disorder. The records reflect that the staff were aware of this. Despite being stable prior to admission, acute physical illness with infections can trigger acute confused states (delirium), especially within intensive care units. This is well recognised in the NICE guidelines for delirium. 
    
    27.	The NICE guidelines state healthcare professionals should assess the risk of delirium in patients who have a cognitive impairment and who are experiencing a severe illness. The guidelines recommend, in order to try and prevent delirium, doctors should avoid moving people between wards or rooms unless necessary, facilitate regular visits from family, and treat the underlying severe illness. 
    
    28.	We have not seen any evidence that the doctors did a formal risk assessment in Mrs B’s case. This is not in line with the NICE guidelines, and we find this to be a failing. 
    
    29.	However, the doctors did comply with the recommendations in the NICE guidelines, by moving Mrs B only when necessary, facilitating visits from family and treating the infection. Despite this, Mrs B developed hyperactive delirium whilst on the ICU on 11 March. This is delirium which causes a person to become abnormally alert, restless or agitated and even aggressive.
    
    30.	Our physician adviser said the doctors treated the delirium appropriately with haloperidol (anti-psychotic medicine recommended in the NICE guidelines) and diazepam (used to treat anxiety). The doctors also continued to treat the underlying infection with antibiotics.  
    
    31.	During the admission, the ICU doctors also sought advice from a psychiatric specialist and a consultant psychiatrist saw Mrs B on 11 March and gave specific therapeutic advice. This included stopping her previous treatment (duloxetine – an antidepressant, and modecate injections – antipsychotic medication) and substituting other medicine which are more effective for managing delirium. What happened is in line with the GMC guidelines to refer a patient to another practitioner when this serves the patient’s needs. 
    
    32.	The psychiatric specialist team continued to review the management of Mrs B’s mental health during her admission. By 17 March Mrs B’s respiratory state had much improved, and the doctors moved her from the ICU. Our physician adviser said this was also important for managing her delirium and in line with NICE recommendations.   
    
    33.	We have seen no evidence to suggest the staff did not understand Mrs B’s mental health condition during this admission. We have seen the staff were aware of her diagnosis from admission and we find the doctors and ICU staff managed this appropriately. The staff also appropriately sought specialist psychiatric advice throughout her admission. 
    
    34.	We have not seen evidence doctors conducted a specific risk assessment of the possibility of Mrs B developing delirium. But the team was aware of her mental health condition, and the main concern at admission was her severe physical illness. We find once Mrs B developed confusion and aggressive behaviour, her mental health state was correctly managed. As such, our physician adviser said, earlier risk assessment would not have altered Mrs B’s management. 
    
    35.	A deprivation of liberty (DoL) order is used in situations where it is necessary to deprive of someone of their liberty in order to keep them safe from harm when they lack capacity to consent to their care and treatment. Any form of restraint is an assault, and if required in a patient’s best interests, then a Trust can apply for a DoL order. This order allows staff to introduce measures to restrain the patient. 
    
    36.	In its complaint response, the Trust said Mrs B required cosy mitts, and it cannot use cosy mitts without a DoL order being in place. Cosy mitts are soft mittens, like boxing gloves, which cover the hands and prevent patients from pulling out any lines or tubes that are used to give them medication, fluids or nutrition. Our physician adviser said during the admission, Mrs B required the use of mittens to prevent her from pulling out her intravenous cannula (which was delivering her medication), naso-gastric tube (for food), urinary catheter, and the oxygen masks. All these measures were crucial to her condition improving. 
    
    37.	Therefore, as Mrs B required the use of the cosy mitts to aid her recovery, and the Trust could only use the cosy mitts with a DoL order, we find it was appropriate for the Trust to have applied for the DoL order. 
    
    The use of CPAP hood 
    
    38.	Mrs A complains the use of the CPAP hood was inappropriate as this caused her mother agitation.
    
    39.	When she was admitted to hospital, Mrs B was in hypoxic respiratory failure. As a result, she required high flow 60% oxygen to maintain blood oxygen within normal parameters. Our physician adviser said it is clear from the records that two consultants carefully considered the use of CPAP during her first day in hospital. 
    
    40.	When Mrs B’s oxygen levels fell and she was breathing rapidly (45 breaths per minute) and at risk of exhaustion, the consultants decided to transfer her to the ICU and start using CPAP. Our physician adviser said this decision was appropriate and in line with the BTS guidelines on non-invasive ventilation. It also prevented the need for an invasive ventilator (respiratory support delivered through a tube placed down the throat or through an opening created at the front of the neck).  
    
    41.	We have seen no evidence in the records that the use of CPAP caused Mrs B’s agitation and confusion. Our physician adviser said hypoxia, infection and nicotine withdrawal were more likely reasons for the agitation and onset of delirium. 
    
    42.	Subsequent attempts by the doctors to remove the hood resulted in Mrs B’s oxygen levels falling significantly and she started to breathe more rapidly. Therefore, we find the use of CPAP hood was appropriate and have seen no evidence that this specifically caused her agitation. 
    
    Medication and sedation 
    
    43.	Mrs A complains the staff failed to administer her mother’s usual psychiatric medication as soon as possible following admission which led to them having to use sedation to keep her manageable. 
    
    44.	In its complaint response the Trust said it needed to sedate Mrs B in order to manage her safely whilst she was agitated. The Trust said this was to ensure Mrs B’s safety.
    
    45.	Following her admission to the Trust, the doctors noted Mrs B’s usual medication. This included modecate injections (to treat schizophrenia) duloxetine (an antidepressant), pregabalin (used to treat epilepsy and anxiety), procyclidine (used to relieve unwanted side effects caused by antipsychotics), and amitriptyline (used to treat bipolar disorder). Mrs B was also taking amlodipine and losartan to treat high blood pressure. 
    
    46.	The NICE guidance on medicine optimisation states within 24 hours after admission to hospital, doctors must compile a list of the patient’s regular medication. This list should include the name, dosage, frequency and route of administration. We have seen from the records the doctors did compile a list of Mrs B’s usual medication shortly after she was admitted. 
    
    47.	Our physician adviser said Mrs B’s former medications were multiple, and the doctors had to omit some of these medications due to her clinical situation. He said respiratory failure is a very serious situation and the doctors appropriately reviewed and recorded all Mrs B’s medication with a pharmacist. 
    
    48.	Her regular monthly anti-psychotic medicine (modecate given by intramuscular injection) was due, but our physician adviser said it was not as urgent as her physical condition on admission. When she became delirious, our physician adviser said the doctors gave her haloperidol which was the correct, immediate treatment for acute confusion as recommended in the NICE guidance for delirium. Subsequent advice from a consultant psychiatrist tailored her treatment to the most appropriate regime. 
    
    49.	As such, we find the doctors correctly managed Mrs B’s medication for her medical and psychiatric conditions throughout her admission. As we have stated above, the hypoxia, infection and nicotine withdrawal were more likely reasons for the agitation and onset of delirium. 
    
    Transfer from the ICU 
    
    50.	Mrs A complains the ICU discharged her mother to a ward too soon. She said the family raised concerns that Mrs B was not well enough at the time, but the doctors transferred her anyway. 
    
    51.	Intensive care is needed if someone is seriously ill and requires intensive treatment and close monitoring. Most people in an ICU have problems with one or more organs (for example, they may be unable to breathe on their own). However, once a person no longer needs intensive care, they should be transferred to a different ward to continue their recovery before eventually going home.
    
    52.	When Mrs B first went to the ICU, she was on 60% oxygen and CPAP. She was in the ICU for respiratory support and close clinical care. By the time the ICU discharged her, our physician adviser said she had significantly improved and no longer required ICU supervision. She was requiring 28% oxygen, breathing independently, did not need any blood pressure support and was on reduced doses of sedation. Although she was still unwell with pneumonia, there was a clear plan for care for Mrs B on ward D26. 
    
    53.	Therefore, as Mrs B’s condition had significantly improved and she no longer required the respiratory support, we find it was appropriate for her care to be ‘stepped down’ from the ICU to a general ward with additional support as planned.
    
    Mouth care and dignity 
    
    54.	Mrs A complains there was a lack of mouth care and a lack of dignity shown to her mother when she was sedated. Mrs A says on one occasion when she went to visit her mother on ward D26 she found her in an undignified position. She then had to find a nurse to support her in covering her mother up and putting her safely in bed. 
    
    55.	Our nursing adviser said oral hygiene is a fundamental aspect of nursing and the NMC Code says nurses should deliver this effectively. Our nursing adviser said, as Mrs B was not having anything to eat or drink orally, the nurses should have offered and provided oral care when they undertook the two hourly care interventions.
    
    56.	The nurses commenced daily care records on 17 March at 8pm following Mrs B’s admission to ward D26. The nurses did not provide oral care during the evening of 17 March. On 18 March, the nurses provided oral and eye care at 4am, 6am, 8am, 11am, 2pm and midnight. The nurses only provided oral care at 9am on the morning of 19 March. 
    
    57.	Therefore, the evidence suggests the nurses did provide some oral care, but not regularly, whilst Mrs B was on ward D26. This is not in line with the NMC Code.  We find this was failing. This caused Mrs A distress and she lost faith that the nurses were monitoring her mother as closely as they should have been.
    
    58.	The NMC Code also states the provision of person centred, dignified care is at the very heart of nursing practice. The incident when Mrs B’s dignity was compromised is not documented in the medical records. Consequently, it is not possible to know how Mrs B got into that position and how long she had been like that. We cannot tell whether it had happened immediately prior to Mrs A arriving at the ward and nurses had not yet had an opportunity to attend to Mrs B, or whether she had been in that position for some time.
    
    59.	The daily care records indicate nursing staff did undertake two to four hourly continence care (including urinary catheter management) and re-positioning. 
    
    60.	Whilst we appreciate it would have been distressing for Mrs A to witness her mother in an undignified position, we do not know what happened here. Accordingly, we cannot reach a conclusion as to whether the care provided was appropriate or not. 
    
    Focused care on the ward
    
    61.	Mrs A says following her mother’s discharge from the ICU she was supposed to have focused, 1 to 1, care whilst on the ward. She does not think the Trust provided this. 
    
    62.	In its complaint response the Trust said a healthcare assistant provided 1 to 1 care and there was clear evidence in Mrs B’s healthcare notes that she was receiving focused care. However, the Trust acknowledged the healthcare assistant was not visible which may have been why the family thought that one was not present.
     
    63.	An ICU consultant reviewed Mrs B in the ICU at 10am on 17 March. The consultant noted Mrs B could be transferred to a ward with ‘special’ (1 to 1) monitoring by a registered nurse, one to two hourly urine output monitoring, and four hourly temperature, pulse, respiration and blood pressure observations. The consultant did not document the rationale for these requirements. 
    
    64.	During her time in the ICU Mrs B had episodes of extreme agitation and aggression, requiring physical restraint and sedation. The doctors had reduced her sedation prior to transfer to the ward. Our nursing adviser said, based on the available evidence, the decision for 1 to 1 care is likely to have been to monitor Mrs B’s distressed, agitated and aggressive behaviour and to prevent her from causing harm to herself or others.
    
    65.	On transfer to the ward, nursing staff noted Mrs B was agitated and attempting to pull out intravenous lines and her naso-gastric tube. This was despite cosy mitts being in place. The nurses were administering essential medication for the management of her mental health needs via the intravenous lines. If she succeeded in pulling out these lines, the nurses could not administer her medications, which would potentially increase her agitation and distress. Therefore, our nursing adviser said 1 to 1 care was necessary based on Mrs B’s clinical presentation.
    
    66.	The NMC Code states when delegating care, registered nurses must ‘be accountable for [their] decisions to delegate tasks and duties to other people’. They must only delegate tasks and duties that are within the other person’s scope of competence and must ensure that the person is adequately supported and supervised so they can provide safe and compassionate care. 
    
    67.	As it is likely the decision for 1 to 1 care was based on the need to monitor Mrs B’s distressed and agitated behaviour and to prevent her from causing harm to herself, our nursing adviser said a healthcare assistant would have been qualified to undertake physiological observation and monitoring under the direction/supervision of a registered nurse, as per the NMC guidelines.
    
    68.	There are no specific guidelines on 1 to 1 care, but there are NICE guidelines on the management of violence and aggression regarding the level of supervision required for a patient. This states when a person requires continuous observation, the patient needs to be kept within eyesight or arms-length of a designated 1 to 1 nurse, with immediate access to other members of staff if needed. 
    
    69.	In line with this, Mrs B should have had continuous 1 to 1 supervision and observation by a nurse or healthcare assistant until such time as the doctors deemed this no longer necessary. We have seen no evidence to indicate that Mrs B did not require this level of supervision between 17 and 19 March. 
    
    70.	The ICU discharged Mrs B to ward D26 at approximately 4pm on 17 March. A member of the critical care outreach team subsequently reviewed Mrs B (time not documented) and noted no ‘special nurse’ was present and the need to chase a ‘special nurse’ for the following day. At 8:30pm, a ward nurse noted Mrs B required 1 to 1 care. There are no entries in the clinical records after this point regarding 1 to 1 care or from a 1 to 1 healthcare assistant.  
    
    71.	As such we have seen no evidence to indicate that the Trust provided the planned focused, 1 to 1 care for Mrs B between 17 and 19 March. We find this to be a failing. We will go on to discuss the impact of this failing in the next section. 
    
    72.	As well as providing 1 to 1 care, the plan of care following Mrs B’s transfer to ward D26 included four hourly temperature, pulse, respiration and blood pressure observations. 
    
    73.	In 2012, the Royal College of Physicians issued guidance on assessing the severity of acute illness based on observations of critical signs of deteriorating illness (the National Early Warning Score, NEWS). Six simple physiological observations form the basis of the NEWS scoring system:
    o	respiratory rate
    o	oxygen saturations
    o	temperature
    o	systolic blood pressure
    o	pulse rate
    o	level of consciousness.
    
    74.	A score is allocated to each observation as they are measured: the greater the variation from normal for each observation, the higher the score. The various scores are then added together and uplifted for people requiring oxygen. 
    
    75.	The calculated NEWS score should determine the frequency of observations and the urgency of the clinical response. A senior doctor can recommend more or less frequent monitoring if they consider this to be appropriate. In this case, a consultant had recommended four hourly observations. 
    
    76.	Following transfer to the ward on 17 March, the nurses conducted observations at 4pm. The nurse did not record the total NEWS score. Our nursing adviser said observations indicated the score would have been 7. In line with the Royal College of Physicians’ guidance, a NEWS score of 7 should trigger a senior medical review within 15 minutes and observations being recorded at least every 15 minutes. We have seen no evidence that this happened. 
    
    77.	At 7:20pm a nurse conducted further observations. Mrs B had an increased respiratory rate of 27, a temperature of 38.2 degrees, systolic blood pressure of 131, oxygen saturations of 96% on two litres of oxygen, and a heart rate of 120. The nurse again did not record the total NEWS score. Our nursing adviser said this would have been 7. This again should have triggered a senior medical review within 15 minutes and observations at least every 15 minutes. We again have seen no evidence that this happened. 
    
    78.	The nursing staff thereafter conducted four hourly observations and Mrs B’s NEWS score remained stable at 3 or 4 which did not require any further action. At 6:32pm on 18 March, the nurses recorded a NEWS score of 8. At this stage the nursing staff appropriately requested a medical review. A doctor from the critical care outreach team reviewed Mrs B and suggested administration of 200mls of intravenous fluids. Subsequent observations taken at 8:58pm demonstrated an improvement in her blood pressure. By 12:29am on 19 March Mrs B’s NEWS score was back to 3. 
    
    79.	There are no further observations recorded after this time. The nursing staff should have conducted observations at around 4:30am and 8:30am, but there is no evidence they did. 
    
    80.	At 5:10am on 19 March, a nurse noted in the handwritten records that Mrs B’s granddaughter had spent the night with her. At this time the nurse administered her medication via the naso-gastric tube. The nurse noted she had taken and recorded Mrs B’s vital signs. These are not in the records the Trust provided to us. 
    
    81.	A retrospective note written at 12.40pm says a nurse had again administered medication via the naso-gastric tube and begun the feed at 9am. The nurse also assessed Mrs B’s fundamental care needs but did not record any observations at this time. 
    
    82.	Whilst the evidence suggests some observations were done on D26, they do not appear to have been done as often as they should have been, and care was not always escalated when required. This is not in line with the care plan or the Royal College of Physicians’ issued guidance. We find this to be a failing.
    
    Cardiac arrest & impact of failings  
    
    83.	Mrs A complains the staff on ward D26 did not notice her mother had a cardiac arrest on 19 March. She said her mother was unconscious for over 15 minutes and this led to her developing brain damage. She also wonders what caused the cardiac arrest. She believes if a focused care nurse had been present then it could have been avoided.
    
    84.	A note written retrospectively by the coordinator of ward D26 at approximately 12:30pm states she walked past Mrs B’s bed (it is not clear when) and she appeared not to be breathing. She was unable to find a pulse, so she called the cardiac arrest team. Cardiopulmonary resuscitation (CPR) was performed until the arrest team arrived approximately 3 minutes after the call.
    
    85.	Our physician adviser said the cause of Mrs B’s cardiac arrest is difficult to precisely identify. The night nursing report states Mrs B had been agitated during the night. As such, our physician adviser said it is possible the further lorazepam given to calm her caused her to become sedated, in turn leading to respiratory arrest (when a patient stops breathing). 
    
    86.	After resuscitation, the doctors removed a lot of feeding fluid from Mrs B’s pharynx (back of throat) and our physician adviser said Mrs B breathing this fluid into her lungs whilst sedated may also have caused her arrest.  
    
    87.	Our physician adviser said it seems the most likely cause was hypoxia (a deprivation of the oxygen supply) caused by sedation. He considered this was most likely because, following the cardiac arrest, the doctors in the ICU excluded other conditions such as pulmonary embolism (a blockage of an artery in the lungs), stroke and heart attack.
    
    88.	If the nurses had undertaken four hourly observations, our physician adviser said it is possible they may have recognised Mrs B’s acute deterioration earlier and called for medical input before the cardiac arrest happened. Our physician adviser said basic observations would have seen altered responses in conscious level, respiratory rate, pulse rate and oxygen saturations, before the cardiac arrest. However, in the absence of any records or observations for this period, it is not possible for us to state whether Mrs B was showing any signs of decline earlier that morning that the Trust missed. 
    
    89.	We find the failure to undertake four hourly observations, and the failure to escalate for examination by a senior doctor within 15 mins on two occasions (as the NEWS score required), has led to Mrs A not knowing whether there would have been chance for staff to identify that her mother’s condition was deteriorating. This uncertainty will be a continued source of distress for Mrs A and her family. 
     
    90.	We have also found a failing in that the Trust did not provide the planned, focused, 1 to 1 care for Mrs B between 17 and 19 March. If the Trust had provided this, then in line with the NICE guidelines on violence and aggression, the healthcare assistant would have been continuously observing Mrs B and would have been within eyesight or arms-length. 
    
    91.	The Resuscitation Council’s quality standards for CPR practice and training state all clinical staff must have at least annual training in CPR. As a minimum, all clinical staff should be able to recognise cardio-respiratory arrest, summon help and commence CPR. In line with this, our nursing adviser said the healthcare assistant providing the 1 to 1 care should have been able to recognise that Mrs B was having a cardiac arrest.
    
    92.	We find, on the balance of probabilities, the healthcare assistant would have spotted Mrs B’s cardiac arrest either at the time or within a couple of minutes, if the 1 to 1 care been in place. They would then have either been able to commence CPR themselves or summon a colleague to start CPR.
    
    93.	As no one was observing Mrs B at the time of her cardiac arrest, it is not possible to say when the arrest occurred and how long she had been unresponsive before the coordinator walked past. The Trust has estimated that Mrs B suffered the cardiac arrest 3 to 4 minutes before the coordinator made the cardiac call. However, it is not clear from the records, or the complaint investigation, how it reached this estimate. 
    
    94.	The cardiac arrest team documented it took them 3 minutes to arrive on ward D26. The team immediately administered oxygen to Mrs B and took over the CPR. The team used the defibrillator and administered adrenaline. The team successfully resuscitated Mrs B 8 minutes after they arrived on the ward. 
    
    95.	Studies (listed in the evidence section above) into the factors which influence the outcome of CPR, show delays in starting CPR of more than 4 minutes make resuscitation attempts futile, as the likelihood of hypoxic brain damage is almost certain. If blood flow to the brain had been interrupted for more than 4 minutes, then cerebral brain damage will occur. Even if cardiac output is restored, the brain injury will have happened, and may result in severe cerebral injury with unsustainable recovery.
    
    96.	The Resuscitation Council guidelines also state defibrillation within 3–5 minutes of the cardiac arrest can produce survival rates as high as 50–70%.
    
    97.	Our physician adviser said it is possible when a brain is completely starved of oxygen for more than 15 seconds, some brain injury may result. However, if the period of oxygen starvation is short (less than 4 minutes), then partial (rather than full) injury, and potential reversible injury, are possible. Consequently, successful CPR as soon as possible prevents irreversible brain damage by maintaining blood flow to the brain.
    
    98.	If the Trust had noticed Mrs B’s cardiac arrest sooner (within 1-2 minutes), started CPR immediately, and used the defibrillator soon thereafter, we find on the balance of probabilities it is likely the blood flow to the brain would have been maintained and effective brain circulation would have been restored quickly enough to prevent significant brain injury. Mrs B would have been resuscitated and not suffered irreversible cerebral hypoxic damage.  
    
    99.	Mrs B died on 23 March as a direct result of hypoxic brain injury. We know Mrs B was unwell at the time of her cardiac arrest. She was still recovering from severe lung injury and had signs of ongoing infection. She also had co-morbidities of obesity, high blood pressure and mental illness which may have complicated her recovery. 
    
    100.	However, our physician adviser said the fact that successful cardiac function was achieved when resuscitation was eventually performed indicates Mrs B’s heart was in a good state. This further suggests even with the above comorbidities, Mrs B would have been successfully resuscitated if her arrest had been immediately noticed. Therefore, overall, we find if Mrs B’s cardiac arrest had been recognised sooner, it is more likely than not that she would have been successfully resuscitated without suffering significant brain injury.
    
    101.	We therefore find, on the balance of probabilities, Mrs B’s death could have been avoided. We understand knowing this will cause Mrs A and her family significant and ongoing distress. 
    
    End of life care 
    
    102.	Mrs A complains after suffering a cardiac arrest, the doctors did not give her mother the opportunity to have an end of life care package or discuss end of life care with her family. She says her mother was taken back to the ICU and put on life support until the family were give the devastating news that there was nothing further that could be done.
    
    103.	The NICE guidelines on care of dying adults recognises it can often be difficult to be certain when a person is dying. In order to recognise when someone is in their last few days, doctors should assess for changes in symptoms and review any investigation results that may suggest a person is entering the last days of life.
    
    104.	When the doctors resuscitated Mrs B and restored circulation successfully, they transferred Mrs B back to the ICU. Following this, our physician adviser said it was appropriate, and in line with the GMC guidelines on good clinical care and treatment, for the doctors to arrange investigations (such as a CT brain and body scan, heart tests etc.) to assess her condition. 
    
    105.	It was a couple of days before it was clear what Mrs B’s long term prognosis would be. Our physician adviser said until then it was not appropriate to discuss end of life plans as the doctors were not sure whether Mrs B was approaching the end of her life. Whilst the investigations were ongoing, our adviser said the doctors correctly maintained life support and provided treatment and antibiotics. 
    
    106.	By 22 March the doctors had the results from their investigations. The EEG showed irreversible brain damage and a neurology assessment had confirmed a vegetative state and recovery was unlikely. Our physician adviser said it was then appropriate to discuss end of life matters with the family as it was known at that time that Mrs B would not survive. 
    
    107.	A consultant held a meeting with the family on 22 March at 5pm where they explained the situation and investigation results. At this stage the consultant made it clear Mrs B was at the end of her life and began making end of life plans with them.
    
    108.	Therefore, whilst we appreciate this situation would have been incredibly distressing for Mrs A and her family, we find the doctors could not have known that Mrs B was at the end of her life, or have end of life discussions with the family, any sooner. 
    
    Communication with the family 
    
    109.	Mrs A says there was a lack of communication with the family about her mother’s diagnosis and prognosis during the admission. 
    
    110.	The GMC guidelines on good medical practice state doctors must communicate effectively and be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
    
    111.	Mrs B arrived in A&E at around 1am on 8 March. When it was known what the diagnosis and plan of treatment was, a consultant documented a discussion with both of Mrs B’s daughters at 12:30pm on 8 March. During this conversation the consultant explained Mrs B had pneumonia and respiratory failure, and what treatment they were providing. 
    
    112.	A nurse documented she called Mrs B’s daughter, Denise, at 11:30pm on 8 March to inform her they were transferring her mother to the ICU. Following this, there was a period of around a week where there are no documented discussions with the family. 
    
    113.	On 15 March, a psychiatrist spoke to Denise and explained the current treatment and plan of care. The family was also informed on 17 March that Mrs B was going to be discharged from the ICU to a ward with a special nurse in place. 
    
    114.	After Mrs B suffered a cardiac arrest, the nurses tried to contact the family to inform them. When there was no answer, they called the police to inform the family. When the family arrived at the hospital, a doctor documented a discussion with the family at 3:15pm, and a further discussion at 4:10pm. During these conversations the doctor explained what had happened, what was going to happen next, and the poor prognosis. 
    
    115.	On 22 March, when the results of the investigations were known, the doctor again spoke to the family at 5pm to explain that Mrs B was not going to survive and what would happen next. 
    
    116.	On 23 March, the doctors documented several conversations with the family to discuss the family’s complaint about the care. At 6:34pm the doctor explained to the family that Mrs B was dying, and they were withdrawing active care. 
    
    117.	We have seen evidence that the doctors did provide updates to the family during this admission, each time the diagnosis or plan of care changed. The doctors also answered any concerns when the family raised these. This is in line with the GMC guidelines. 
    
    118.	We acknowledge there was a week whilst Mrs B was in the ICU when there are no documented discussions. We appreciate this lack of communication was distressing for Mrs A and her family, especially as Mrs B was very unwell at this time. 
    
    119.	However, as Mrs B’s diagnosis and treatment plan did not change during this period, and the family were informed when the plan did change, we do not consider this amounts to service failure. As such, we find the overall communication provided to the family during the admission was appropriate.  
    
    Complaint handling 
    
    120.	Mrs A also complains about the way in which the Trust handled her complaint. She says the Trust took too long to respond to her complaint. 
    
    121.	NHS Complaint Regulations say organisations must: ‘investigate a complaint in a manner appropriate to resolve it speedily and efficiently’. The Regulations also say as soon as is reasonably practicable after completing the investigation, the organisation must send the complainant a written response, which includes the conclusions reached in relation to the complaint. The Regulations specify this response should be provided within six months of the day on which the complaint was received.
    
    122.	Mrs A made her initial complaint to the Trust on 6 July 2016. The Trust arranged a meeting with Mrs A to discuss the complaint on 22 November 2016. The Trust sent Mrs A a CD recording of the meeting thereafter but did not follow this up with a written response. This is not in line with the Regulations. 
    
    123.	We wrote to the Trust in June 2017 asking it to provide a full written response to Mrs A. The Trust agreed to provide this in July 2017 but did not send it until July 2018. 
    
    124.	It took a year for the Trust to provide a written response to Mrs A’s concerns when we asked them to, and two years from when she first made her complaint. We find this to be a failing as it is not in line with the Regulations. We consider this delay in providing a response caused Mrs A additional distress and frustration at a time when she was grieving.  
    
    125.	We have seen the Trust wrote to Mrs A on 4 October 2018 to acknowledge its handling of her complaint was not acceptable. The Trust apologised for the delays and the lack of updates throughout. The Trust explained several staff changes occurred at the time we asked the Trust to provide the written response. It said this impacted on her case, together with inaccurate recording on its complaints management system. The Trust also provided Mrs A with £150 as a goodwill payment for distress caused by its complaint handling. 
    
    126.	In its letter of 4 October, the Trust also explained some improvements it had made to its complaint handling process since the original complaint. The Trust explained when a member of staff leaves, their cases are now handed over to another handler on the complaint management system to ensure they are monitored and progressed appropriately. Also, when it holds a complaint meeting, the Trust now prepares a summary letter covering the main topics, any decisions made and any further actions, and sends this together with the CD recording of the meeting. 
    
    127.	We have seen evidence that the Trust has already acknowledged this failing, apologised, and identified improvements in this area. We find this to be a reasonable remedy for this aspect of the complaint.
    
    128.	Mrs A also complains the response from the Trust did not adequately address all her concerns. Our Principles state organisations should be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions. 
    
    129.	The written response from the Trust dated 26 July 2018 is simply a summary of what was said during the meeting. As such, we have seen no evidence that the Trust conducted a full investigation into Ms A’s concerns. An example of this is that Mrs A asked about her mother’s medications as she did not think they had been managed well. The response from the Trust states the ICU consultant present at the meeting could not comment on the psychiatric medication. Consequently, this issue was fully not addressed. 
    
    130.	The Trust also did not highlight any of the failings we have identified above in relation to the observations and 1 to 1 care. 
    
    131.	It is our view that the written response from the Trust does not provide a detailed response to all the areas Mrs A expressed concerns about. Throughout the response, the Trust did not provide clear, evidence-based explanations, and reasons for its decisions. This is not in line with our Principles. 
    
    132.	We find a failing with the Trust’s investigation into this complaint. We find this has led to Mrs A not fully understanding what happened to her mother and questioning for over three years whether any other treatment could have been provided which would have led to a different outcome. We recognise this means she has not been able to fully and properly grieve for her mother. 
    
  • 133.	In considering our recommendations, we have referred to our Principles for Remedy. These state where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. Therefore, we recommend that within one month of our final report the Trust should acknowledge the failings we have found in relation to the lack of regular observations, 1 to 1 care, mouth care and complaint handling, and apologise to Mrs A for the impact these had.
    
    134.	Our Principles say public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure they do not repeat maladministration or poor service. 
    
    135.	Therefore, we also recommend that within three months of our final report the Trust should produce an action plan to explain what action it has taken or will take to learn lessons from the failings we have identified in relation to the lack of regular observations, 1 to 1 care, mouth care and complaint handling. This should include specific measurable steps and an explanation of how these will be monitored going forward. It should share evidence of this action with Mrs A, us, the Care Quality Commission and NHS Improvement.
    
    136.	Our Principles state public organisations should ‘put things right’ and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.
    
    137.	To determine a level of financial remedy, we review similar cases where similar injustice has arisen, along with our severity of injustice scale. Following this review, we recommend the Trust should pay Mrs A £10,000 in recognition of the distress arising out of knowing that it is likely her mother’s death would have been avoided if she had received appropriate care and treatment.
    
    Conclusion 
    
    138.	In this report we have set out our decisions into Mrs A’s complaint. We have thoroughly and impartially investigated the complaint and drawn conclusions from careful consideration of the evidence. We have found some aspects of care and treatment the Trust provided were in line with the relevant guidance. However, we have found the Trust should have assessed the risk of Mrs B developing delirium, observed Mrs B every four hours and provided 1 to 1 care for her whilst on ward D26. We have also found the Trust’s complaint handling was maladministrative.
    
    139.	Had 1 to 1 care been provided as it should have, it is likely Mrs B’s cardiac arrest would have been observed within one or two minutes. If this had happened, we consider it likely Mrs B would have been resuscitated without suffering the irreversible brain damage that led to her death. We have therefore concluded it is more likely than not that the failings we have identified led to her death. We therefore uphold this complaint.