19. Mrs A says that she feels a feeding tube should have been inserted sooner than it was to give Miss A the nutritional support she needed. The Trust says that Miss A was assessed by a dietician who determined that she should be encouraged to eat a high protein diet along with nutritional supplements in order to meet her nutritional needs orally. It said that on 14 March 2018 it considered whether to insert a feeding tube but that this was not done as it coincided with a worsening of Miss A’s condition and insertion of a feeding tube could have increased her breathing difficulties.
20. In reaching our views in relation to this part of the complaint we have considered advice received from our dietician adviser as well as the guidance referred to. The NICE guidance says that a feeding tube should be considered where the patient is malnourished or at risk of malnutrition and has inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract. We understand from the clinical records and advice from our dietician adviser that Miss A was assessed in line with this guidance on 2 March 2018, and that she was able to take food and drink safely by mouth and was willing to try oral nutritional supplement drinks. In our view it was therefore an appropriate clinical plan and in line with the guidance to first assess if Miss A was able to meet her nutritional requirements orally before considering insertion of a feeding tube.
21. Miss A was reviewed by the dietician again on 5 March 2018. She identified that Miss A was falling slightly short of her daily nutritional requirements and prescribed an additional nutritional supplement to remedy this. In our view this was an appropriate clinical action and in line with the guidance, as Miss A could then meet her nutritional requirements orally and tube feeding could be avoided.
22. On 9 March 2018 Miss A was assessed again by the dietician. She found that Miss A was not meeting her nutritional intake requirements. The records indicate that she felt this was due to oral nutritional supplements not being given due to a supply issue and also due to Miss A not being offered high protein menu choices. The records reflect it was therefore difficult for the dietitian to assess whether Miss A would have been able to meet her nutritional requirements orally, with high protein choices and prescribed oral nutritional supplements, or whether despite her intake was still inadequate and a feeding tube would be indicated. For the same reason, we have not been able to determine whether tube feeding should have been considered at this time in line with the guidance. We therefore cannot give a view as to whether a feeding tube should have been inserted at this stage.
23. On 14 March 2018 Miss A was reviewed again by the dietician. The dietician documented that Miss A was likely to not be meeting her nutritional requirements and documented her advice for either a continuation of oral nutrition or insertion of a feeding tube. In our view, from the information documented at this review Miss A’s dietary intake was inadequate and as such tube feeding should have been considered in accordance with the above guidance. The records show Mrs A was reluctant to discuss tube feeding with Miss A at that point. However, we understand that this was a decision which should have been made by the managing consultant. There is no record of the medical team considering whether tube feeding should be commenced at this point.
24. The Trust has explained that a feeding tube was not inserted at this stage as this coincided with Miss A overall condition worsening and it had to prioritise stabilising her breathing, as insertion of a feeding tube at this point could have exacerbated the issues she was having with breathing. However, it is not clear from the evidence we have seen whether this is an observation that has been made after the fact or whether the Trust is saying that consideration was given to the issue at the time. In any event, as there is no record of such consideration, our view is that the lack of such consideration is a failing. We will go on to consider the impact of this failing later in this document.
Monitoring of nutritional intake
25. Mrs A says that after the dietician made recommendations to ensure Miss A met her nutritional requirements, her nutritional intake was not monitored properly by the Trust to make sure the dietician’s plan was adhered to. The Trust acknowledged that there are gaps in the completion of Miss A’s food intake charts but says this was due to Miss A spending long periods of time off the ward, making completion of food charts difficult.
26. In reaching our views in relation to this part of the complaint we have considered advice received from our dietician adviser as well as the guidance referred to. We understand the requirement for food intake charts to be completed is dependent on a patient’s Malnutrition Universal Screening Tool (MUST) score. Miss A was screened using MUST on her admission on 2 March 2018. Her weight of 63.5kg (wet weight with ascites) was used for this assessment, which gave her a body mass index (BMI) of 24kg/m2. This resulted in her MUST score being calculated as 0.
27. As Miss A’s estimated dry weight was around 53kg, this would very likely give her a lower BMI of around 20kg/m2. Had these values been used, a higher MUST score would have been generated. Given her history of poor intake and her clinical condition (decompensated liver disease) she should have been given a MUST score of at least 2 due to the disease affect score.
28. According to the Trust’s Nutritional Screening Policy for Adult Inpatients, for patients with a MUST score of 1 or 2, the Trust should keep food record charts documenting all diet taken. There are gaps in the food intake charts with there being no record of food intake at all on 6 March 2018, 7 March 2018 and 13 March 2018.
29. We recognise that the records mention Miss A spending time off the ward frequently. However, if this was the reason for the gaps in the food intake chart, a note should have been made in the food intake chart at the time to say an attempt had been made to complete it. Our view is that the error in calculating Miss A’s MUST score and the gaps in the completion of the food intake charts are failings by the Trust. We will go on to consider the impact of these failings later in this document.
Provision of recommended diet
30. Mrs A says that after the dietician recommended a high protein diet with nutritional supplements for Miss A, there were many occasions where the Trust did not provide this. The Trust says that Miss A’s nutritional supplements were always given as prescribed except on three occasions where Miss A declined them. The Trust says that Miss A was often off the ward at mealtimes, which made it difficult for staff to monitor her nutritional intake. It says that the food recorded on the food intake chart mostly fits the special dietary requirement suggested by the dietician but some of the choices made are down to patient preference.
31. We asked the Trust to give us information about its process for the provision of therapeutic diets, including a high protein diet. It said that once a patient is reviewed and assessed by a dietician, the patient is educated on how to request the recommended therapeutic diet from this menu.
32. The Trust said the ward has a nutritional board that highlight patients’ specialist dietary needs. The high protein diet is requested via a completed menu card for each patient. These menu cards are distributed by the ward staff to the ward patients after review of the board, with each patient then choosing their preferred menu options from the recommended diet. If a patient lacks capacity, the nursing staff will assist the patient in choosing the recommended meals on the menu. The completed menu card is then returned by the ward staff to the Catering Team the day before the meal is provided. During mealtimes, the ward’s mealtime coordinator also uses the ward’s nutritional board as guidance to ensure that patients each receive their recommended meal.
33. In reaching our views in relation to this part of the complaint we have considered advice received from our dietician adviser as well as the guidance referred to. We are satisfied from the notes made by the dietician when she assessed Miss A on 2 March 2018 that she was provided with the necessary information on how to make informed meal choices. We will not be able to give any view as to whether the nutritional board contained the correct dietary requirements for Miss A as although it is documented in the dietician’s notes in Miss A’s medical records, the dietary requirement is not recorded in the nursing records between 2 and 7 March 2018.
34. The Trust says that despite the error in the nursing documentation, the food recorded on the food intake chart mostly fits with a high protein diet. We have considered this carefully and do not agree that the food intake chart shows that Miss A’s recommended diet was mostly adhered to. There are no entries at all on 2 March 2018 or 6 March 2018 and the entries for the evening meal on 4 March 2018 and 5 March 2018 both say sandwiches, so there is no record of whether these were from the high protein options or not.
35. We have considered Mrs A’s views that her daughter did not receive high protein menu options and the records of the dietician’s concerns in this regard. These matters concerned the dietician enough that she wished to raise an incident report about it. We have also considered that there is nothing in the documentation kept by the Trust to suggest that Miss A did receive high protein menu options and that there nothing in the evidence to show us on the balance of probabilities that the requirement for those options were recorded on the ward’s nutrition board. On balance, we have concluded that there were failings in the Trust’s provision of the recommended high protein diet. We will return to these matters to consider the likely impact.
Reporting of issues with the provision of recommended diet
36. Mrs A says that when the dietician assessed Miss A on 9 March 2018, she said she was going to raise an incident report as Miss A had not been getting the right meals and this had compromised her care. The Trust says that the dietician could not access its incident reporting system at the time due to IT issues but that she instead discussed the issue with ward staff.
37. We note that the dietician did attempt to raise an incident report but was unable to do so at the time. She therefore alerted the ward staff of the issue instead. We consider that this was a reasonable action to take in the circumstances. We consider that it would have been helpful if the dietician had communicated this to Mrs A at the time. However, our view is that we do not consider that the fact she did not do so to be significant enough to constitute a failing in service.
Note made by doctor regarding nutrition
38. On 14 March 2018 a doctor noted in Miss A’s medical records that she had eaten and drunk, when her food chart shows she had only had yoghurt. Mrs A feels this paints an inaccurate picture of Miss A’s nutritional status. However, the Trust says the comment was intended as meaning Miss A’s had managed some oral intake.
39. In reaching our views in relation to this part of the complaint we have considered advice received from our dietician adviser as well as the guidance referred to. We understand that the comment recorded by the doctor was likely intended to say that Miss A was taking diet and fluids. The doctor made no mention of the adequacy of her intake, so we do not agree this statement is misleading or inappropriate. Our view is that there is no failing here.
Impact of the failings in nutrition
40. We have identified failings in the lack of consideration of inserting a feeding tube on 14 March 2018, the error in the calculation of Miss A’s MUST score, the gaps in the completion of the food charts and the issues in the provision of a high protein diet.
41. We have very carefully considered the failings we identified and whether the evidence available indicates Miss A’s death might have been prevented if it were not for these occurring. In doing so we have considered advice received from our gastroenterology adviser. We can see that the main period when Miss A’s nutrition was substantially below the recommended levels was 14 March to 16 March 2018. We understand that given the severity of Miss A’s underlying liver disease and the flu she was suffering from, it is very unlikely that the failings identified would have had any significant impact on her chances of survival or that Miss A’s death could have been prevented.
42. We do not know what the outcome would have been if consideration had been given to insertion of a feeding tube on 14 March 2018, or whether the Trust’s recording of Miss A’s nutritional intake would have improved had her MUST score been correctly calculated. We cannot know how many times food intake information was available but not inputted or on how many occasions staff should simply have recorded that completion had not been possible due to absence from the ward. The gaps in the food intake chart also mean that we cannot say on balance what impact the issues with the provision of the high protein diet had on Miss A’s nutritional status, although we have not seen any evidence of a significant clinical impact, as above.
43. The impact on Mrs A of the failings we have identified is the uncertainty she will undoubtedly be left with over the impact these issues may have had on Miss A’s nutritional status during her admission. This will no doubt leave Mrs A questioning whether her daughter’s chances of survival could have improved if these failings had not occurred. As we have identified several failings which have caused Mrs A avoidable uncertainty and distress, we uphold this part of the complaint. We have made a recommendation below to put things right.
Clinical treatment during admission
44. Mrs A feels that the Trust did not sufficiently take note of and treat Miss A’s oedema and water retention. She also believes the Trust should have inserted an abdominal drain for Miss A after it was suggested by night staff. Mrs A feels that Miss A should have been transferred to Critical Care sooner and that dialysis should havenation.
Treatment of oedema/water retention
45. In reaching our views in relation to this part of the complaint we have considered advice received from our gastroenterologist adviser as well as the guidance referred to. We understand that it is common for patients with liver disease to have too much water and salt in the body. This tends to accumulate in the legs (oedema) and the abdomen (ascites). The function of diuretics is to remove water and salt from the body slowly by increasing the amount lost from the body in urine.
46. The BSG guidance says that oedema and ascites should be treated with diuretics and a low salt diet. Both treatments were provided to Miss A from the point of admission and her oedema and ascites were well documented throughout the admission. The records show Miss A continued to have fluid overload despite the use of diuretics, that the dose was increased gradually in attempts to reduce the swelling and that it was appropriate and in line with BSG guidance to continue the diuretics as long as she had ascites and her renal function was satisfactory. We can see this continued until the last 24 hours of her life when her treatment changed accordingly. Our view is that there are no failings in this regard.
Delay in attempting dialysis
47. In reaching our views in relation to this part of the complaint we have considered advice received from our physician adviser as well as the guidance referred to. The records show that at 00:48 on 17 March 2018 Miss A’s blood pressure dropped and that at approximately 03:30 a dialysis line was inserted on the second attempt but this caused a further drop in blood pressure and the development of a heart arrythmia. It was therefore noted that dialysis to remove fluids was not an option as this would result in Miss A’s blood pressure dropping further. From the information available, we have seen no indication that the dialysis would have been possible if it had been attempted immediately at 00:48 when the problem was identified. Our view is that there are no failings in relation to this part of the complaint and the Trust acted in line with the GMC guidance which says that a clinician must provide effective treatments based on the best available evidence.
Decision regarding drain insertion
48. In reaching our views in relation to this part of the complaint we have considered advice received from our gastroenterologist adviser as well as the guidance referred to. The records indicate that the night team which assessed Miss A on 14 March 2018 consisted of a registrar and a junior doctor who felt that an abdominal drain may assist with her breathing. However, the consultant who reviewed her the following morning felt that her breathing difficulties were a result of her pneumonia and therefore there was no indication for insertion of an abdominal drain. The consultant is the more qualified clinician, so it is reasonable that this decision was made by him.
49. The GMC guidance says a clinician must adequately assess the patient’s conditions, taking account of their history, their views and values and where necessary examine the patient. As this clinical judgement appears to have been reached in line with this standard, our view is that there are no failings in relation to this point of complaint.
Observations taken by student nurse
50. We have not seen anything to suggest it was not appropriate for a suitably trained student nurse to be taking observations, and we can see that the observations were recorded in the case notes. We have not seen anything in the evidence provided to suggest these observations were not taken properly. Our view is that there are no failings on this point as the Trust appears to have acted in line with GMC Good Medical Practice, which sets out clinicians should act within the limits of their professional competence.
Decision regarding transfer to critical care
51. We have seen evidence in the records of an appropriate review being undertaken by a Critical Care Senior House Officer, with discussion with the senior medical team from intensive care. Based on this assessment, a decision was made that admission to Critical Care was not needed at that point. Given Miss A’s clinical needs at that time, as set out in the records, this decision appears to have been made in line with the GMC guidance referred to above. Our view is that there are no failings in how the decision was made.
Drips given in error
52. The GMC guidance on Good Medical Practice says a clinician must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs. The records show that on 10 March 2018 the drips were initially prescribed due to Miss A having a flu diagnosis accompanied by a raised temperature, but that they were not appropriate in Miss A situation due to her fluid retention. We can see from the records that the prescription was ordered and then cancelled approximately 20 minutes later. We can see that the Trust’s electronic system which records medication administered shows no entry for these drips although other medications given that day are shown.
53. Mrs A told us that she recalls being present at Miss A’s bedside when the drips were stopped and that when she queried this she was told, ‘I've read her notes and she shouldn't be having these’. However, she confirmed that she was not at the hospital on the night of 10 March 2018 and in her recollection this incident occurred on the night of 14 March 2018. The only entries in the medical records relating to drips being prescribed in error are from 10 March 2018, so we will not be able to give any view what occurred on 14 March 2018. On balance, we have concluded that the drips prescribed and then cancelled on 10 March 2018 were not given to Miss A. We have concluded that while the drips being prescribed in error should not have happened, the fact that the prescription was cancelled shortly afterwards and was not given to Miss A, this is not so serious as to be considered a failing by the Trust.
54. We understand that while patients with chronic liver disease are generally suited to be vaccinated against pneumonia, this would not have been appropriate in Miss A’s case for as long as she remained acutely unwell. Our view is that there is no failing here as to provide such a vaccination when Miss A was so unwell would not have been within the NICE guideline included in the evidence section.
55. The records show that a CT scan was requested on 7 March 2018 and was not performed. The records indicate this was for the purpose of further clarifying the extent of Miss A’s liver damage. The EASL guidance recommends ultrasound for this purpose and does not require the use of CT scan. Miss A had an ultrasound on 3 March 2018 which confirmed cirrhosis, so our view is that the fact she did not have a CT scan is not a failing.
Cleanliness of the room
56. The Trust acknowledged that Miss A’s room should have been cleaned daily and that this did not happen. The Trust said in its complaint response that the ward sister discussed this failing with the domestic supervisor and was continuing to monitor the situation to ensure that standards were being maintained. Mrs A said she would like to see evidence in the form of paperwork to ensure that changes have been made. She said that she visited the ward to see another patient a few months later and it still looked as though the cleanliness was not up to scratch.
57. We asked the Trust if it could share any further updates or assurances with Mrs A regarding the cleanliness of the ward. The Trust said it would like to assure Mrs A that its Hotel Services Department conducts monthly audits to assess the cleanliness of the ward. Furthermore, ward cleanliness is discussed monthly at the divisional Infection Control Meeting, and any issues are highlighted to the relevant department. The ward sister is still overall responsible for the general tidiness and cleanliness of the ward, and this is assessed each day by either the ward manager or the deputy ward manager. Ward matrons also carry out monthly environmental audits and daily spot checks to assess the cleanliness of the ward.
58. The Trust said that based on the last three infection control audits and environmental safety audits, there have been some marked improvements and no cause for concerns regarding the ward’s cleanliness. The infection control audit score has improved from 59% on 11 December 2018 to 90.7% on 7 November 2019. The environmental safety audit score has improved from 73% on 11 December 2018 to 87% on 7 November 2019.
59. Based on the information provided by the Trust we are satisfied that it has made appropriate improvements to the cleanliness of the ward. We are satisfied that although its failure to ensure Miss A’s room was clean at all times caused Mrs A distress, it has acted in line with Our Principles for Remedy by providing an apology and service improvements to put things right. Our view is that we do not uphold this part of the complaint as the Trust has already taken steps to address the impact its mistakes caused.
60. The BMA, RCUK & RCN guidance says that when a person lacks capacity and a decision is made that CPR will not be attempted because it will not be successful, those close to that person must be informed of this decision and of the reasons for it. to the records indicate that staff held a discussion with the family on 17 March 2018 at 03:43 where the Trust informed them of Miss A’s deterioration and that resuscitation would not be appropriate. The records of that discussion indicate the family were advised of the decision in line with the guidance. Our view is that there are no failings on this point.
62. In reaching our views in relation to this part of the complaint we have considered advice received from our physician adviser as well as the guidance referred to. Sepsis is a response to an infection, and the treatment of infection was a focus of Miss A’s treatment throughout the admission. The records show that Miss A was diagnosed with sepsis on 16 March 2018, with the presumed source being chest i.e. the pneumonia. The notes reflect the Trust had suspected sepsis since as early as 2 March 2018 and was treating Miss A accordingly.
63. The GMC guidance says clinicians must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. The discussions with the family appear to have focused on the underlying condition, i.e. pneumonia and the additional problem caused by her liver disease, and there is no mention of the word sepsis being used. However, there is good evidence that the family were kept informed throughout of how unwell Miss A was.
64. We recognise that with the benefit of hindsight perhaps the family would have gained better understanding of the cause of Miss A’s severe illness and death if the term sepsis had been used. However, the communication by staff based on the information available to them and the clinical issues they were considering at that time indicates that the communication by the Trust with the family was in line with the guidance. Our view is that there are no failings in relation to this part of the complaint.