Staff laid Mrs N down to wash her
17. Mrs A and the Trust have given different accounts of how Mrs N was positioned when staff washed her, and whether her nose was bleeding at this time or not. Unfortunately, Mrs N’s medical records do not contain enough information to clarify exactly what happened.
18. The Trust’s response says Mrs N’s nose was not bleeding when staff washed her around 9am. The response says staff washed Mrs N in a sitting up position as she could not tolerate lying flat. The response says Mrs N’s nose started bleeding again around 10am.
19. The nurse’s statement to the Trust said she was aware Mrs N did not like lying flat because of her health conditions. She also said she was aware patients should be kept upright if they have a nosebleed.
20. Mrs A says Mrs N’s nose was bleeding continually all morning, and had not stopped when staff came to wash her around 9.45am. Mrs A says staff asked her to leave the bedside at this time, so she left the ward to make a telephone call. She says Mrs N’s nosebleed had worsened when she returned a few minutes later. She says she could see blood collecting in her mouth, and she brought up two large clots of blood.
21. Mrs A says staff always had to lie Mrs N down to change her incontinence pad and bed sheets, so she is sure she was not sat up the whole time.
22. NICE nosebleed guidance says patients should sit up with their body tilted forwards. It says they should avoid lying down unless they are feeling faint. If Mrs N’s nose was actively bleeding when staff came to wash her, we would expect them to keep her upright in line with this guidance.
23. In our provisional views report, we said we thought it was unlikely Mrs N’s nose had been bleeding continually all morning. We said staff would have noted this in the records and sought medical advice sooner.
24. In response to this Mrs A told us the staff would not have known it was continually bleeding. She says the nurse briefly saw them at the 8am handover, and then when she dropped off Mrs N’s medication. She says staff did not attend to Mrs N again until they came to wash her at 9.45am.
25. In our provisional views report we said if Mrs N’s nose was actively bleeding when staff came to wash her, it was unlikely Mrs A would have left the ward.
26. In response to this Mrs A told us she only left because staff asked her to. She says this was unusual, as staff usually encouraged her to stay and comfort her mother while she was laid flat. Mrs A says she was taken aback by the nurse’s request, so left without questioning it or considering the impact of lying flat with a nosebleed.
27. We understand why Mrs A is so concerned about her mother potentially being laid flat. However, as staff would not have been aware Mrs N’s nose had been dripping constantly for several hours, we see no reason to criticise them if they briefly laid her down to change her pad and sheets.
28. Staff are likely to have seen, at most, a few drips of blood. Given they were washing her, they may have assumed the blood was dislodged from the earlier nosebleed night staff documented at 6am. If blood had been flowing from Mrs N’s nose we would expect staff to follow NICE nosebleed guidance. In this scenario we find there is insufficient evidence this was necessary.
Monitoring of Mrs N’s observations
29. The Trust used the National Early Warning System (NEWS) to monitor Mrs N’s observations. Using this system staff calculate a score based on the patient’s clinical observations. Higher scores indicate the patient’s observations are further from normal and they are more likely to be seriously unwell. The score also determines what actions staff should take, and when they should next review the patient’s observations.
30. The NEWS charts for 23 April show staff measured Mrs N’s observations at 1.30am (NEWS score one), 5.10am (NEWS score two), 10.15am (NEWS score four) and 10.35am. Staff did not calculate Mrs N’s NEWS score on the last occasion because they could not get a blood pressure reading. However, we can see from the information recorded the score would have been at least six.
31. NEWS guidance says if the total score is between one and four, staff should monitor the patient’s observations every four to six hours unless a registered nurse decides to increase the frequency. The NEWS chart shows staff decided to increase the frequency of observations to hourly at 10.15am. We are satisfied the documentation indicates staff measured Mrs N’s observations with appropriate frequency in line with NEWS guidance.
32. Mrs A says staff did not measure Mrs N’s observations at 10.15am. We note the records show the same observations on the SBAR (situation, background, assessment, recommendation) form the nurse completed at 10am when she asked the doctor to review Mrs N.
33. It is unlikely Mrs N’s observations were the same at 10am and 10.15am, so the timing of one of these sets of observations is probably incorrect.
34. Mrs A says staff did not take Mrs N’s observations at 10am either. She says she did not see the day staff bring the observations monitoring equipment to her mother’s bedside at any point. She also says she is sure they did not do this while they were washing her.
35. Whilst we respect Mrs A’s recollection of events, there is no other evidence to indicate the observations at 10am or 10.15am were falsified. The only irregularity we have seen is around the timing. We do not consider recording the timing incorrectly by 15 minutes to be such a significant error that it would be a failure to act in line with the NMC code.
36. It would be a serious breach of the NMC code if a nurse knowingly entered false information on Mrs N’s records, or allowed another member of staff to do so. Taking such action could potentially lead to the NMC removing a nurse from the register. We can see no reason why staff would take such a risk and write down false observations. We also recognise it is possible staff took Mrs N’s observations when Mrs A was away from the ward, but she was not aware of this.
37. At 10.35am the NEWS chart indicates Mrs N had a NEWS score of at least six. If staff had been able to read Mrs N’s blood pressure the score could have been as high as nine (if her blood pressure was very low).
38. NEWS guidance says a score of five or six should trigger hourly observations and an urgent review by medical or nursing staff competent in caring for acutely unwell patients. NEWS guidance says a score of seven or above should trigger an emergency assessment by a team with critical care competencies. In this scenario it says staff should continually monitor the patient’s vital signs.
39. Our nursing adviser explained that in an emergency when continuous monitoring of vital signs is required, this means a member of staff should stay with the patient and observe what is happening. It does not mean the nurse needs to continually write down observations. This can be impractical when staff are also trying to give urgent care.
40. Although there are no further observations recorded after 10.35am, all the evidence we have seen indicates the nurse stayed with Mrs N until she died a few minutes later. This shows the nurse monitored Mrs N appropriately.
41. Mrs A says the nurse did not take her mother’s observations at 10.35am. She says at this time the nurse was at the nurse’s station when she went to call for help. The care plan evaluation notes say Mrs A called the nurse for help around 10.40am, and the nurse then stayed with Mrs N until she died.
42. The timings here are inconsistent. If the nurse had taken Mrs N’s observations at 10.35am and her NEWS score was six, we would have expected her to stay with the patient rather than return to the nurse’s station.
43. On the balance of probabilities, it is likely Mrs A called for help between 10.35am and 10.40am. It is also likely the nurse then measured Mrs N’s observations and stayed with her whilst waiting for the doctor, who had already been asked to review her urgently.
44. We understand Mrs A firmly believes no observations were taken at this time. However, this was an emergency where the nurse said in her statement ‘everything happened very quickly’. Things may have happened without Mrs A realising due to the speed staff moved and the stress of the situation.
45. Whilst there are some indications of inaccurate timings in the records, we see no evidence of deliberately falsified records. We also see no evidence staff failed to monitor Mrs N’s observations at the expected frequency. Therefore, we do not uphold this part of the complaint.
Suctioning Mrs N’s airway
46. Airway suctioning is a treatment for patients who need help clearing secretions from their upper airway. This can be useful for patients with breathing problems who have a weak cough.
47. The RMM guidelines explain there are some risks associated with airway suctioning. These include pain and distress, reduction in oxygen levels, slowing the heart rate, destabilising the cardiovascular system, damage to the airway, bleeding and infection. RMM guidelines say the risk of complications is higher if staff choose the wrong type of equipment, use poor technique, or too much pressure.
48. Mrs A and the Trust have given conflicting accounts about who suctioned Mrs N’s airway when she needed help clearing the blood from her nosebleed. Mrs N’s notes do not clarify who suctioned her airway. They simply record that suctioning was done around 10am.
49. Mrs A said the nurse asked the health care assistant to set up the suction machine and show Mrs A how to use it. She says the instruction was minimal. She says the staff told her it was like the suction machine at the dentist, and she should keep her finger over the hole and keep dipping the pipe in saline so it did not get blocked. She says staff then left her alone for 30 minutes while she was suctioning her mother’s airway.
50. During the local resolution meeting the Trust acknowledged Mrs A had detailed knowledge of suctioning which could only have come from a member of staff training her.
51. However, the Trust’s final written response concluded the nurse suctioned Mrs N’s airway herself. The nurse and health care assistant both denied showing Mrs A how to suction Mrs N’s airway or leaving her alone to do this. In addition, the ward sister reported she saw the nurse suctioning Mrs N’s airway.
52. During our conversations Mrs A gave a compelling and clear explanation of how her mother deteriorated suddenly while she was suctioning her airway. Mrs A said she was worried she had accidentally done something wrong which caused her mother’s deterioration and death.
53. These are strong statements from Mrs A. As she told us she is worried she may have caused her mother’s death, this adds weight to the likelihood staff left her alone to suction her mother’s airway. We cannot see why Mrs A would say these things if her account was not true.
54. The healthcare assistant said she did not remember Mrs N, but had never taught or instructed a visitor or relative to suction or any other procedure. Our nursing adviser agreed it is highly unlikely a healthcare assistant would show a relative how to suction a patient’s airway. This is because most healthcare assistants would not be trained in suctioning themselves, so could not show someone else how to do it.
55. The nurse did not give her statement of events until at least January 2019, as she was on maternity leave. This passage of at least 21 months since the event will have led to her memories fading and being less reliable than if she had given her statement sooner.
56. The ward sister said they saw the nurse suctioning Mrs N’s airway. However, the sister only briefly witnessed this in passing. They were not present the whole time. The sister also said they never saw Mrs N’s son doing suctioning. This is not the complaint put to the Trust. The complaint is that Mrs A was left alone to do the suctioning, not her brother.
57. It is not clear why the ward sister felt it necessary to comment on whether she had seen another family member carrying out the suctioning. This calls the accuracy of the statement into question.
58. On balance, it is likely staff did show Mrs A how to suction her mother’s airway and then left her alone to complete this task. This is not in line with the NMC code, which says nurses should only delegate tasks to others if the task is within the other person’s scope of competence. It also says the person must be properly supervised and supported when carrying out a delegated task.
59. Further, we note our nursing adviser explained airway suctioning is not a task all nurses can do. It carries risks and is often done by specialist physiotherapists. Although nurses may learn how to do suctioning during their nursing training, this does not mean they are competent in the procedure.
60. Our nursing adviser said nurses can do airway suctioning if they have been trained and assessed as competent in this task and are working within their employer’s local policies or standard operating procedure (SOP).
61. As airway suctioning is often done by physiotherapists, many nurses will not use the skill regularly and will need regular refresher training to keep their competency up to date.
62. Many examples of suctioning policies or SOPs are available on different NHS organisations websites. These typically set out which staff can do suctioning, what training they need, the clinical indications and contra indications for suctioning, and what technique, equipment and setting should be used. These policies protect staff and patients by ensuring staff are following best practice in giving safe and effective care.
63. The Trust has not provided any policy or SOP relating to airway suctioning, or evidence the nurse had undergone the necessary training and been assessed as competent in this task.
64. Our nursing adviser said nurses should not be giving this care without a local policy or SOP. This is because the NMC code says nurses must work safely and within the limits of their competence. It also says nurses must take measures to reduce the likelihood of mistakes that can cause harm.
65. Without a local policy or SOP nurses cannot identify the limits of their competence or ensure they are working safely and in line with best practice. Further, without a local policy or SOP it was not in line with the NMC code even if the nurse had suctioned Mrs N’s airway.
66. When considering the impact this had, we took advice from our physician adviser. They said the risk of causing significant damage during suctioning is very low, even if Mrs A had been left unsupervised following minimal training. Our physician adviser said it was very unlikely suctioning had an adverse effect on Mrs N’s health or contributed to her death.
67. Our physician adviser explained nosebleeds can be fatal in frail older patients. He said Mrs N’s age, respiratory failure and heart failure meant she was at increased risk of dying from a nosebleed. This is because she was more likely to aspirate (inhale) blood which can be fatal.
68. Our physician adviser noted the observations recorded on Mrs N’s NEWS chart show she had already started to deteriorate by the time staff decided her airway should be suctioned. Between 5.10am and 10.15am her breathing rate had increased from 20 to 22, her heart rate had reduced from 61 to 46, and her systolic blood pressure had reduced from 122/62 to 110/71. These observations increased her NEWS score from two to four, which indicated she was becoming more unwell.
69. Our physician adviser said the evidence suggests suctioning was done because Mrs N had started to deteriorate as a result of her prolonged sporadic nosebleed. They said there is no evidence suctioning caused her to deteriorate further, and it is very unlikely suctioning (even by someone with inadequate training and without adequate local policies) would have caused Mrs N’s deterioration or increased her risk of dying.
70. Although we have seen no evidence suctioning had a clinical impact, we recognise it has caused Mrs A significant worry and distress. The timing of Mrs N’s final deterioration left Mrs A feeling as if she accidentally caused this and contributed to her death. This is an injustice to her. If staff had done suctioning rather than delegating to Mrs A, this additional worry and distress could have been avoided.
71. The Trust has not taken any action to put right what went wrong, so we partly uphold this complaint. We have set out some recommendations for the Trust at the end of this report.
Use of NIV outside prescribed times
72. The records show staff prescribed NIV to Mrs N in the Emergency Department because she had signs of respiratory failure and a chest wall deformity (kyphoscoliosis). When Mrs N’s condition stabilised, doctors prescribed NIV for use overnight. The records show Mrs N was stable on NIV and did not have any complications, although she sometimes found it difficult to wear the mask for a long time.
73. These actions were in line with BTS NIV guidelines, which say NIV is the ventilation mode of choice for patients with chest wall deformity and respiratory failure. They say following an episode of acute respiratory failure, NIV should usually continue overnight.
74. The records for 23 April say the nurse put Mrs N on NIV around 10.40am. The observations documented at 10.35am say Mrs N’s breathing rate had increased to 24 breaths (with the normal range being 12-20) and her oxygen levels were 92%. This oxygen level was within the normal target range for Mrs N.
75. In her statement to the Trust, the nurse said Mrs N’s oxygen levels kept dropping. In the meeting, the Trust told Mrs A the nurse said she took additional observations which she did not write down as everything happened very fast. She said she gave Mrs N NIV to try and stabilise her whilst waiting for the doctor.
76. The Trust acknowledged the recorded observations did not show Mrs N needed additional NIV outside the prescribed times.
77. As we have already explained, our nursing adviser said in an emergency staff may not be able to write down all observations if they are also giving urgent care. If we accept the nurse saw evidence Mrs N’s oxygen levels were dropping rapidly, this would be an emergency. In this situation the nurse would have two options while waiting for the doctor: do nothing or try NIV and see if this helped.
78. BTS NIV guidelines say patients with chest wall deformity can deteriorate rapidly during breaks from NIV. Therefore, it was important for the nurse to act quickly if there were signs Mrs N was deteriorating.
79. Both our nursing and physician advisers said it would be acceptable practice for a suitably trained and experienced nurse, working within clear local protocols, to give NIV in an emergency to a patient like Mrs N. This is because Mrs N had been using NIV without complications, and it is a low risk treatment which can increase oxygen levels.
80. The Trust has not provided evidence of the nurse’s training and experience in NIV. The BTS NIV guidelines say it is essential staff giving NIV have regular training and education.
81. The Trust has also not provided sufficient evidence of its local protocols for NIV. BTS NIV guidelines say it is essential hospitals offering NIV have local protocols that are applied uniformly in all areas where this treatment is given. The guidelines also say NIV must only be used in specified areas of the hospital where there are enhanced monitoring facilities and staffing levels.
82. The NIV protocol the Trust shared with us says it is only for use in the Emergency Department and Acute Assessment Unit of Chelsea and Westminster Hospital.
83. We find it was not in line with the expected standard for staff to give Mrs N NIV on 23 April outside the prescribed times. This is because there is no evidence the nurse had adequate training or was working to an appropriate NIV protocol.
84. We have carefully considered whether there is any evidence giving NIV outside prescribed times led to Mrs N’s deterioration or death.
85. Our physician adviser noted that as Mrs N had been bleeding from her nose and mouth, this increased the risk of NIV. This is because NIV works by forcing air into the airway. If there is blood (or any other secretions) in the nose or mouth, there is a risk NIV will force this into the airway and make the patient more unwell.
86. That said, it is important to recognise there are different accounts of whether Mrs N was bleeding at the time NIV was given.
87. The nurse told the Trust Mrs N was not bleeding when NIV was started, and the mask was removed a few minutes later when she started bleeding again. Mrs A says the bleeding had not stopped. She says shortly after the nurse put the NIV mask on, the sister ran in and immediately told her to take the mask off and sit Mrs N upright. She says the sister could see Mrs N was bleeding as soon as she arrived.
88. What is clear from both these accounts and the medical records is Mrs N was only on NIV for around five minutes. Our physician adviser said it is very unlikely using NIV for such a short time caused Mrs N’s deterioration or death, even if Mrs N’s nose was still bleeding.
89. Our physician adviser noted Mrs N’s documented observations show she was steadily deteriorating as the morning progressed. The increase in her breathing and heart rate, and reduction in her oxygen saturations and blood pressure showed she was becoming more unwell.
90. Our physician adviser said these observations indicate it is likely Mrs N had already aspirated before NIV was applied. As we have explained in the previous section, Mrs N sadly had several risk factors that increased her risk of aspirating and dying from a nosebleed.
91. Although we can see no evidence the brief use of NIV outside prescribed times led to Mrs N’s death, we recognise it has given Mrs A significant questions about the circumstances surrounding her mother’s death. Mrs A understands how NIV worked, so it is natural she would question whether this could have caused her mother’s death. This has been a source of great distress to her.
92. The Trust’s responses did not acknowledge any failings or offer any apologies for the inappropriate use of NIV. The Trust said it would review its policies for NIV and ensure the nurse received formal training on this. The Trust has not provided us with an updated NIV policy or given any evidence the nurse received training in this.
93. We find the Trust has done enough to put things right. Therefore, we partly uphold this aspect of the complaint. We have made some recommendations to the Trust at the end of this report.
94. Mrs A complains the investigation took too long. We are satisfied the Trust’s response of November 2017, meetings of January and February 2018, and response of June 2018 were arranged in a timely manner. The NHS complaints regulations say the ‘relevant period’ for responding to a complaint is six months. The Trust did not exceed this timescale before June 2018.
95. We note the response of June 2018 said the Trust would write to Mrs A again to share the outcome of an internal investigation into the nurse’s actions. In April 2019, the Trust said it could not share the outcome of the disciplinary investigation with Mrs A.
96. We find this delay was unnecessary. The outcome of an internal investigation into an individual staff member is personal data as defined in the GDPR.
97. The ICO guidance says employers have a duty to respect employee’s rights to a private life. It says employers should only disclose personal information if there is a legal obligation to do so, if the worker consents, or if there is a wider public interest that justifies disclosure.
98. Whilst this does not prohibit the Trust from sharing the outcome of disciplinary investigations, it makes it clear personal information should only be disclosed in exceptional circumstances.
99. The Trust had already answered Mrs A’s questions and should have directed her to PHSO in June 2018, in line with the NHS complaints regulations. By offering to share the outcome of the internal investigation with Mrs A the Trust delayed the conclusion of the complaints process by ten months. This was an unnecessary delay which did not add any value as the Trust subsequently decided not to share the outcome with her.
100. After we informed the Trust of our proposal to investigate this complaint, the Trust decided to share an anonymised version of the outcome of the disciplinary hearing with Mrs A. This was not something we expected or asked the Trust to do.
101. Mrs A also complains the Trust has not given an adequate explanation of what happened and why her mother died. We recognise it was difficult for the Trust to confirm exactly what happened regarding some aspects of Mrs N’s care due to differing accounts given by Mrs A and the staff on duty. It was not possible to say with certainty what happened.
102. We understand why the Trust’s initial response focused on the evidence in the medical records, as records made at the time are often more reliable than statements made later.
103. After meeting Mrs A, the Trust then acknowledged she had detailed knowledge of suctioning which is likely to have come from staff training, this indicated the Trust believed Mrs A’s account.
104. The Trust’s disciplinary investigation report said there was ‘no evidence’ Mrs A was left to suction her mother’s airway. The Trust did not explain why it reached a different conclusion than it reached following the meeting with Mrs A.
105. These contradictory explanations have left Mrs A without a satisfactory explanation of what the Trust’s believes happened.
106. We recognise the Trust could not say with certainty what caused Mrs N’s death, as she did not have a post-mortem.
107. In trying to answer Mrs A’s question the Trust’s first response speculated on potential causes of Mrs N’s death. The response said Mrs N’s deterioration and death may have been due to aspiration pneumonia, hospital-acquired pneumonia or mucus plug.
108. The response did not explain what these conditions are, or why the Trust believed these could have been potential causes of Mrs N’s death. This speculation without explanation added to Mrs A’s confusion about what happened.
109. The Trust’s response of June 2018 said if Mrs A’s account of events was correct it is likely Mrs N aspirated some blood and this led to her respiratory condition deteriorating further. Our physician adviser agreed the evidence suggests this was the likely sequence of events. This was a good explanation of the likely cause of
Mrs N’s death.
110. Overall, we find the Trust failed to act in line with our complaint handling principles, which say organisations should avoid undue delay and give clear, evidence based explanations of the decision.
111. These failings had a negative impact on Mrs A. She had to wait longer than necessary before being able to bring her complaint to us. The responses also left Mrs A more confused about what happened, and why her mother died.
112. The Trust has not acknowledged the delays or poor explanations it has provided. Therefore, we uphold this part of the complaint. We have made recommendations below for how the Trust should put this right.