University Hospitals of North Midlands NHS Trust

3. Mrs A complains about the end-of-life care the Trust gave to her mother, Mrs B, between 4 and 7 December 2019. Mrs A complains:

• the types of medication the Trust gave to Mrs B were inappropriate for her needs • the way antibiotics were given to Mrs B was inappropriate for her needs • there were delays in antibiotics being given to Mrs B.

4. Mrs A says that Mrs B suffered a horrific death and this was very distressing to watch for her and her sisters. She says it should have been managed in a more caring way. Mrs A says she has suffered from flashbacks ever since.

5. As an outcome, Mrs A wants a further explanation about the timings of certain end-of-life medications given to Mrs B. She also wants changes in procedure so no one else goes through such a distressing experience.

6. Mrs B was in her seventies. She had a background of breast cancer in 2017 and was diagnosed with lung cancer in August 2019. She had started chemotherapy treatment in October 2019.

7. Mrs B was admitted to hospital on 4 December 2019 due to reduced eating and drinking. She had reported pyrexia which is increased body temperature or fever. At first, Mrs B’s condition was stable, but she became more unwell that afternoon.

8. Mrs B had a D-Dimer to test for blood clots. A CT scan on 6 December 2019 showed no blood clots. She was getting fluids and antibiotics due to dehydration but developed a chest sepsis (infection).

9. Unfortunately, Mrs B experienced more deterioration in her condition and she sadly died. The causes of her death were pneumonia and cancer.

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that something has gone wrong with Mrs B’s medication.

15. We can see from the records including Mrs B’s medication charts that she was prescribed many different medications at the time she was in hospital, including antibiotics and painkillers. We note that Mrs A has questioned whether some of this medication was right for Mrs B. We do not intend to comment on each and every medication Mrs B was prescribed, but some of it was regular medications such as dalteparin to reduce blood clots, morphine for pain relief, and once only medication like ondansetron for nausea. Mrs B was also given intravenous fluids (IV).

16. IV fluids are needed for patients who cannot meet their own fluid requirements orally or who need extra fluids due to illness or ongoing losses. The NICE guidance on IV therapy in adults in hospital states, ‘Assess and manage patients' fluid and electrolyte needs as part of every ward review. Provide intravenous (IV) fluid therapy only for patients whose needs cannot be met by oral or enteral routes and stop as soon as possible’.

17. Mrs B was clinically assessed to have been dehydrated and acutely ill with severe pneumonia. Therefore, IV fluids were needed on the 4, 5 and 6 December 2019 in line with the NICE guidance.

18. Having considered Mrs B’s medication charts, our consultant adviser says all her medications and IV fluids were appropriate to treat her different symptoms and conditions at the time.

19. Mrs B was given antibiotics (tazocin and meropenem) by a cannula ¬– a device in the form of a small tube inserted into a patient’s vein so the medication goes straight into the bloodstream.

20. By 6 December 2019, Mrs B had a chest infection. This likely developed into neutropenic sepsis, which is a whole-body reaction to an infection, as our consultant adviser says her condition eventually became overwhelming. The NICE guidance on managing neutropenic sepsis states:

‘Give an intravenous broad-spectrum antibiotic at the maximum recommended dose. The choice of antibiotic will depend on the person's age, clinical presentation, most likely source of infection, recent antibiotic use, and local antibiotic prescribing guidelines.

• Antibiotic treatment should not be delayed until neutropenia is confirmed.

• Anti-pseudomonal cover is important for people with suspected neutropenic sepsis, so a first-line choice may be monotherapy with piperacillin/tazobactam, depending on local protocols. Prolonged antibiotic therapy may be needed’.

21. We appreciate Mrs A’s concerns about how antibiotics were given to Mrs B, but we consider that both antibiotics were given correctly in line with the NICE guidance.

22. The Trust said in its complaint response that Mrs B got her last dose of tazocin at 2pm on 6 December 2019. Meropenem was then given at 6.30pm on 6 December. Mrs A is concerned that there was then a delay of almost 14 hours until Mrs B got her second dose of meropenem at 8.15am on 7 December 2019. We have looked at the claimed delay between doses of Mrs B’s meropenem and any negative impact this may have had.

23. BNF guidance for indications and doses of meropenem in adults states, ‘0.5 to 1 g every 8 hours by intravenous infusion or intravenous injection’. Therefore, our consultant adviser says that antibiotic medication like meropenem is usually given three times a day (every eight hours) at approximately 6am, 1 or 2pm and then at around 10pm. It is given during scheduled medication rounds by nurses.

24. The records reflect that Mrs B had a full course of tazocin from the time she arrived at the hospital. The decision to switch her on to meropenem is documented on 6 December 2019, after her last dose of tazocin was given at 2pm.

25. If Mrs B’s first dose of meropenem was at 6.30pm on 6 December 2019 then, ideally, our consultant adviser says her next dose should have been at approximately 2.30am instead of 8.15am on 7 December 2019. We appreciate this may cause some anxiety for Mrs A in terms of how Mrs B’s antibiotic medication was being managed overnight to treat her infection.

26. Our consultant adviser says that while this is not ideal, there are no signs the delay in giving Mrs B’s meropenem on 7 December 2019 had any impact on her. This is because by that point, Mrs B was unfortunately experiencing overwhelming sepsis. Information in Mrs B’s hospital records, especially her increasing oxygen demands, high levels of lactate and deteriorating vital signs, show that her condition was sadly worsening.

27. We are sorry to hear that this was a very distressing experience for Mrs A and her family to witness. It is always difficult when a family member is unwell in hospital, especially if the outcome is that they sadly pass away.

28. Mrs B had terminal cancer and, in hindsight, she was at the end of her life when she went into hospital on 4 December 2019. This did not become clear until later in the admission, when she had a noticeable deterioration in her condition due to infection (sepsis). In this respect, we appreciate that Mrs B’s quick deterioration and her death was unexpected at that time. We recognise this was distressing and traumatic for Mrs A and her family.

29. We have not seen any indication of a link between Mrs B’s sad death and the medication she was taking, which overall was managed appropriately. We hope that our review of Mrs B’s medication gives the reassurance that Mrs A is looking for.

1. We have carefully considered Mrs A’s complaint about University Hospitals of North Midlands NHS Trust (the Trust) regarding the medication given to her mother, Mrs B, at the end of her life between 4 and 7 December 2019. We are deeply sorry to hear that Mrs B experienced a horrific death and this was very distressing for Mrs A and her family to witness. We are also sorry to hear about the wider health impact these events have had on Mrs A.

2. From the evidence we have seen, there is no indication that anything went seriously wrong with Mrs B’s medication when she was in hospital.