East Kent Hospitals University NHS Foundation Trust

5. Miss R complains that when her father, Mr G, was a patient at the Trust from 24 March until 1 May 2022, it: • gave him food and drink and did not refer him for a swallow assessment, despite his suspected stroke and problems swallowing • did not isolate him in a side room, even though he was extremely vulnerable to COVID-19.

6. Miss R considers her father could have survived the stroke, but his poor care meant he developed aspiration pneumonia, caught COVID-19, and sadly died on 2 May. This caused her significant worry and upset and has had an ongoing emotional impact on her wider family.

7. Miss R wants the Trust to acknowledge its mistakes, apologise for the impact these had, make improvements, and pay a financial remedy.

8. Mr G, aged 77 at the time, had a history of myelodysplastic syndrome (MDS). This is a rare type of blood cancer, where the bone marrow does not work properly causing a drop in the number of blood cells. It can cause tiredness, bleeding, and infections.

9. On 24 March 2022 Mr G was due to attend a hospital appointment but was found collapsed at home with slurred speech. An ambulance took him to the Trust’s Queen Elizabeth the Queen Mother hospital at around 8.40am.

10. Doctors reviewed him and suspected a stroke, which was confirmed after a brain scan the following morning. Later on 25 March he was made ‘nil by mouth’. This means he was not allowed to have any oral intake such as food and drink.

11. On the evening of 25 March Mr G became unwell and was diagnosed with aspiration pneumonia. He was given antibiotic treatment for this.

12. On 26 March Mr G was transferred to the acute stroke unit at the Trust’s Kent and Canterbury hospital, where he continued to receive treatment for his aspiration pneumonia and stroke. He then moved to the stroke rehabilitation ward on 1 April.

13. Mr G tested positive for COVID-19 on 9 April and developed COVID-19 pneumonitis (inflammation of the lung). This made him more unwell. He had increasing oxygen needs and over the next few weeks did not improve, despite treatment.

14. On 29 April doctors decided the focus of his care should shift to providing end of life care. On 1 May he was discharged to a hospice, and sadly died from his illness on 2 May.

Complaint about being given food and drink with no swallow assessment

18. The stroke guidelines say: ‘patients with residual neurological symptoms or signs should remain nil by mouth until screened for dysphagia by a specifically trained healthcare professional’. Dysphagia is the medical term for difficulty swallowing.

19. Miss R says the Trust did not follow this guidance despite her father having signs of a stroke and difficulty swallowing when he was admitted. The Trust accepts this. It agrees it should have made Mr G nil by mouth and referred him to the Speech and Language Therapy Team (SALT) for a swallow assessment when he was admitted.

20. We looked at the records to help us reach our own view. These show a doctor suspected a stroke from as early as 9.45am when Mr G was first assessed. At this stage, the doctor did not comment on whether Mr G could swallow or whether he should be nil by mouth and no referral to SALT was done.

21. Then, at 10am, a specialist cancer nurse saw Mr G. They noticed he coughed when drinking water, which is a sign of difficulty swallowing. They recommended a SALT assessment, but this was not arranged.

22. Despite having signs of a stroke and difficulty swallowing, the Trust did not make Mr G nil by mouth and did not assess his swallowing. According to the records, it gave him food and drink, including at least three meals, snacks, and drinks, for around 28 hours until 2pm on 25 March when he was finally made nil by mouth.

23. This was not in line with the stroke guidelines, and constitutes a failing. Later in the report we set out our thinking about the impact of this failing.

Complaint about not being isolated in a side room

24. Mr G’s medical condition, MDS, meant he was one of the people the COVID-19 green book described as being ‘clinically extremely vulnerable’. This meant he was considered at high risk of serious illness from COVID-19 and had to take extra precautions during the pandemic such as shielding and early vaccination.

25. Miss R considers this meant her father should have been isolated in a side room during his admission to hospital. The Trust disagrees. It told us he was not a high priority to be placed in a side room, and it was not ‘clinically required’.

26. The infection prevention guidelines say people admitted to hospital ‘with underlying health conditions who are at higher risk of severe outcomes should be prioritised for placement in single rooms whilst awaiting testing [for COVID-19]’.

27. This process is called protective isolation. The purpose of this is to reduce the chances of someone with a weakened immune system catching an infection such as COVID-19.

28. Hospitals need to balance the need for protective isolation of patients, with another type of isolation called source isolation. This is when a patient with a contagious infection needs to be kept in isolation to stop it spreading to other patients.

29. Isolating patients was challenging during the COVID-19 pandemic as high numbers of people in hospital with COVID-19 meant single side rooms were in high demand.

30. To make sure its side rooms were used by people who needed them the most, the Trust’s isolation policy sets out how it measures whether people have a weakened enough immune system to go into protective isolation.

31. It says: ‘protective isolation is indicated when a patient is neutropenic (defined as a neutrophil count of less than 0.5 x 109/L)’. Neutrophils are a type of infection-fighting white blood cell and form part of the immune system.

32. Our adviser explained another measure of someone’s immune system is looking at their overall white cell count. People with a lower than normal count would be considered for protective isolation.

33. We examined Mr G’s records and saw that during the period we are looking at, which is the date from when he was admitted until the date he tested positive for COVID-19, his white cell count and neutrophil count never dropped below normal levels. This supports the Trust’s view that he was not a priority for isolation in a side room.

34. There is no doubt that having MDS meant Mr G was at higher risk of a severe outcome from COVID-19 compared to someone without this condition. We recognise it would have been ideal for Mr G to be cared for in a side room. It would have reassured him and Miss R that he was getting the maximum protection for his immune system.

35. Although the national guidance says people in this position should be prioritised for side rooms, we can see that, in practice, organisations needed to balance this with the availability of side rooms. To do this the Trust had a specific policy where the integrity of an individual’s immune system would be considered when deciding on protective isolation. We note the Trust did not mention this policy at the time or in its complaint response, but nonetheless this policy still applied.

36. In Mr G’s case, although he was at higher risk of severe outcomes, his immune system was not weakened enough to need protective isolation. Therefore, we think the Trust acted with due regard to its policy when it did not place him in a side room before he caught COVID-19.

37. As we have seen no failing here, we have not found that Mr G caught COVID-19 from a lapse in his care as Miss R suspects. Although this is not the finding Miss R was hoping for, we hope the explanation here reassures her about the Trust’s actions.

Impact of the stroke failing

38. Miss R thinks the Trust’s failure to make her father nil by mouth and refer him for a swallow assessment caused his aspiration pneumonia. She thinks this contributed to his death because it made him more vulnerable when he later caught COVID-19, and his chances of surviving would have been higher if he did not also have aspiration pneumonia.

39. The records show Mr G started to become unwell at around 6pm on 25 March. He had a high temperature and shivers. Staff diagnosed aspiration pneumonia and started antibiotic treatment for this.

40. The pneumonia did not resolve, and doctors tried Mr G on some new antibiotics on 4 April. He was also needing low levels of oxygen most days. By 8 April he was getting worse, and the Trust swabbed him for COVID-19. This came back positive the following day, and Mr G needed antiviral medication, and higher levels of oxygen.

41. Mr G’s condition deteriorated again on 16 April. He was treated with steroids, even higher strength oxygen, and a new course of antibiotics. He did not respond to treatment and needed end of life care, sadly dying on 2 May.

42. We considered whether the deterioration in Mr G’s condition described above was related to the Trust’s failing. We note the Trust says Mr G could have developed aspiration pneumonia even if he was made nil by mouth at the right time, as he could have aspirated on his own saliva. We think that is unlikely the reason for what happened on 25 March.

43. People with difficulty swallowing after a stroke are at risk of developing aspiration pneumonia. Ingested food and liquids can enter the airway and travel to the lungs, leading to an infection. The Trust is correct that some patients can develop pneumonia by aspirating on saliva, even when they are nil by mouth.

44. However, our adviser says the fact Mr G, who could not swallow properly, was consistently given oral intake over a long period of time means it is more likely than not that the Trust’s failing led to Mr G developing aspiration pneumonia on 25 March.

45. Having established this, we next looked at whether the aspiration pneumonia affected Mr G’s chances of survival when he caught COVID-19. This involved thinking about the various ways in which Mr G’s conditions affected his chances of survival.

46. Having a stroke can increase someone’s risk of death. The NICE CKS says in 2020 nearly 12% of people who had a stroke caused by a blood clot (like Mr G) died within 30 days of hospital admission. Our adviser explained Mr G’s stroke, on its own, was very likely survivable as it mainly affected his speech and swallowing.

47. Stroke research shows the additional complication of aspiration pneumonia in people with stroke increases the risk of death, and this risk gets worse when there are delays in screening someone’s swallowing.

48. The COVID-19 green book says the risk of death from COVID-19 is higher in people who are older and have other health problems. The 4C mortality score can be used to calculate an individual’s risk of death from COVID-19. Our adviser calculated Mr G’s score as a 46.9% chance of death.

49. However, this was based on the combined effects of his COVID-19 and aspiration pneumonia. Our adviser says it’s difficult to separate out the effects of these two conditions and this number may have been lower if he had COVID-19 alone.

50. On review of the records our adviser says COVID-19 appeared to be the more dominant factor in Mr G’s deterioration. This is based on the way in which he deteriorated, and the timing of this deterioration after he tested positive. Our adviser says Mr G may still have died from COVID-19 even without aspiration pneumonia.

51. However, it is also possible the underlying aspiration pneumonia contributed to the severity of his COVID-19 infection. Our adviser says his risk of death might have been lower if he did not also have aspiration pneumonia, but we can never know, even on the balance of probabilities, by how much.

52. On the balance of probabilities, we cannot say Mr G’s death was avoidable. He may still have died even if the failing had not happened. However, we acknowledge there is a possibility he may have had a better chance of survival if not for the failing. We recognise this will be difficult for Miss R to hear.

53. Unfortunately, we are left in a position where we will never know how much better his chances may have been, and if the outcome would have been any different for him if the failing had not occurred.

54. This means Miss R is now left with ongoing uncertainty about whether the Trust’s actions denied her father the best chance of survival. This injustice is significant and will be lifelong. We recognise this will add to the distress and worry she was already feeling from witnessing her father’s deterioration.

55. We think the Trust should take action to put things right, and we address this in the next section of our report.

1. We are very sorry to hear Miss R’s concerns about the care provided to her father. We find that although Mr G was vulnerable, it was not clinically indicated for him to be in a side room based on his blood test results and the Trust’s policy.

2. We find the Trust failed to assess Mr G’s swallow and inappropriately gave him food and drink. This entered his airway and led to an infection called aspiration pneumonia (which is a type of serious inflammation in the lungs).

3. Whilst we do not think this caused Mr G’s death, we will unfortunately never know to what extent it made it harder for him to recover from COVID-19. Miss R is now sadly left with ongoing uncertainty about whether her father could have survived. This injustice to her is significant and will be everlasting.

4. We partly uphold this complaint. We recommend the Trust to acts to put things right for Miss R. This includes an apology, an explanation of improvements, and a financial remedy of £2000.