The Hillingdon Hospitals NHS Foundation Trust

4. Mr C complains that during his mother, Mrs C’s admission between 2 December 2022 and 7 January 2023: • the Trust wrongly discharged her on 12 December when she was unfit • she did not receive appropriate clinical care for 10 days over the Christmas and New Year period because there were no consultants present to provide it • the Trust took three days to check the nasogastric tube (NGT), inserted on 3 January, was properly aligned and to first give his mother medication through it • on 6 January the doctor failed to explain his mother could die that weekend • she died 15 minutes after drugs were administered to her on 7 January.

5. Mr C says the decision to discharge was clearly unsafe as his mother was readmitted hours later, having deteriorated. He says she never recovered from this deterioration and her health continued to decline, only contributed to by the lack of consultants to give the care she needed, and delays in giving medication through the NGT. Mr C queries whether the NGT was properly aligned and whether this, and the medication given on 7 January, were contributory or even causal factors for his mother’s death.

6. Mr C says he was left with false hope at the discussion on 6 January, and had he been made aware his mother could die so soon, he and his father would have had time to prepare and would have made sure they were with his mother when she died. He has been left with considerable distress, as he feels he is left not knowing what happened have caused his mother to have died so suddenly and unexpectedly. Mr C explains this has had a profound impact on him and the family.

7. To resolve his complaint, Mr C would like the Trust to acknowledge its failings and to apologise to him for their impact. He also seeks improvements at the Trust, for lessons to be learned and action taken to ensure these events do not happen to anyone else in future.

8. Mrs C was 87 years of age when she arrived at the Trust on 1 December 2022. She was admitted with frank haematuria (visible blood in the urine). Mr C reported to staff that his mother had a hospital bed with a riser recliner at home, with carers attending most days, using a hoist to transfer her out of bed every few months.

9. Mrs C’s management plan included bladder irrigation (flushing the bladder using sterile liquid), intravenous (IV) antibiotics and surgical review for her abdominal distension. A CT scan found stones in both kidneys.

10. On 5 December the surgical team noted bleeding from the urinary tract, which it felt was likely related to the kidney stones. On 7 December a urology review determined Mrs C was not fit for general anaesthesia. In agreement with the surgical team, the plan was to manage the kidney stones conservatively (medically, not surgically).

11. On 12 December the urology team discharged Mrs C from its care. She was deemed medically fit for discharge. Mrs C remained in hospital at the family’s request, due to a problem with her boiler and the heating at her home. The care of the elderly team reviewed Mrs C on 14 December and determined she would benefit from a step-down bed (sometimes referred to as rehabilitation, a non-acute hospital environment) whilst awaiting resolution of the home heating situation, acknowledging she had no major rehabilitation goal.

12. Entries on 15 December note Mrs C was awaiting a bed space at Hawthorn Intermediate Care Unit (HICU). She was discharged with medication including antibiotics and transferred to HICU on 21 December. The HICU clerking doctor requested Mrs C be transferred back to the Trust, to rule out a bleed. Mrs C was seen in the Trust’s emergency department in the early hours of 22 December and readmitted later that morning.

13. A CT scan found no evidence of active bleeding. Microbiology found a urinary tract infection (UTI) and she was continued on IV antibiotics. Mrs C was monitored and in the following days, considered to have delirium secondary to her UTI and progression of her frailty and Parkinson’s disease. Speech and language therapy and dieticians reviewed Mrs C and a plan was made for a short-term NGT to improve her poor oral nutritional intake.

14. From 4 January different antibiotic types were added to the IV antibiotic regimen in place, as it was felt Mrs C likely had urosepsis (sepsis is when an infection becomes overwhelming and can be life-threatening; urosepsis is a term used when the infection is felt to have started in the urinary tract).

15. The NGT was put in place on 5 January and feeding was first given through it the next day. Also on 6 January, the consultant spoke with Mr C to update him on his mother’s condition and the management plan for the weekend ahead. A nursing record on the morning of 7 January notes Mrs C was given her medications via NGT at 9am and was responding as normal, however when the nurse returned at 9.30am Mrs C was not breathing. Very sadly, her death was confirmed.

Discharge 19. Records show Mrs C was discharged to HICU on 21 December, not 12 December as Mr C suggests.

20. Statutory Discharge Guidance contains a list of criteria to reside in hospital. It says every patient on every ward should be assessed daily to determine whether these criteria are met, and if the answer to each is ‘no’, the patient can be discharged.

21. The criteria include factors such as does the patient require oxygen therapy, are they in the last hours of life, and have they undergone surgery within the last 48 hours, for example. At the point of discharge, Mrs C did not meet any of the criteria within Statutory Discharge Guidance.

22. NHS Discharge Policy supports the above guidance and says hospitals must discharge all patients who no longer meet these criteria as soon as they are clinically safe to do so. We know Mr C has raised concern that his mother was unfit at that time.

23. Our adviser has carefully reviewed the records and confirms this was a clinically safe decision. Mrs C had been discharged from the urology service nine days previously, and her vital signs were checked on the day of transfer and were all in the normal range. There is nothing clinically to suggest she was unfit for discharge at the point she left the Trust.

Bank Holiday provision 24. There are no specific guidelines or requirements about how often a patient should be seen by a consultant in hospital, whether during a Bank Holiday period or not. GMC Guidance applies, and says doctors must adequately assess the patient’s condition, examining the patient and promptly providing or arranging suitable advice, investigations or treatment, where necessary.

25. Mr C is concerned his mother did not receive appropriate clinical care due to a lack of consultant provision. For the period in question, records show Mrs C was reviewed by a consultant on five separate days, on 23, 28, 29 and 30 December, and on 3 January. We consider this in line with GMC Guidance.

26. Records show Mrs C was stable and was continued on treatment from IV antibiotics and fluids during this time, which was the appropriate care. Our clinical adviser confirms there was no clinical need for her to be reviewed by the on call clinical team during this time, further showing Mrs C appeared stable around the times she was reviewed by consultants.

NGT alignment 27. Records show the NGT was inserted on 5 January, not 3 January as Mr C suggests.

28. Records show a chest X-ray was taken after the NGT was put in place. Our clinical adviser confirms this shows the NGT was in the correct position. Records also show Trust doctors reviewed the X-ray on 6 January, confirming its positioning. A nursing entry confirms NGT feeding had been started on 6 January, within 24 hours of the NGT’s insertion.

29. There are no specific guidelines relating to the time from NGT insertion to its use. Our clinical adviser says use within 24 hours is in line with usual practice, and it is important to confirm the position of the tube before use, to reduce the risk of feed entering the lungs. We can assure Mr C we do not see any delay between the NGT’s insertion, the check to confirm it was properly aligned, and it first being used.

Communicating the prognosis 30. Mr C complains that on 6 January the doctor failed to explain his mother could die that weekend. He recalls the doctor discussing the plan for antibiotics and monitoring over the weekend and for review on Monday, which he says left him with false hope and without awareness that this mother could die so soon.

31. We were not there at the discussion, and so must rely on Mr C’s recollection and the documented evidence. We accept what Mr C remembers being discussed at the time. We find an entry in the records made by the consultant who spoke with Mr C on 6 January.

32. The consultant wrote that they explained to Mr C his mother was very unwell and was being treated with three different antibiotics for sepsis. The consultant noted explaining that they had introduced the NGT to improve her nutritional intake and would monitor Mrs C with blood testing over the weekend. We find records of similar discussions between Trust doctors and Mr C on 28 and 29 December, and on 4 January.

33. On each of those occasions, records note it was explained to Mr C that his mother remained very unwell. It was explained that she was vulnerable to infection and then later that she had sepsis, that her prognosis was poor and the outcome could not be predicted, and it was likely she would deteriorate further despite their best efforts and providing treatment. As early as 22 December, a consultant had spoken with Mr C and gained his agreement for a ‘do not attempt cardiopulmonary resuscitation’ order to be put in place.

34. GMC Guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them the information and support they need. We find the recorded evidence of what was discussed with Mr C on 6 January, and on these earlier occasions, appropriate and in line with GMC Guidance.

35. From Mr C’s recollection and the recorded evidence, we agree it was not explained that Mrs C could die that weekend. Yet, we would not expect this to have been said, because this could not have been predicted. The Trust continued to actively treat Mrs C and its plan on 6 January was to continue to monitor her alongside giving treatment. This was the explanation given to Mr C, which was accurate to Mrs C’s condition and the plan in place.

36. We do not consider it reasonable to say the explanation given gave Mr C false hope. On this as well as on several earlier occasions, we find the Trust made sure Mr C was fully informed about how unwell his mother was, the likelihood of deterioration and sadly a likely poor outcome at any time.

NGT drug administration 37. The medicine administration record documents that Mrs C was given her medicines on 7 January as they were prescribed at that morning’s drug round. Our clinical adviser confirms there were no new drugs prescribed or given to Mrs C that day than were prescribed or given on earlier occasions. The nursing note does not record any issues when those medicines were administered.

38. We know Mr C is very concerned that his mother died so soon after drugs were given to her on 7 January. We hope to assure Mr C we do not see any indication that anything was wrong with drug prescription or administration that morning.

1. Mr C complains about aspects of the care and treatment provided to his mother in hospital, from 2 December 2022 up to the time of her death on 7 January 2023.

2. We have considered the evidence carefully and we do not see any indication of failings in the complaints raised about the Trust’s care, treatment or communication.

3. As we have seen no indication of wrongdoing, we have decided not to investigate further. We recognise how important this complaint is to Mr C and we extend our condolences to him on the loss of his beloved mother.