Airedale NHS Foundation Trust

3. Mrs A complains about aspects of the care and treatment clinicians at Airedale Hospital (part of the Airedale Trust) gave to her father on 27 and 28 February 2023. She says they delayed his treatment and did not arrange for the intensive care he needed. She says doctors transferred him to another hospital instead.

4. Mrs A also complains about how doctors at Bradford Royal Infirmary (the BRI - part of the Bradford Trust) treated her father during two admissions. Specifically, she says they failed to give her father antibiotics after changing his femoral line (a type of catheter inserted into the groin that is sometimes used for dialysis when other approaches cannot be used) and before discharging him on 23 February 2023. She also complains there were delays in providing the treatment her father needed following his readmission on 28 February 2023. She believes there was a delay in providing him with intensive care.

5. Mrs A questions whether her father would not have died if clinicians had provided the treatment he needed. She says these events were distressing for her father and his family. She says her family was denied an opportunity to say goodbye because her father went into a coma.

6. Mrs A wants the organisations to acknowledge their failings and apologise for the impact they had. She also wants to ensure they make changes to procedures so other patients do not have the same experience. She also seeks a financial remedy

7. Mr K (aged 82) had a history of end stage kidney disease, diabetes, high blood pressure, heart disease and stroke. He had a fistula (this is a connection between an artery and a vein that is used for dialysis) for regular dialysis.

8. On 18 February 2023 Mr K attended his dialysis clinic as planned. However, they suspected the fistula was blocked and could not provide the treatment. They recommended he should attend the BRI, which he did the next day. Doctors admitted him to the Hospital where they inserted a femoral line. A scan confirmed the fistula was blocked by a blood clot.

9. The clinicians responsible for Mr K’s care and treatment at the BRI met on 22 February 2023. They confirmed it was no longer safe to use the fistula and that it could not be repaired. The next day they inserted a tunnelled catheter into Mr K’s neck. Doctors decided to discharge him from the hospital later that day.

10. On 27 February 2023 Mr K appeared confused and drowsy. His family called an ambulance which took him to Airedale Hospital. Doctors there admitted him to the acute assessment unit (AAU). They established he needed specialist care and referred him to the renal department at the BRI. This was because dialysis was not available at Airedale Hospital.

11. At this point Mr K was seriously unwell and had sepsis (the body’s overwhelming response to an infection which can lead to organ damage). While waiting for the transfer doctors treated Mr K with intravenous antibiotics and arranged reviews from the critical care outreach team (CCOT).

12. Mr K arrived at the BRI on the evening of 28 February 2023. Doctors then treated him with dialysis. In the early hours of the next morning his health worsened and doctors transferred him to the intensive care unit (ICU). At that point they sedated him while continuing active treatment. Sadly, Mr K’s health did not improve, and he died in the ICU on 7 March.

The Airedale Trust

16. Mrs A believes doctors should have transferred her father to the ICU while he was at Airedale Hospital on 27 February 2023. Instead, they decided to transfer him to a different hospital when she considers he was too unwell for that. She says they delayed his treatment.

17. The NEWS Guideline aims to improve the detection of and response to clinical deterioration in patients with acute illness. It is based on a simple scoring system where scores are allocated to specific physiological measurements (breathing rate, levels of oxygen in the blood, blood pressure, pulse, consciousness and temperature). The NEWS tells clinicians how they should respond when the total score is between specific values.

18. The NEWS Guideline explains that, if a patient has a NEWS score of seven or more this passes the threshold for an emergency response. This should include:

• escalation to the medical team • emergency assessment from a team with critical care competencies • consideration of a transfer to a level two or level three facility (meaning critical or intensive care) • providing clinical care in an environment with monitoring facilities.

19. The Sepsis Guideline explains how healthcare professionals should recognise signs of sepsis. It also explains how they should treat sepsis once it is suspected or diagnosed. This includes treating the patient with intravenous fluids and antibiotics. The Sepsis Guideline recommends starting treatment within one hour of calculating the NEWS score.

20. The clinical records show Mr K arrived at Airedale Hospital at 6.12pm on 27 February 2023. At this point a nurse noted Mr K had a NEWS score of eight (including fast heart and breathing rates). A doctor in the emergency department reviewed him at 6.42pm. They noted his history and his recent symptoms. The doctor examined him and found his chest was clear with no abdominal problems. The sites of the central and femoral lines were clean and did not look infected. The doctor diagnosed sepsis resulting from a chest infection.

21. The records also show the doctor prescribed intravenous fluids and antibiotics just over one hour after the NEWS score. The Medical Adviser told us this was just outside the one hour recommended in the Sepsis Guideline. They said, in reality, administering antibiotics in just over an hour is prompt in the context of how busy most emergency departments are. We cannot say this was a significant delay.

22. The Medical Adviser said Mr K’s observation charts suggest he was unwell, but stable and he appeared to improve a little of the course of the evening. It should be noted that clinicians in the emergency department would have had critical care competencies and appropriate monitoring facilities. A doctor saw Mr K within thirty minutes of arrival. The NEWS Guideline only specifies that there should be consideration of critical or intensive care, this does not mean such care must be arranged. The emergency department would have been a suitable place for doctors to assess any emergency response.

23. The clinical records are unclear about whether there was a referral to and review by the ICU team before Mr K left the emergency department. The Medical Adviser did not consider referral to ICU would have made a significant difference in this case. Mr K needed dialysis. This would not have happened more quickly by him being admitted to ICU. There is no suggestion that the emergency department was unable to manage the problems Mr K had at the time.

24. By 5.10am on 28 February 2023 Mr K had moved to the AAU. A junior doctor reviewed him at that time. They noted his history and agreed with the earlier diagnosis of sepsis. They also questioned whether he had a stroke based on the results of a CT scan of the head.

25. At 6.15am a more senior doctor attended to review Mr K. They did not consider it likely that Mr K had a stroke. They noted Mr K needed dialysis, which was unavailable at Airedale Hospital. They said they would liaise with the BRI about a transfer. The consultant at the BRI later agreed to accept Mr K when a bed became available.

26. The CCOT assessed Mr K at 9.50am. A doctor from ICU then reviewed him at 10.45am. The plan was not to admit him to ICU at that stage and to keep him under the care of CCOT for the time being. A consultant then reviewed Mr K at 3pm. All the doctors agreed Mr K had sepsis and needed to transfer for dialysis.

27. The Medical Adviser said prompt delivery of intravenous fluids, intravenous antibiotics and oxygen was the appropriate treatment at the time Mr K was assessed in ED. A referral and transfer to ICU was not warranted. Doctors recognised Mr K needed dialysis. The Medical Adviser said it was commendable that the consultant chased the transfer up and spoke to the renal consultant at the BRI. Mr K was fit for transfer based on his blood gas results and his NEWS scores being stable at around five by that stage.

28. Unfortunately, Airedale Hospital does not have a renal unit (which is not uncommon in some smaller hospitals in the UK) and so Mr K needed a transfer. It would not have been appropriate to transfer him to ICU at Airedale Hospital instead. He would have needed a transfer for dialysis a few hours later and so this would have caused unnecessary disruption. Mr K would not have benefited from being in ICU at that point and it could have delayed his transfer.

29. We find doctors at Airedale Hospital followed the NEWS Guideline and the Sepsis Guideline when managing Mr K’s care and treatment on 27 and 28 February 2023. We appreciate this has been a concern for Mrs A. We hope she is reassured we have seen no evidence of any failings relating to the decision transfer her father to a different hospital rather than to the ICU.

The Bradford Trust

19 February 2023

30. Mrs A believes the Trust should have offered antibiotics to her father when they inserted the femoral line or, at least, before they discharged him. She says this should be standard practice.

31. Epic 3 explains there is no evidence of any benefit in prescribing antibiotics when inserting central lines such as a femoral line according to any studies or trials. It says there is no evidence that providing antibiotics before using catheters of this type prevent infection.

32. Mr K arrived at the BRI on 19 February 2023. His fistula was blocked and could not be used. The Renal Adviser told us dialysis removes potassium from the blood. If there is too much potassium in the blood it can make the heart stop without warning. Mr K’s potassium level was moderately elevated on arrival but was not immediately life threatening. The Renal Adviser told us that, without ongoing dialysis, the potassium level would have risen and become life threatening.

33. Clinicians scanned Mr K’s fistula and established it could not be saved as it was too heavily thrombosed (clotted or blocked). They planned for a tunnelled (semi-permanent) line to be inserted into his neck to facilitate dialysis in the absence of a working fistula. This was essential because a femoral line can only be left in for a few days at most. A tunnelled line is where the line goes under the skin on the chest up to the neck before going into the vein. This can be used for months (or sometimes longer) for dialysis if needed, while a new fistula or dialysis graft is formed and develops. The tunnelled line was inserted. Doctors discharged Mr K on 23 February 2023.

34. The records show doctors applied antiseptic and disinfectant products around the site of the line insertion. The Renal Adviser told us these can help reduce the risk of infection. There is also evidence that clinicians followed the appropriate sterile technique during the procedure. This involved using a Biopatch (an antiseptic disc that is placed where the line enters the skin). The evidence shows clinicians did everything they could to prevent infection associated with the femoral line insertion.

35. The Renal Adviser told us prescribing antibiotics when there is no evidence of benefit is associated with the development of antibiotic resistant bacteria. This can sometimes result in subsequent infections that are difficult, and sometimes impossible, to treat effectively.

36. We appreciate Mrs A has strong feelings about this issue. We find there was no requirement for doctors to prescribe antibiotics to Mr K before they inserted the femoral line. They followed Epic 3 in this respect.

28 February 2023

37. Mrs A complains that her father was seriously unwell when he returned to the BRI on 28 February 2023 and doctors did not immediately transfer him to the ICU. She believes had there been no delay in providing intensive care this could have saved her father’s life.

38. Levels of Care redefined the levels of adult critical care to reflect changing demands in UK hospitals. It explains where clinicians should deliver care based on the patient's needs. It includes illustrations to explain when people should be cared for in different environments. Levels of Care explains that an ICU is classed as level three, critical, care. It says this is for patients who need a ventilator (a machine to support breathing), respiratory support or organ support.

39. When Mr K returned to the BRI on 28 February 2023 doctors diagnosed an infection in his blood. On arrival Mr K’s observations all seem to have been stable. The Renal Adviser told us ICU admission is required for life support treatments when a patient’s blood pressure is so low that medication is needed to increase it (for example, adrenaline) or if breathing is so limited that a ventilator is needed. This was not the case when Mr K first arrived at the BRI.

40. On the evening of 28 February 2023 clinicians started dialysis for Mr K. He had two cycles, with the second one in the early hours of 1 March. Earlier that day an intensive care consultant met with Mr K’s family. They explained Mr K had severe sepsis and the initial tests appeared to suggest this was associated with the femoral or tunnelled lines. They said the plan was to keep Mr K sedated and to continue dialysis in ICU while they tried to locate the source of the infection. The consultant explained to the family that Mr K had a life threatening illness.

41. Mr K’s health worsened soon after his second cycle of dialysis, with lower blood pressure and a fast heart rate. Doctors intubated him (meaning they inserted a breathing tube into his windpipe) to put him on a ventilator. He also needed a new femoral line to measure his blood pressure and provide adrenaline-like medications. The Renal Adviser said without these measures Mr K would have died then. He also received appropriate antibiotics for the infection.

42. On 2 March 2023 a consultant reviewed an echocardiogram (a scan that looks at the heart). They considered there was evidence of vegetation (infected scabs) in the heart, which would have been forming for some time. Doctors felt these infections in the heart would have been present before the insertions of the femoral or tunnelled lines. The Renal Adviser said they agreed with this diagnosis.

43. Over the following days Mr K was sedated and unconscious. On 7 March 2023 the critical care team met with Mr K’s family. They explained that he was being kept alive by the machine that was supporting his blood pressure. They said his death was now inevitable. Sadly, he died three hours later.

44. The Renal Adviser said Mr K’s body was failing despite the best efforts of the medical team to support him. He was too frail to have any cardiac surgery and the chance of him dying was always high. Many clinicians would have felt ICU admission was inappropriate as it was unlikely to change the outcome for Mr K. The Renal Adviser said it was unfortunate that Mr K’s infection was too severe, and he was not strong enough to recover.

45. The clinical records suggest Mr K did not need level three care until after his second cycle of dialysis in the early hours of 1 March 2023. Before then he did not meet the requirements for level three care as set out in Levels of Care. We have seen no indication that any necessary treatment was delayed.

46. We can see how distressing it was for Mrs A and her family to witness Mr K’s worsening health following his admission to the BRI. We find doctors followed the relevant standards when they did not immediately admit Mr K to the ICU.

Conclusion

47. We have seen no evidence to suggest clinicians at either trust fell below the relevant standards when providing care and treatment for Mr K. We appreciate Mrs A had concerns about her father’s care and we do not underestimate how distressing this time was for her. It must have been incredibly upsetting not to be able to converse with her father towards the end of his life.

48. We find there were no failings relating to the issues we have investigated. We do not uphold Mrs A’s complaint. We have not made any recommendations to the organisations.

1. Mrs A complains about how clinicians from two different NHS organisations cared for and treated her father, Mr K, in the last few days of his life in February and March 2023. We can see how devastating these events have been for Mrs A and her family. We offer our sincere condolences to them for their loss.

2. We have reviewed all the relevant information, and we have seen no evidence clinicians fell below the relevant standards. We recognise this will be a disappointment for Mrs A. We do not uphold her complaint.