University Hospitals of Morecambe Bay NHS Foundation Trust

4. Mr D complains about the treatment his wife received when she was admitted to Royal Lancaster Infirmary (managed by University Hospitals of Morecambe Bay NHS Foundation Trust) on 16 December 2022. Mrs D was diagnosed with a urinary tract infection (UTI) and initially improved with antibiotics. However, she deteriorated on the morning of 21 December and she was put on end-of-life care. Sadly, she died soon after.

5. Mr D believes his wife was not investigated thoroughly enough and therefore her diagnosis and treatment may not have been appropriate. He thinks his wife may have had a better chance of survival if she had been investigated and treated appropriately.

6. Mr D also says there was a lack of communication until the last day, when staff rang him to say his wife was gasping for breath and asked him to come in.

7. Mr D wants the Trust to acknowledge and apologise for its failures and take action to avoid this happening to other patients and their families.

8. Mrs D was admitted to the Acute Medical Unit (AMU) at Royal Lancaster Infirmary (RLI) on 17 December 2022. She was 74 years old and had a medical history which included hypertension, stroke, hyperthyroidism and type-2 diabetes. She was frail, bedbound, and had a suprapubic catheter in situ. She was admitted to hospital because she had been confused for the previous few days. She had been taking antibiotics.

9. Blood tests suggested Mrs D had an infection. She was therefore treated with intravenous (IV) antibiotics for a presumed UTI. When blood tests indicated some improvement in the infection, doctors changed the medication to oral antibiotics on 19 December. Because a person does not have to be in hospital to take oral antibiotics, staff started to make plans for her discharge home.

10. At 5:10am on 21 December, a nurse asked a doctor to review Mrs D. The doctor saw her within the hour and found she had suddenly deteriorated. The doctor was unable to get a blood pressure reading or feel her pulse, and noted she was breathing with difficulty. The doctor discussed the situation with Mrs D’s son on the phone and explained that his mother appeared to be dying. Staff started end-of-life care. Mr D and his son were advised to come in and Mr D was with his wife when she died soon after.

16. While looking at the care and treatment Mrs D received, we have considered Good Medical Practice, which says:

You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • Adequately assess the patient’s condition, taking account of their history (including the symptoms, and psychological, spiritual, social and cultural factors); their views and values; where necessary, examine the patient • Promptly provide or arrange suitable advice, investigations or treatment where necessary

In providing clinical care you must: • prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence

17. Mrs D arrived at the Emergency Department (ED) at 8:55pm on 16 December. An Emergency Medicine doctor reviewed her at 2:38 in the early hours of 17 December, and another doctor soon after. They diagnosed her with UTI. She was admitted to the Acute Medical Unit (AMU) and a consultant physician carried out the post take ward round (the first time a patient is reviewed by a consultant when they are admitted to hospital) at 8:37am. The doctor agreed she probably had a UTI and planned her to treat her for this.

18. It is understandable that doctors thought a UTI explained Mrs D’s symptoms when she was admitted. Many people with a catheter frequently have UTIs. The NHS website explains: ‘In older, frail people who have problems with memory, learning and concentration (such as dementia), and people with a urinary catheter, symptoms of a UTI may also include: changes in behaviour, such as acting agitated or confused (delirium).’

19. A blood test showed that white cell count (WCC) and C-reactive protein (CRP) were high. These two measures are markers of a possible infection. Often the higher the levels, the more serious and worse the infection. So the results supported a diagnosis of an infection.

20. However, records show there were signs of other problems which doctors did not explore further. For clarity, we explain these under separate headings.

Medical History

21. We did not see evidence that doctors took an adequate history, which Good Medical Practice requires. This is an important element of diagnosing and treating a patient. Given her condition, it was unlikely that Mrs D would be able to have given a history herself and the records show that staff recognised this.

22. Soon after arriving, a member of the REACT team saw Mr D and got some key information from him about his wife. The Trust’s website explains that this team ‘assess patients within the first 48 hours of admission or in ED to support with rapid discharge back into the community to receive their treatment if this is appropriate.’ Mr D told them his wife could normally hold a conversation and was not normally confused. However, at that time, the REACT team member could not rouse Mrs D to speak to her. This showed that she was now very different to her baseline and it was not appropriate for her to go home. A patient’s baseline refers to their state of health before the illness that led to their hospital admission.

23. The first doctor in ED took a very brief history from Mrs D’s daughter, which was about her recent confusion, but after that there is no record to show any of the medical team got a history from Mrs D’s family. The post take ward round record notes ‘this lady is not too far from her baseline’. The evidence in the records and from Mr D suggests this was not the case; he had said she was not usually drowsy and was normally able to converse.

24. Her baseline was never truly acknowledged and any claim that she was near to baseline would be inaccurate. Without a comprehensive history, the diagnosis was not as robust as it should have been.

Liver function test results

25. The results of the blood test carried out soon after Mrs D arrived at hospital showed she had significantly abnormal liver function test results (LFT, and also called ‘liver blood test’); her levels of ALP and GGT (alkaline phosphatase and gamma-glutamyl transferase, enzymes that suggest a liver problem) were elevated at 642 and 387 respectively.

26. An adverse LFT result does not necessarily show a problem with the liver; it could be something else, such as a systemic infection or a drug reaction. Our adviser said an abdominal scan (such as a CT scan) should have been considered at this point to investigate possible causes, in particular whether there was infection related to the liver or bile ducts or other problem in this area. The senior doctor who assessed Mrs D in the ED included a CT scan of her abdomen and pelvis as part of the management plan, but we saw no evidence that this was followed up.

Heart rate

27. Mrs D had a persistently high heart rate during her time in hospital, mostly above 110 beats per minutes, which was not explained throughout the admission. Staff were still hoping to discharge her despite this. We saw no evidence it was explored further. A high heart rate is a non-specific sign of ongoing illness, such as a continuing infection. Taken into consideration with the other clinical signs (drowsiness, unable to take oral medication) this was an indication that Mrs D remained unwell.

Drowsiness

28. Mrs D was drowsy on admission and remained so throughout her time in hospital. As Mr D’s explanation to the REACT team shows, this was not normal for her and so was significant. This can be associated with an infection but there are other possible causes. The change from her baseline condition does not appear to have been appreciated by the clinical team. During a ward round on 18 December at 8:41am, the doctor noted ‘remains partially confused – not sure whether this is her normal’.

29. If someone has a poor baseline – for example, if they are usually immobile or unable to get out of bed, as was the case with Mrs D - it can be more difficult to recognise how unwell they are. Therefore in this context, Mrs D’s persistent drowsiness and confusion were more significant.

30. On 20 December at 10:54, it was noted that Mrs D appeared drowsy, sleepy, and had a persistently high heart rate. The plan was to ensure she was not having a hypoglycaemic episode (it was confirmed she was not) and to give her IV fluids.

31. Our adviser said Mrs D most probably had a type of delirium called hypoactive delirium. NICE CKS Delirium describes this; ‘the person may be lethargic, have reduced mobility and movement, lack interest in daily activities, have a reduced appetite, and become quiet and withdrawn.’

32. We saw no documented evidence that anyone considered or diagnosed delirium. NICE CG103, 1.3.2 says ‘Be particularly vigilant for changes that may indicate hypoactive delirium, which are often missed, such as withdrawal, slow responses, reduced mobility and movement, worsened concentration and reduced appetite.’

33. Our adviser said the delirium was probably caused by an infection. But the team needed to recognise delirium in first place. They would need to treat the infection but also need to support Mrs D and recognise she was not swallowing, eating or drinking i.e. give supportive treatment. They would also need to explain the situation to her family. Delirium complicates recovery from an infection.

34. The post-take ward round diagnoses do not mention delirium. CG103 section 1.7 includes recommendations on how to treat delirium. As well as treating the underlying cause (in this case likely to be infection), it says there should be effective communication, reorientation and reassurance for the patient and that staff should consider family to help with this. The following section also emphasises the importance of information and support to family. There is no indication this happened.

Medication

35. A repeat blood test on 19 December showed that the CRP level had improved, suggesting Mrs D had responded positively to the antibiotics. Doctors therefore changed the medication from IV to oral antibiotics. This is documented in nursing notes, but not in the medical notes. In normal circumstances, this change to oral medication would be appropriate and reflects good antibiotic management. It is more comfortable to take oral medication than have IV in place, and a patient can continue to take oral medication when they are discharged home. However, Mrs D had difficulty in swallowing and was drowsy. A nurse had asked doctors to prescribe IV fluids as she was drinking very little. At 5:03 on the morning of 21 December a nurse noted ‘Patient not alert enough to take anything orally (drink/food/medication)’. Therefore, we found the decision to change to oral medication did not take into account the full clinical picture.

36. Records show that after receiving a 1-gram injection of the antibiotic amoxicillin at 2:23 in the early hours of 19 December, this was changed to oral co-amoxiclav. The first dose was given at 12:44pm that day, but not after. It was recorded as ‘not given’ at 9pm that evening and at 8am, 1pm and 9pm the next day (20 December). After that, the prescription was stopped. It is not specified why it was not given, but it seems likely Mrs D was unable to take oral medication due to her low consciousness level and being unable to swallow. We note that Mrs D did not take any other oral medications during this time. If she was unable to take key medications, nurses should have advised the medical team. It showed that they did not respond to how unwell she was. As such we do not consider this treatment was in line with Good Medical Practice.

37. It would have been reasonable to continue with IV antibiotics and explore why she was drowsy and unable to swallow. If she had an ongoing infection, stopping the antibiotics early before the full course was completed could have been detrimental.

Summary of medical investigations and treatment and impact

38. We found that investigations and diagnosis were not in line with Good Medical Practice because there is evidence doctors did not take into account and explore all Mrs D’s symptoms; delirium, persistently high heart rate, high liver function tests, inability to take oral medication.

39. It is still reasonable to say the most likely diagnosis was indeed some sort of infection, whether a UTI or a focus of infection elsewhere in the abdomen. Mrs D was treated with broad spectrum antibiotics for an assumed UTI. These were appropriate for a UTI and for other infections.

40. We saw no indication they could have changed the eventual sad outcome. We recognise Mrs D was very frail and we did not see there was a lost opportunity to have prolonged her life. She had already had four days of antibiotics and was not improving. As such, do not think her death was avoidable. However, we were unable to reassure Mr D that his wife was fully investigated. We recognise this will cause him distress.

Communication

41. Above, we have addressed the issue of investigation, diagnosis and treatment. From what we saw in the records, there was little by way of communication or explanation to the family about what was happening.

42. Good Medical Practice says that doctors should be ‘considerate to those close to the patient and be sensitive and responsive in giving them information and support.’

43. The GMC’s ‘Treatment and care towards the end of life’ outlines the role of relatives:

‘It is important that you and other members of the healthcare team acknowledge the role and responsibilities of people close to the patient. You should make sure, as far as possible, that their needs for support are met and their feelings respected, although the focus of care must remain on the patient.’

44. A nurse phoned Mr D when his wife was deteriorating on the day of her death; that was appropriate and fortunately, he was able to be with her at the end.

45. However, the day before (20 December) Mrs D’s NEWS score went up to 4 at 7:48am, and then to 6 at 7:02pm. NEWS is a system for scoring measurements, including respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness and temperature, in order to help identify patients who are deteriorating. The ‘Acutely ill adults in hospital’ guidance includes using NEWS scores to recognise people who are unwell. It includes how a deteriorating patient should be managed.

46. The NEWS score of 6 is referred to in the nurses’ documentation. The RCP guidance describes this score as a ‘key threshold for urgent response’ and should trigger an urgent medical review. A nurse spoke to a doctor, who was ‘happy with it’ and there was no revaluation. Our adviser said this was not an appropriate response to a NEWS of 6 and as such we found this was a failing. We recognise that a review may not had led to different treatment. However, it should have triggered a recognition that Mrs D was deteriorating and that her family should be notified. As explained above, at this time, Mrs D was not taking medication.

47. We found the Trust failed to communicate fully with Mr D as required by GMC guidance. Given Mrs D’s frailty, it would have been reasonable to start preparing Mr D and his family on 20 December because she was particularly unwell and her NEWS had risen. This would have given them more time to come to terms with the fact she was approaching the end of her life.

1. We carefully considered Mr D’s complaint about University Hospitals of Morecambe Bay NHS Foundation Trust’s care and treatment of his late wife, Mrs D. We partly uphold the complaint.

2. We found the Trust failed to carry out appropriate investigations. While we did not see any evidence to say Mrs D could have survived longer, we cannot reassure Mr D that his wife’s condition was fully investigated. This has caused him distress. Furthermore, we found Mr D and his family should have been told sooner that his wife was approaching the end of her life. This uncertainty about this will continue to cause distress.

3. We recommend the Trust acknowledge its failings, apologise for the impact they had and take action to prevent a recurrence.