The Dudley Group NHS Foundation Trust

5. Mr R complains about aspects of the care and treatment clinicians at the Hospital gave to his mother between 30 April and 25 May 2023. Specifically, he says:

• the investigation and treatment of his mother’s heart condition from 1 May 2023 was poor • there were delays in arranging a SALT assessment from admission • clinicians did not recognise and treat sepsis (the body’s overwhelming response to an infection which can lead to organ damage) from 6 May 2023 • there was a lack of support and monitoring of hydration and nutrition • there was inadequate pain relief and planning for end of life care • communication about his mother’s prognosis was inadequate.

6. Mr R believes his mother experienced pain and distress and a lack of dignity at the end of her life that could have been avoided. He says the family would have been better prepared if these failings had not happened.

7. Mr R wants the Trust to acknowledge its failings and apologise for the impact they had. He wants the Trust to take action to ensure there is learning from his complaint. He also seeks a financial remedy.

8. Mrs R was in her nineties and had a history of osteoporosis. On 30 April 2023 she attended the Hospital following a fall. Doctors found she had fractured her pelvis and were concerned that she could also have a heart problem. They identified she had aortic stenosis (narrowing of the aortic valve of the heart leading to restricted blood flow). She later developed a urinary infection causing sepsis and heart failure.

9. Doctors initially treated Mrs R with pain relief and mobilisation. They planned for treatment to continue once she left the Hospital. When her health deteriorated doctors treated her with antibiotics. Sadly, Mrs R died on 25 May 2023 from sepsis.

10. Mr R complained to the Trust soon after these events. Over the following two years the Trust provided four written responses and arranged a virtual meeting to discuss the complaint with Mr R and his brother. Mr R remained dissatisfied, so he complained to us.

Cardiology

14. Mr R says his mother needed an electrocardiogram (ECG – a test to record the electrical activity of the heart) and this was delayed for six days. He says this meant his mother’s aortic stenosis and heart failure were left untreated.

15. The Heart Valve Guideline explains when doctors should consider carrying out an echocardiogram. It says doctors should consider an echocardiogram (an ultrasound scan of the heart) for adults who have a heart murmur if they present with the symptoms Mrs R had. This should be arranged urgently, to take place within two weeks.

16. The Vascular Heart Disease Guidelines explain the circumstances when surgical intervention is required for patients who have heart valve disease. It says intervention is not recommended in patients with other health problems or where it is unlikely to improve quality of life or prolong survival for more than one year.

17. Emergency department records from 30 April 2023 show a nurse could not carry out an ECG in the department because the machines were all in use. In the early hours of the next morning a doctor reviewed Mrs R and referred to a possible heart murmur. The doctor believed she had aortic stenosis with possible mitral regurgitation (where one of the heart valves does work properly so that blood flows in the wrong direction). They requested an urgent echocardiogram to take place as an outpatient appointment.

18. The clinical records show Mrs R had an ECG on 2 May 2023 and a second one the following day. She did wait for an echocardiogram. Clinicians identified this needed to take place in the Hospital on 3 May. It took place on 5 May and confirmed the diagnosis of severe aortic stenosis. We believe Mr R’s complaint relates to a possible delay in carrying out an echocardiogram rather than an ECG.

19. A cardiologist first reviewed Mrs R on the ward on 5 May 2023 and again on the following day. Their impression was that Mrs R had heart failure. They did not consider surgery was appropriate. They planned to discharge her from the Hospital and prescribed medication for her heart problems.

20. Mrs R was found to have a urinary infection on 7 May 2023 which developed into sepsis. This then became the focus of her medical treatment.

21. The Cardiology Adviser told us it is important to stress that the heart problems were not the reason for Mrs R’s admission to the Hospital. She attended because of the fall and fracture of her pelvis. The heart problems made the fracture harder to treat.

22. During the first few days of her admission doctors were right to concentrate on the pelvic fracture with pain relief and help Mrs R to mobilise. The Cardiology Adviser said that, at that point, it was appropriate to arrange an outpatient appointment for an echocardiogram. Doctors later changed this to an inpatient scan and the reasons for this change are unclear. But the time taken to arrange the echocardiogram had no impact on Mrs R’s care.

23. An urgent echocardiogram should have taken place within two weeks. We can see evidence that it took place two days after the referral and six days after Mrs R’s admission. This was in line with the Heart Valve Guideline.

24. The Cardiology Adviser said there is evidence that doctors arranged appropriate blood tests, ECGs, echocardiograms and checked samples for infection.

25. We asked the Cardiology Adviser whether Mrs R should have had surgery for her heart problems. They said aortic stenosis can be treated by surgery, usually with a replacement of one of the valves in the heart. But this cannot be done for people who have a significant acute illness or sepsis. It is unusual for someone in their nineties to have such surgery. It is unlikely surgery would have improved Mrs R’s quality of life or led to her living longer.

26. We find that doctors followed both the Heart Valve Guideline and the Vascular Heart Disease Guidelines. There was no significant delay on the part of the cardiologists who treated Mrs R. We have seen no evidence of any failings in cardiology management. We hope Mr R is reassured that we have seen nothing to suggest doctors fell below the required standards.

SALT referral, nutrition and hydration

27. Mr R complains that nurses were inconsistent when providing food and drink for his mother. He also says there was a delay in clinicians processing a referral to the SALT team. He says his mother was unable to eat or drink from the time she arrived at the Hospital. He says his family tried to help Mrs R by using thickeners and straws they bought into the Hospital themselves.

28. The NMC Code contains the professional standards that nurses must follow. It says nurses must deliver the fundamentals of care effectively. It says they should ensure any treatment, assistance, or care they are responsible for is delivered without undue delay. Nutrition and hydration are considered to be fundamental aspects of nursing care.

29. The Nutrition Guideline says all hospital inpatients should be screened for malnutrition and their risk of malnutrition on admission. This should be repeated at least weekly. It says screening should assess body mass index (BMI) and percentage of unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and the likelihood of future impaired nutrient intake.

30. The Nutrition Guideline recommends using a tool such as the Malnutrition Universal Screening Tool (MUST). This is a system widely used in the NHS, including at the Trust. It helps detect malnutrition risk and recommends appropriate interventions. MUST provides a score to help healthcare professionals establish whether someone has a low, medium or high risk of malnutrition.

31. The Nutrition Guideline says nutrition support should be considered in people who have eaten little or nothing for more than five days and are likely to eat little or nothing for the next five days or longer. It says this should be reviewed regularly.

32. On 1 May 2023 a nurse completed an initial MUST assessment. The Nursing Adviser told us this assessment was poorly recorded. A section of the MUST form related to recent weight loss, and the nurse did not fully complete this. They scored this section as zero, suggesting there was no weight loss, but without details of Mrs R’s usual weight.

33. The initial MUST assessment also included a section about the effect of any acute disease. In this case the nurse recorded Mrs R did not have any acute disease. The Nursing Adviser noted doctors had admitted Mrs R to the Hospital with serious health problems. The Nursing Adviser considered the nurse should have established that Mrs R was at high risk of malnutrition.

34. On 2 May 2023 a nurse recorded that Mrs R was ‘eating well’ and on 4 May they noted she ‘tolerated oral medication and fluids well.’ Over the following days they recorded that she was able to eat and drink. There is no suggestion in the records around this time that Mrs R was having any difficulties eating or drinking. On 4 May doctors instructed nurses to restrict Mrs R’s fluids because of her heart problems.

35. A nurse reviewed Mrs R’s MUST score on 7 May 2023. The evidence shows that information from the first assessment was copied into a chart. It seems nurses reviewed her nutrition again on 18 and 21 May, but there is little information on the MUST chart to suggest that detailed review took place on any of these occasions. There is also insufficient information about Mrs R’s weight. There is a comment that she could not be weighed but no explanation about why this was the case and, on 18 May, whether her weight could be estimated.

36. On 9 May 2023 a nurse noted Mrs R had a normal diet and fluids. There are limited nursing entries about food and drink over the following days. There were daily care review charts for some of the days which showed she had some nutrition and hydration, but which did not provide details of the amounts taken. Fluid charts were used between 12 and 16 May and show Mrs R had coffee and water on those days.

37. On 13 May 2023 a nurse made a referral to the SALT team. This was because they were concerned that Mrs R was finding it difficult to drink water and chew food. The SALT assessment took place on 17 May. This established Mrs R needed to be alert and in an upright position when eating or drinking and that she needed assistance from nurses. She also needed food that was easy to chew and thickened fluids. Records show thickened fluids started later that day.

38. The clinical records from 18 May 2023 show Mrs R had fluids and food in line with the SALT recommendations. Nurses noted Mrs R’s family assisted her with her evening meal. She had intravenous fluids from 19 May onwards.

39. The Nursing Adviser considered Mrs R’s initial MUST assessment on 1 May 2023 to be incomplete. This was then repeated the following week at a time when Mrs R’s condition had clearly deteriorated. By 7 May 2023 her observations showed signs of deterioration. This was largely due to an infection and sepsis. By this point clinicians were aware Mrs R had a fractured pelvis and aortic stenosis. The Nursing Adviser said this should have again highlighted Mrs R’s high risk of malnutrition. There is nothing in the records to show any detailed consideration of her nutritional status.

40. We find the nurses did not follow the Nutrition Guideline in terms of the MUST assessments. By 7 May 2023, at the latest, Mrs R’s MUST score should have led to a referral to dieticians along with steps being taken to improve her nutritional intake. It should also have led to monitoring of food intake. These did not happen.

41. The Nursing Adviser told us a SALT referral would only be made if nurses had concerns that a patient had swallowing difficulties or if they were choking on food or drink. There is no evidence in the clinical records that Mrs R had such difficulties before the SALT referral on 13 May 2023. We can see no evidence to suggest there was a failing relating to the time taken to make a SALT referral.

42. The Nursing Adviser told us there was no specific requirement for nurses to monitor Mrs R’s fluid intake until the last few days of her admission. There is nothing to suggest she was not receiving enough fluids.

43. The Cardiology Adviser did not consider hydration management had an impact on the progression of Mrs R’s illness. They said it is always a preference to avoid intravenous fluids when possible. But for patients who had the problems Mrs R had, including signs of heart failure, fluids need to be added with caution to avoid heart congestion. It is a nuanced clinical decision about how to balance fluids in these situations. The medical records show that doctors were considering Mrs R’s fluids every day and they made appropriate clinical decisions.

44. The standard of record keeping relating to Mrs R’s nutrition was inconsistent. The Nursing Adviser told us that the records that were completed do not suggest Mrs R needed assistance with food and drink until the last few days of her admission to the Hospital. Nurses had no concerns about her nutrition and repeatedly referred to her being able to tolerate food and drink. This contrasts with Mr R’s evidence that his mother needed assistance at mealtimes, and that food and drinks were often left untouched. We have no reason to doubt the accounts from Mr R and his family.

45. At the complaints meeting the Trust’s representatives said the family’s description of the lack of support with food and drink was ‘completely unacceptable.’ They said they were embarrassed about some of the incidents Mr R described.

46. Mr R said his mother could not eat or drink from the time she arrived at the Hospital. We have seen several entries in the nursing records, made by different healthcare professionals at different times, that show Mrs R could eat and drink. We do not consider there was a delay in making a SALT referral. We also consider nurses provided appropriate hydration in line with the NMC Code. But we have seen evidence of failings.

47. We find that nurses fell below the standards set out in the Nutrition Guideline. This is because they did not carry out adequate assessments of Mrs R’s risk of malnutrition. Based on the inconsistent nursing records, and the family’s recollections, we also consider that nurses did not provide Mrs R with the support she needed at mealtimes. Nutrition is a fundamental aspect of nursing care. The nurses did not follow the NMC Code in this respect.

48. The Nursing Adviser told us that many hospitals have initiatives involving coloured trays. The Trust’s representatives at the complaint meeting indicated the Trust also uses coloured trays to identify when people need help at mealtimes. Had Mrs R been identified correctly as at high risk of malnutrition this should have prompted a dietician referral and further monitoring. It would likely have led to the use of coloured trays to ensure she was receiving adequate nutrition. It is also likely that food charts would have been implemented to improve monitoring.

49. The Cardiology Adviser did not consider issues with nutrition support would have had any effect on the progression of Mrs R’s illness. We cannot say the failings relating to nutrition had an impact on Mrs R’s health. But we can see how they led to distress for her and, also for her family, that could have been avoided.

Sepsis

50. Mr R says his mother had signs of sepsis from 6 May 2023 that were ignored. He believes clinicians did not recognise the severity of her condition quickly enough.

51. Clinicians should have followed the Sepsis Guideline. This explains how healthcare professionals should identify and treat sepsis. It says they should prescribe antibiotics within one hour of suspecting that someone has sepsis. They should also prescribe intravenous fluids. Sepsis is a life-threatening condition. It usually develops in within hours and if not treated rapidly can lead to septic shock, organ failure and death.

52. The NEWS Guideline refers to the NEWS system, which 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).

53. The NEWS tells clinicians how they should respond when the total score is between specific values. A NEWS below four indicates the person in question is in the low risk category. A score of five or six is considered medium risk and requires an urgent response. A score of seven or more is considered high risk and needs emergency action.

54. The NEWS Guideline says clinicians should consider sepsis in any patient with a known infection, signs or symptoms of infection, or in patients at high risk of infection, and a NEWS score of five or more. Patients who have a suspected infection and a NEWS higher than five require urgent assessment and intervention by a clinician competent in managing sepsis.

55. The clinical records show that clinicians regularly recorded Mrs R’s NEWS score. The score was two or below until 5 May 2023 when it rose to three. It was still three on the following day and increased to four on 7 May.

56. On the morning of 7 May 2023 doctors noted in their ward round that Mrs R had an episode of confusion on the previous day along with foul smelling urine. They arranged a urine test, encouraged fluid intake and started antibiotics that were specifically for a urine infection.

57. At 11.20pm a nurse completed a sepsis screening assessment tool. They noted Mrs R’s NEWS was three at that stage, but they considered she still needed a senior review irrespective of the NEWS because of her low blood pressure.

58. A senior doctor reviewed Mrs R at 12.28am on 8 May 2023. This led to a prescription for intravenous fluids and increased blood pressure monitoring. Later that morning a nurses recorded that Mrs R’s NEWS was six. The nurses requested an urgent medical review. A cardiologist attended within an hour. They confirmed Mrs R had sepsis and contacted the microbiology team for advice about whether more appropriate antibiotics should be used. This led to a change in antibiotics later that day.

59. Test results from 9 May 2023 confirmed the organism that doctors believed was responsible for Mrs R’s infection and sepsis. This meant they changed her antibiotics again to one more suitable for fighting the organism in question.

60. Over the following days doctors continued to treat Mrs R for sepsis using antibiotics and fluids. Doctors were careful to monitor the use of fluids because of the impact this could have had on Mrs R’s heart failure. They also continued to monitor her NEWS which fluctuated between one and four.

61. There is no evidence in the records to suggest Mrs R had sepsis on 6 May 2023. At that stage her clinical observations were within normal limits, and her NEWS score did not suggest care needed to be escalated. This changed the following night. Nurses correctly identified that Mrs R had a suspected infection and a NEWS score above five and arranged for a doctor to attend. Nurses followed the NEWS Guideline.

62. Both the Nursing Adviser and Cardiology Adviser told us clinicians followed the Sepsis Guideline. We can see that Mrs R was already taking antibiotics and intravenous fluids when doctors first diagnosed sepsis. They were right to suspect sepsis on the night of 7 and 8 May 2023 and provided Mrs R with appropriate treatment.

63. We recognise Mr R believes clinicians should have responded quicker to his mother’s deteriorating health. We have not seen any clinical evidence to support this view. Based on the information we have seen we find that healthcare professionals followed the Sepsis Guideline and the NEWS Guideline from 6 May 2023 onwards.

Pain relief and end of life care

64. Mr R says a syringe driver did not start until 24 May 2023 despite several requests from family members. He says the pain relief provided was inadequate. He recalled an occasion when his mother was found writhing in agony. He said his mother would often say she was in pain when this was not the case. He recalled a member of staff from the local hospice being shocked at his mother’s pain when they visited her.

65. The End of Life Guideline stresses the importance of recognising that not all people in the last days of life experience pain. It says, when pain is identified, it should be managed promptly and effectively, and any reversible causes of pain should be treated. Medication should be matched to the severity of pain.

66. On 14 May 2023 a nurse noted that Mrs R cried out in pain when they tried to reposition her. The pain team at the Hospital reviewed Mrs R later that day. Their assessment did not include any information about Mrs R’s pain at rest or when active. It concluded she should have intravenous paracetamol and morphine injections when needed for breakthrough pain. The pain team recommended considering a referral to the palliative care team.

67. Later that day a nurse noted Mrs R had ‘frequent pain’ after morphine had been administered. The pain team agreed to revisit. Later that day Mr R complained to one of the nurses that his mother had been screaming due to pain. They again noted the need for a further review from the pain team.

68. The pain team assessed Mrs R again on 15 May 2023. There is minimal information recorded about the assessment. The pain team concluded that Mrs R was settled on morphine and again recommended involving palliative care. They discharged Mrs R from the pain team. Later that day a nurse noted Mrs R had ‘severe pain’ and after a morphine injection was a ‘bit comfortable.’

69. On 16 May 2023 a doctor reviewed Mrs R and noted she did not like the morphine injections and had been reluctant to ask for them. The doctor recommended using a fentanyl patch (an opioid medication applied to the skin). They also listed the actions to take depending on Mrs R response to the medication. Records show this was discussed with Mrs R and her family.

70. The clinical records show doctors knew Mrs R was approaching the end of her life within the next few hours or days on 22 May 2023. A palliative care nurse reviewed her the next day and recommended starting a syringe driver. We could find no documentation showing a formal pain assessment. While there are references to Mrs R having pain, the records are limited.

71. The palliative care nurse requested syringe driver at 4.14pm on 23 May 2023 and records show it started at 6.31pm on 24 May 2023. The request followed a discussion with a member of Mrs R’s family.

72. The Nursing Adviser told us a patient should only be offered a syringe driver if they are in constant excruciating pain or cannot tolerate oral medication. The Nursing Adviser was critical that the pain records were unclear about why pain relief was prescribed and what Mrs R’ss pain levels were like before and after taking medication. In fact, the nursing records are unclear about why the syringe driver was requested on 23 May 2023, as there is nothing to indicate severe pain at that point.

73. At the complaints meeting the one of the Trust’s representatives agreed that the syringe driver was not in place quickly enough. The Trust also accepted there were occasions when its staff did not document the reasons why Mrs R refused pain medication at times. It agreed they should have investigated the reasons why Mrs R denied she was in pain.

74. We find there is insufficient evidence in the clinical records to show that nurses gave Mrs R the pain relief she needed towards the end of her life. Despite references to the need for palliative care support the records do not show that this happened until 23 May 2023. Based on Mr R’s account we are persuaded that what happened in this respect fell below the standard expected in the End of Life Guideline. There is no evidence that Mrs R’s pain was managed promptly and effectively while she was in the Hospital.

75. On balance we consider Mrs R experienced pain, and a lack of dignity, that could have been avoided. We can see how this would have been incredibly distressing for her and her family.

Communication

76. Mr R says doctors failed to tell his family how serious his mother’s illness was until 13 May 2023. He says a cardiologist had been aware of this for a week before saying anything about his mother’s prognosis. He said there had been a meeting on 9 May, but it was not made clear to him that the prognosis was poor. The family believed she had been recovering well from her fall.

77. Good Medical Practice says doctors must communicate effectively. It says they must give patients the information they want or need to know. It says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. When on duty doctors must be readily accessible to patients seeking information.

78. The clinical records show that a doctor first had a discussion with Mrs R about her diagnosis of heart failure and the planned treatment on the afternoon of 4 May 2023. On the following day a cardiologist discussed the risks of surgery with Mrs R. They explained that treatment would be by medication only and discussed what should happen in the event that her heart or breathing stopped. The doctor said resuscitation would not be in Mrs R best interests and noted she had capacity to have such a discussion.

79. On 9 May 2023 a doctor recorded a discussion with Mrs R’s family. They said they spoke about the ‘palliative intent of treatment’ due to Mrs R’s advanced age, frailty and the risk of her developing complications from any treatment. They wrote, ‘concerns addressed and relevant information provided.’

80. Mr R asked to speak to a cardiology consultant on 13 May 2023. He said nobody had mentioned severe aortic stenosis to him and there had only been a reference to heart failure. The consultant then discussed aortic stenosis and explained it was not possible to provide surgery for Mrs R. They explained how Mrs R was nearing the end of her life and noted Mr R understood.

81. On 15 May 2023 Mr R asked for a discussion with a clinician on the ward. He was concerned that he had been told his mother was dying. The clinician noted they explained ‘palliative versus end of life care needs.’

82. A doctor spoke to Mr R again on 19 May 2023. They recorded they gave a description of the inpatient stay and had explained that there was a high chance Mrs R’s health would deteriorate further. If there was further deterioration over the next few days then treatment would stop.

83. On 22 May 2023 a meeting took place between Mrs R’s family and one of the doctors. The doctor discussed what had happened during the admission and noted their concerns about fluids and pain relief. The doctor said Mrs R looked unwell and if there was further deterioration treatment would not continue. After a further review the doctor decided to stop further treatment apart from medication and fluids to keep Mrs R comfortable.

84. The Trust accepted in is complaint responses that communication fell below the expected standard. At the complaints meeting a cardiologist explained to the family that a doctor should have spoken to the family early in the admission to paint ‘a grim picture of the likelihood of Mrs R’ss survival.’

85. It is clear that Mr R and his family have different recollections of discussions to what the clinicians noted in the records. This often happens because people have differing perceptions. It is difficult at this stage to be sure about exactly what was said during these conversations. We would not expect clinicians to record everything they say to relatives in these circumstances. But we would expect the main points to be documented.

86. We can see evidence that doctors initially had discussions with Mrs R rather than with her family. This was appropriate given that Mrs R had capacity to make decisions about her own care. We can also see that after the discussion on 13 May 2023 doctors communicated effectively with Mrs R’s family.

87. We can see no evidence that doctors communicated effectively with Mrs R’s family from the point when they diagnosed sepsis on 8 May up until the meeting Mr R had on 13 May. There was no explanation during this period about what was happening to Mrs R. While the meeting on 9 May suggests there was some discussion about the issues, the note that appears in the records supports Mr R’s recollection that the full gravity of the situation was not clearly explained.

88. We find that doctors were not sensitive and responsive to Mrs R’s family when they did not communicate effectively with them for part of her admission to the Hospital. Doctors did not follow Good Medical Practice. We can see how this led to avoidable distress for the family. They may have been better prepared for the deterioration in Mrs R’s health if the communication failings had not happened.

1. Mr R complains about how healthcare professionals at the Hospital (part of the Trust) cared for his mother, Mrs R, in the last few weeks of her life. We can see how devastating these events have been for Mr R and his family. We offer our sincere condolences to them for their loss.

2. We find there were no failings relating to the recognition and treatment of Mrs R’s heart problems and sepsis. We do not consider the time taken to arrange a referral for a speech and language therapy (SALT) assessment fell below the relevant standard. Neither have we seen failings relating to managing hydration. But we have seen evidence of failings relating to nutrition, pain relief and communication.

3. We consider the failings we have seen led to Mrs R experiencing pain and distress that could have been avoided. We can also see that she experienced a lack of dignity towards the end of life. Her family also experienced avoidable distress, and they may have been better prepared for her death if communication failings had not happened.

4. We partly uphold Mr R’s complaint and make recommendations to the Trust. The Trust should acknowledge its failings and apologise for the impact they had. It should also pay Mr R a financial remedy. The Trust should produce an action plan to ensure there is learning from the complaint.