Tees, Esk and Wear Valleys NHS Foundation Trust

4. Mrs E complains about aspects of the care clinicians at the Hospital gave to her son between 14 December 2022 and 19 February 2023. Specifically, she says:

• staff on the ward did not ensure her son was properly observed and care plans were insufficient • clozapine (an antipsychotic medication) was not used appropriately • regular drug tests did not take place during the admission.

5. Mrs E questions whether her son’s death could have been avoided. She wants to ensure the Trust makes improvements to its services, so other patients and their families do not have the same experience.

6. Mr E was a young man with a history of paranoid schizophrenia and drug use. In December 2022 doctors admitted him to the Hospital for mental health treatment. They gave him clozapine.

7. On 19 February 2023 he had a sudden cardiac arrest in a side room on the ward. Healthcare professionals on the ward gave him cardiopulmonary resuscitation (CPR) and contacted the ambulance services. Paramedics continued resuscitation attempts and took Mr E to an acute hospital. Doctors there gave him life support, but Mr E was found to have a hypoxic brain injury (where the brain is damaged due to lack of oxygen). Sadly, he died on 25 February.

8. Mrs E complained to the Trust in February 2024. Over the following months the Trust provided two written responses and arranged a meeting with Mrs E. She remained dissatisfied so complained to us.

Care plans and observations

11. Mrs E complains that five members of staff were on the ward when her son ‘choked to death.’ She says they were not observing her son properly and had a duty of care towards him. Mrs E referred to CCTV footage showing nurses leaving a staff room and a kitchen when the alarm was raised on 19 February 2023.

12. The Trust Policy explains staff should provide a safe and supportive environment to service users. It says the effective and appropriate implementation of supportive observations and engagement is fundamental to discharging a duty of care.

13. The Trust Policy says all service users in a ward environment should be allocated a level of observation and engagement in a care plan. At the end of each period of observation the responsible staff member should document a brief summary of the service user’s behaviour, mental state and general well-being.

14. The Trust Policy specifies four levels of observation and engagement:

• General Observation – This is the minimum level of observation for service users and applies to those who are at low risk of vulnerability, suicide, self-harm or harm to others.

• Intermittent Observation – This is for service users who have a potential risk of disturbed behaviour, increased vulnerability and self-harm. The care plan for such service users should detail the risks for them based on their history and suggested interventions and activities to engage with them. Staff should have awareness of the service user’s whereabouts at all times and will observe them at specified intervals ranging from five to thirty minutes, or a specified number of times in an hour. This must be documented at the point of observation and engagement.

• Within Eyesight Observation – This is for service users assessed as being at significant risk. The service user must remain within eyesight at all times unless the care plan specifies otherwise. Again, the care plan must detail the risks for the service user. An allocated nurse must provide one to one support throughout the whole period prescribed for the level of observation.

• Within Arm’s Length Observation – This is prescribed for service users at the highest levels of risk. They need to be nursed in close proximity and be clearly visible at all times to the observing staff member. The care plan must detail risks and how they are to be managed.

15. The Trust Policy says observation levels must respond to dynamic risk factors and be the least restrictive option that ensures safety. Decisions about increasing and decreasing supportive observations and engagement should be made in multi-disciplinary discussions based on ongoing assessments of the service user’s needs.

16. For the most part Mr E was on General Observation during his admission to the Hospital. On 20 January 2023 he was briefly escalated to Within Arm’s Length Observation following an incident of cocaine use and an increased heart rate. On 3 February nurses again escalated his monitoring to Intermittent Observation, with observations every ten minutes for 24 hours. This happened again on 8 February.

17. On 19 February 2023 Mr E had visitors on the ward during the morning. They brought him food which he ate in a side room. Staff checked on him at 12.17pm and again at 12.20pm. At 12.28pm a nurse found Mr E on the floor and raised the alarm. Other team members arrived and started CPR. They called paramedics who took Mr E to an acute hospital.

18. The Clinical Adviser told us there were several incidents that show Mr E needed more than General Observation during his admission. On 5 January 2023 he fell and staff later found him unconscious and on 20 January he broke his foot on leaving the ward. The records contain references to neurological concerns. He had jerky movements and suspected seizures from 3 February onwards. He was also awaiting scans for neurological assessment. The clinical records also refer to episodes of tachycardia (a fast heart rate), which was monitored and also affected the dosage of clozapine clinicians could prescribe.

19. General Observation is intended for service users at low risk of harm. This was not the case for Mr E. His history of recent falls, suspected neurological issues, and physical health instability meant there was a potential, or significant, risk of harm.

20. The Clinical Adviser said it was not sufficient for Mr E to be on General Observation. This was because of his clinical presentation and physical health risks. They said he should have been placed on either Intermittent Observation or Within Eyesight Observation until the risks were mitigated. There is no evidence clinicians ensured Mr E received proportionate and justifiable observation in response to his clinical risk.

21. Mr E had an observation plan, but we can see no evidence this was updated after 6 February 2023 despite ongoing physical health concerns. Staff completed an observation monitoring tool. But there were gaps in the records. For example, no observations were recorded on 8 and 9 February 2023.

22. We find clinicians at the Hospital did not follow the Trust Policy in terms of providing the level of observation Mr E needed. This aspect of care planning fell below the required standard.

23. We must now consider the impact this failing could have had on Mr E. As we have said above, he should have been having Intermittent Observations as a minimum.

24. On 19 February 2023 the records show staff observed Mr E at least hourly in line with General Observation. In the minutes before Mr E’s cardiac arrest staff noted no concerns when they observed him. We do not know exactly when Mr E collapsed but we do know a nurse noted his observations eight minutes before he was found.

25. If clinicians had been observing Mr E under Intermittent Observation they would be expected to be seeing him at least once every thirty minutes. It is unlikely that an increased level of observation would have led to nurses seeing Mr E again between 12.20pm and 12.28pm. There is no evidence this failing had an impact on Mr E’s health or that his death would have been avoided if staff had followed the Trust Policy.

26. The clinical records show Mr E had a sudden cardiac arrest that led to his death. The records show clinicians struggled with resuscitation because of the presence of food particles in his airway. But the coroner was clear that choking was not the cause of death.

27. It is understandable that the CCTV footage was incredibly distressing for Mrs E. We can see how it will also be upsetting for her to know that her son should have had increased levels of observation on 19 February 2023. We cannot say that increased levels of observation could have led to her son’s survival.

Clozapine

28. Mrs E strongly believes her son died because clinicians gave him clozapine. She questions whether the amount of clozapine he took contributed to him having a cardiac arrest.

29. The BNF is a reference guide providing clinicians in the UK with information and advice about prescribing medication. It says the maximum recommended dose for clozapine is 900mg each day. The maximum should be 550mg per day for male smokers, such as Mr E. It says healthcare professionals should monitor the patient’s blood counts, ECG (electrocardiogram – a test that measures the heart’s activity), weight, lipids (the amount of fats in the blood) and glucose when clozapine is being taken.

30. The Clozapine Policy reiterates the monitoring requirements set out in the BNF. It says an ECG and blood tests should be completed before treatment starts. It says there should be weekly blood tests for the first 18 weeks of clozapine treatment and then tests every two weeks for the reminder of the first year. It says physiological observations should be monitored daily if the dose has been adjusted or once a week otherwise. It also says the levels of clozapine in blood plasma should be monitored.

31. The Clozapine Policy says missed doses should be avoided. If there is a break in treatment for more than two days the dosage should then return to a starting level of between 12.5mg and 25mg per day and be gradually increased.

32. The clinical records show clinicians arranged an ECG and blood tests for Mr E before he started taking clozapine at a low dose of 12.5mg on 21 December 2022. The dosage was gradually increased up to 10 February 2023 when Mr E was taking 400mg each day, which was less than the limit for smokers set out in the BNF and the Clozapine Policy.

33. On 12 January 2023 clinicians discussed the fact Mr E had missed two doses of clozapine due to cocaine use. On 18 January a doctor advised that twice weekly blood monitoring was needed. On 20 January doctors noted Mr E had previously had very low levels of clozapine in his blood plasma. By this date they were satisfied his blood test results were in the normal range.

34. Mr E’s levels of clozapine in his blood plasma were again low on 23 January 2023. A nurse recorded that he had admitted not taking some of the clozapine. Over the following two weeks the blood plasma levels of clozapine continued to be low, and staffing was increased to ensure they saw him taking the medication.

35. Doctors stopped Mr E’s clozapine between 10 and 14 February 2023 because he was awaiting an ECG. This did not show any reason to stop clozapine. When he restarted the initial dose was 12.5mg and was again gradually increased. At no point did he exceed the recommended dose.

36. We can see staff at the Hospital carried out weekly blood tests and arranged a further ECG and cardiology advice when heart symptoms were identified. They also checked plasma clozapine levels, particularly when they were concerned about whether Mr E was actually taking the clozapine tablets.

37. The records show some gaps in terms of monitoring Mr E’s observations when he was taking clozapine despite staff noticing jerky movements and following falls. There were also delays in checking his blood plasma levels at times. We do not consider these omissions fell significantly below the relevant standards.

38. The Clinical Adviser told us clozapine can cause several physical health problems. These include myocarditis (disease that causes inflammation of the heart muscle), cardiomyopathy (diseases that affect the heart’s ability to pump blood), tachycardia, constipation and neutropenia (low levels of white blood cells, increasing the risk of infection).

39. The records show Mr E initially experienced constipation and he also had tachycardia. But blood plasma results clearly show the concern was not that he was taking too much clozapine, but that he was not getting enough. The Clinical Adviser said having too little clozapine would not have a significant effect on the heart. There is no evidence in the clinical records that Mr E experienced a cardiac arrest because of overdosing on clozapine.

40. We find that clinicians followed the BNF and the Clozapine Policy when managing Mr E’s clozapine. We cannot see any evidence to suggest clozapine use contributed to his cardiac arrest.

Drug testing

41. Mrs E says clinicians should have been testing her son for drugs every two days and she cannot understand why this did not happen. She says her son’s last test took place sixteen days before the incident that led to his death.

42. The Clinical Adviser told us there were no specific national standards or guidelines that say how frequently people in hospital should have been tested for drugs. The NHS does not dictate routine drug testing for psychiatric inpatients.

43. The Trust Policy explains that a patient’s care plan should explain how they are to be monitored safely in respect of their behaviour and mental wellbeing. The care plan needs to be individualised. It says staff should complete a record of their observations contemporaneously.

44. Mr E’s care plan stated he was to be screened every two days for drug use. The records show this did not happen. While there were drug tests during Mr E’s admission, often showing evidence of illicit drug use, they did not take place every two days. It is unclear from the records whether: Mr E refused the tests; staff did not record the outcome; or staff failed to offer testing. That said there are clear references to times when testing did not take place because Mr E had already admitted taking drugs.

45. Mrs E is right to point out that the last drug test took place on 3 February 2023. The Trust accepted that drug testing did not take place in line with Mr E’s care plan.

46. We find the clinicians responsible for Mr E’s care did not follow his care plan in terms of the need for drug testing. They fell below the Trust Policy in this respect.

47. The Clinical Adviser said the omissions in drug testing would not have changed the clinical pathway for Mr E. Increased testing would not have prevented the cardiac arrest. But we can see how it is distressing for Mrs E to know that staff were not following the care plan.

1. Mrs E complains about the care healthcare professionals at the Hospital (part of the Trust) gave to her son, Mr E, in the last two months of his life. We can see how devastating these events have been for Mrs E and her family. We offer our sincere condolences to them for their loss.

2. We find clinicians did not follow the relevant standards and guidelines in some aspects of their care. But we cannot say Mr E would have survived if the failings had not happened. We can see how Mrs E experienced avoidable distress because, at times, clinicians did not provide the level of observations her son needed and did not carry out drug tests.

3. We partly uphold Mrs E’s complaint. We have made recommendations to the Trust so there is learning from her complaint.