East Suffolk and North Essex NHS Foundation Trust

4. Mrs A complains about aspects of the care and treatment clinicians at Colchester General Hospital gave to her mother between 25 and 27 March 2024. She says:

• there were delays in the emergency department • doctors missed a spinal fracture and did not give enough pain relief for it • doctors delayed diagnosing pneumonia • nurses decided to isolate Mrs S because of a misunderstanding relating to her diagnosis • nurses did not properly observe her mother on 27 March, did not listen to family concerns or escalate care to doctors • clinicians did not give her mother her usual COPD medication. COPD is chronic obstructive pulmonary disease. This is a lung disease which meant she had difficulty breathing at times.

5. Mrs A believes her mother’s death could have been prevented. She believes failings in care contributed to the decline in her mother’s health. She says her family experienced distress and anxiety by witnessing these events.

6. Mrs A wants the Trust to acknowledge its failings and apologise for the impact they had. She wants the Trust to take action to ensure there is learning from her complaint. She also seeks a financial remedy.

7. Mrs S was in her seventies and had a history of angina and COPD. She had a stoma following treatment for a blockage in her bowel in September 2023.

8. On 25 March 2024 Mrs S attended the Hospital by ambulance. She had collapsed at home and had persistent vomiting, headaches and visual problems. She also had tenderness and pain in her back and was shivering.

9. Doctors admitted Mrs S to the Hospital and arranged a series of investigations. They noted she had increased stoma output at home (diarrhoea) and suspected many of her symptoms were due to dehydration. There were no beds available on the wards, so they provided care in a corridor.

10. On 26 March 2024 doctors suspected Mrs S had sepsis (the body’s overwhelming response to infection, which can lead to organ damage) and gave her intravenous antibiotics. An X-ray of her spine showed a fractured vertebra. They also diagnosed NTM (a bacterial infection affecting her lungs).

11. Sadly, on the evening of 27 March 2024 Mrs S had a cardiac arrest and died.

12. Mrs A complained to the Trust a few days after these events. Over the following months the Trust sent a written reply and arranged a meeting for Mrs A and other family members to attend. After the meeting the Trust sent Mrs A a recording. She remained dissatisfied so she complained to us.

Delays in the Emergency Department

16. Mrs A complains that it took too long for someone to assess her mother when she first arrived in the emergency department. She says she was then left in a corridor for more than twenty hours.

17. The ED Management Guideline explains that crowding occurs when the demand on a department exceeds its capacity. It says crowding is unacceptable. It leads to delays in transferring people from ambulances, delays in assessments and long waits for treatment. It lists a range of measures organisations can take to address these issues.

18. The NHS Handbook says all NHS patients should receive high quality care without any unnecessary delay. It includes a list of government pledges. One of the pledges is there should be a maximum four-hour wait from a patient arriving in an emergency department to them being admitted, transferred or discharged. This should apply for 95 percent of patients. In practice this standard has not been consistently met throughout the NHS.

19. Ambulance records show Mrs S arrived at the Hospital at 2.58pm on 25 March 2024. The Trust said Mrs S arrived in the emergency department at 3.05pm and the ambulance crew cared for her on a trolley in a corridor for two hours. Mrs A recalled that her mother arrived in the corridor at 5.30pm following a more than two-hour wait in the ambulance.

20. At 7.50pm a doctor reviewed Mrs S. They noted her history and carried out a detailed examination. They ordered back and chest X-rays and prescribed pain relief. The X- rays took place at 8.04pm. Doctors decided to admit Mrs S at 9.39pm, but there were no beds available and Mrs S moved from the corridor to a bed on the ward at 2.33pm the next day.

21. Based on the evidence we have seen a doctor first reviewed Mrs S around five hours after her arrival at the Hospital. This was outside the four-hour target set out in the NHS Handbook. But this is a target that should apply to 95 percent of patients. So, there would be occasions when this may not apply and this would not be considered to be below the standard. It must also be noted that this target is consistently missed throughout the NHS in England. We cannot say Mrs S’ wait to see a doctor fell below the required standard in this respect.

22. The Emergency Medicine Adviser told us Mrs S’ care in the emergency department fell below the relevant standards. There were inappropriate delays in transferring Mrs S from an ambulance trolley. There was then a prolonged waiting time in a corridor and this was not acceptable.

23. The Trust accepted Mrs S’ stay in the emergency department was prolonged. It apologised that it failed Mrs S and said staff should, ordinarily, have transferred her to a bed within six hours of her arrival at the Hospital. It explained how the department had been overcrowded and how this had been formally reported as an incident. At the complaint meeting the Trust’s representatives explained there had been fifteen ambulances waiting with patients at the time Mrs S arrived. They said she should have been seen within one hour and this did not happen.

24. We asked the Medical Adviser whether Mrs S’ prolonged stay in the corridor had an impact on her health. They said there is no indication in the records that the time Mrs S spent waiting for a bed in the Hospital had a specific adverse effect on her health. Her death was related to her heart problems and pneumonia.

25. The clinical records show that nurses monitored Mrs S’ observations while she waited to be transferred to a ward. We can see clinicians gave pain relief and intravenous fluids to Mrs S while she remained in the emergency department. There is no suggestion that her health was worsening during this time.

26. We find it took too long for a doctor to assess Mrs S on her arrival in the emergency department. But we do not consider this was a failing in the context of the pressures on the NHS. But the Trust did not follow the ED Management Guideline when Mrs S was cared for in a corridor for almost 24 hours. We do not consider the delay had any impact on her health, but we can see that it led to distress for Mrs S and her family that could have been avoided.

Spinal fracture

27. Mrs A says doctors missed evidence of a facture on an X-ray. She says they only looked at this again when a physiotherapist asked them to. She also says her mother’s pain relief was inadequate.

28. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed. They must be satisfied that any medication they prescribe serves the patient’s needs.

29. The clinical records include a radiology report on Mrs S’ spinal X-ray which showed she had a compression fracture of one of her lower vertebrae. It is unclear when this report was available for doctors in the emergency department to review. But there is a note which says, ‘no fracture seen.’ The Trust has accepted this was an error.

30. The Emergency Medicine Adviser told us the fracture was escalated to the trauma and orthopaedics team on 27 March 2024. Their recommendation was for conservative management, which meant focusing on pain relief and mobilisation. So, if the fracture had been identified in the emergency department it would not have led to any significant difference in how Mrs S’ care and treatment was managed.

31. In terms of pain relief, the ambulance crew noted they gave Mrs S paracetamol at 2.45pm on 25 March 2024. They noted she had moderate pain. We can see the emergency department team gave further paracetamol at 9.00pm and morphine at 4.20pm. On the next day she had morphine at 12.10am and 4.45am and oxycodone (another opiate pain medication) at 12.15pm. The Emergency Medicine Adviser told us this medication is considered suitable for moderate pain relief. The records do not suggest Mrs S’ pain relief was inadequate.

32. We find doctors did not provide a good standard of care for Mrs S when they missed evidence of her fractured vertebra. They did not follow Good Medical Practice. We cannot say this had any impact on her health. The evidence shows clinicians provided appropriate pain relief and the way they managed her pain would not have changed if the diagnosis had been made earlier in the admission. But we recognise it has been distressing for Mrs A to learn that doctors did not identify the fracture for around two days.

Pneumonia

33. Mrs A says doctors delayed diagnosing her mother’s pneumonia.

34. Clinicians should have followed the Sepsis Guideline. This explains how healthcare professionals should identify and treat sepsis. 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).

35. 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.

36. 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.

37. The clinical records show the first doctor to review Mrs S made a provisional diagnosis of gastroenteritis (inflammation of the gut due to infection) and possible dehydration. The Medical Adviser told us there were no specific symptoms to suggest pneumonia. A chest X-ray showed Mrs S’ chest was clear. But doctors suspected she had an infection of the gut and prescribed antibiotics and intravenous fluids. The Medical Adviser told us that if doctors had suspected pneumonia they would, in any case, have provided similar treatment.

38. When Mrs S arrived at the Hospital her NEWS score was three based on her increased breathing rate and pulse. This did not suggest she needed an urgent medical response. NEWS scores later that day were one or zero. The Medical Adviser said this improvement suggested Mrs S responded appropriately to treatment. There is no evidence Mrs S developed severe sepsis.

39. The Medical Adviser said Mrs S’ blood test results supported that she had an infection but did not reveal whether this was due to a chest infection (pneumonia). The appropriate action would be to take further samples and continue to monitor to see whether the source of the infection becomes apparent. This action was being followed. Mrs S’ symptoms of vomiting and diarrhoea suggested a diagnosis of gastroenteritis was more likely.

40. The Medical Adviser said the typical signs and symptoms of pneumonia would be cough, wheezing, green sputum, tightness of the chest or extreme temperature (either high or very low). Signs of severe illness would be breathing difficulties, acute confusion, inability to pass urine and cyanosis (where the skin and lips turn blue because of lack of oxygen). Mrs S did not have any of the signs and symptoms based on what clinicians documented during her time in the Hospital.

41. The Medical Adviser said the coroner’s post-mortem report showed Mrs S had a number of abnormalities. The Medical Adviser said it is unlikely Mrs S died from pneumonia, given the absence of any documented symptoms and the fact that her death happened so quickly. Death from pneumonia is generally a slow process. It is more likely that Mrs S’ heart problems led to her death. The post-mortem evidence suggests her heart was starting to fail and the infection placed additional strain on it. The Medical Adviser said it is likely her heart stopped working and this led to her sudden death.

42. We find clinicians followed the relevant standards, as detailed above, when responding to Mrs S’ symptoms. We have seen no evidence to suggest there was a failure, or delay, in diagnosing pneumonia. There is little evidence that Mrs S had pneumonia. We hope Mrs A is reassured that we have seen nothing to suggest there were any failings in this respect.

Isolation

43. Mrs A says nurses placed her mother in isolation in a side room because they assumed she had tuberculosis when this was not the case. Instead, she had NTM which could not be passed on to other people. She says nurses repeatedly closed the door even when her mother and family members asked for it to be kept open.

44. The NMC Code contains the professional standards nurses must uphold. It says nurses must put the interests of people needing nursing first. They must make their care and safety their main concern and make sure their dignity is preserved and their needs are recognised, assessed and responded to. When people are anxious or distressed they must respond compassionately and politely.

45. The Nursing Adviser told us guidance would specify when patients should be isolated in side rooms in relation to infection control. If Mrs S was distressed because she was nursed in a side room the nurses should have considered this.

46. The records do contain references to Mrs S having tuberculosis when this was incorrect. At the complaint meeting the Trust’s representatives accepted the family’s account and apologised for the distress this caused.

47. We find nurses did not respond compassionately to the family’s concerns about Mrs S being isolated with the door closed. This was not in line with the NMC Code. We can see how this led to unnecessary distress for Mrs S and her family.

Nursing response on 27 March 2024

48. Mrs A says clinicians failed to identify the deterioration of her mother’s health on 27 March 2024. She says this was despite family members raising concerns with them.

49. Nurses should have followed the NEWS Guideline, which we have explained earlier in this report. The Trust also had its own escalation pathway which was based on the NEWS Guideline. This said for patients with a NEWS score of zero nurses should carry out observations at least once every twelve hours. For patients with a score between one and four observations should be between every four and six hours. Nurses should also have followed the NMC Code as referenced above.

50. The clinical records include a daily nursing care booklet. This shows Mrs S’ NEWS score on 27 March 2024 was zero, apart from at 3.40pm when it was two because of an increased breathing rate. There is also an observation chart showing nurses checked her at intervals no longer than every two hours. They noted she was in pain at 4.00pm and 6.00pm. In Mrs A’s complaint letter to the Trust, she noted that text messages from her mother earlier in the day did not indicate her health was deteriorating.

51. A doctor reviewed Mrs S at 3.40pm. They planned a further X-ray of the spine and said Mrs S should try to mobilise when she could. They also recommended a review from the pain team. There was no indication of any deterioration at that point. She had a physiotherapy assessment which noted she had pain but did not indicate any sudden worsening of Mrs S’ health.

52. A nurse later recalled they attended Mrs S when a family member advised them she was in pain. The nurse said they left the room to get paracetamol. When they returned a family member said Mrs S could not swallow. The nurse went away again for intravenous paracetamol. They gave this medication and Mrs S became short of breath. They said they tried to take her observations before using a nebuliser, but Mrs S became unresponsive, so they pressed the emergency buzzer.

53. Mrs A recalled a health care assistant telling a family member that Mrs S had been shivering uncontrollably all day. At 6.12pm Mrs A’s sister noted her mother was pale and shivering. She had some pain relief but by 7.07pm her temperature was high and her breathing was shallow. She said they requested more paracetamol, but this took too long. Family members recalled a nurse arriving to take observations at 7.50pm, but Mrs S had stopped breathing, so she called for help.

54. At 8.20pm the arrest team made a note of their response to Mrs S’ cardiac arrest. They noted their attempts to resuscitate her had been unsuccessful.

55. The Nursing Adviser said nurses monitored Mrs S appropriately on 27 March 2024. Nurses recorded observations in line with the Trust’s pathway and the NEWS Guideline. They would not have been expected to record Mrs S’ observations again before 9.40pm. There is no evidence nurses should have escalated Mrs S’ care to doctors earlier in the day.

56. There is clearly a difference between the recollections of family members and nurses about Mrs S’ health in the hours before she died. We recognise Mrs A and her family consider nurses delayed responding to signs that her mother’s health was deteriorating. This is not supported by the clinical records. We can see no independent evidence that nurses failed to respond to Mrs S’ needs. There is nothing to suggest Mrs S was having a cardiac arrest until the nurse tried to take her observations around 7.50pm. The nurse then took appropriate action to alert colleagues to attempt resuscitation. We find the nurses followed the NEWS Guideline and the NMC Code.

COPD medication

57. Mrs A says staff at the Hospital failed to give her mother access to her usual nebulisers. She says they ignored repeated requests from the family.

58. Nurses should have followed the NMC Code. This says nurses should ensure any treatment or care for which they are responsible is delivered without undue delay.

59. The clinical records show a doctor made a list of Mrs S’ usual medication. They noted she was using a salbutamol nebuliser to help with her COPD before she arrived at the Hospital on 25 March 2024. She took this up to three times a day if necessary. At 5.03am on 26 March nurses gave her a single dose of salbutamol because she felt breathless, which shows clinicians were aware of her prescription.

60. The records are clear that Mrs S was breathless at times. They are also clear that, apart from on one occasion, they did not give her the nebulisers she needed.

61. During Mrs S’ admission a doctor prescribed an AirFluSal Forspiro inhaler containing fluticasone and salmeterol along with a tiotropium inhaler. The Medical Adviser said salbutamol is effective for a much shorter period than salmeterol. They said the decision to change was appropriate. This is because the combination of the two inhalers recommended for Mrs S would have been superior to salbutamol alone. The medication charts show that nurses should have administered this medication at 8.00am and 8.00pm from 26 March 2023. The medication was not administered, and nurses did not document the reasons why.

62. At the complaints meeting the Trust’s representatives agreed clinicians should have provided Mrs S with a nebuliser when she needed one. This is not reflected in the complaint responses where the Trust has suggested this was not a failing.

63. We find the nurses fell below the standard expected in the NMC Code when they did not provide nebulisers to Mrs S when she needed them. The Medical Adviser told us the omission of nebulisers would not have had any significant impact on Mrs S’ and would not have contributed to her death. But we can see how this failing led to discomfort and distress for Mrs S that could have been avoided and was also distressing for her family.

1. Mrs A complains about how healthcare professionals at the Hospital (part of the Trust) cared for and treated her mother, Mrs S, in the last three days of her life. We can see how devastating these events have been for Mrs A and her family. We offer them our sincere condolences for their loss.

2. We find failings relating to some of the issues we have investigated. We have seen that Mrs S waited too long in a corridor from her arrival at the Hospital. Doctors also delayed diagnosing Mrs S’ spinal fracture and nurses made an incorrect decision to isolate her. We have also seen that nurses did not give Mrs S sufficient medication for her COPD.

3. Mrs A says her mother’s death could have been prevented. We have seen no evidence of this. But we can see these issues led to distress and discomfort that could have been avoided. We partly uphold the complaint. We recommend the Trust sends an apology letter to Mrs A and that it takes action to try and ensure failings are not repeated for other patients.