A practice in the Shropshire area

2. Mrs A complains about the care provided to her mother, Mrs B, by Shropshire Community Health NHS Trust (the Trust) from 1 to 3 June 2024. Specifically:

• the Trust failed to carry out an assessment of Mrs B before starting her oxygen therapy on 2 June 2024 • despite having a NEWS2 score of 8 on 2 June 2024, the Trust said in its complaint response that Mrs B showed no signs of deterioration at the time • Mrs B suffered from pressure sores on her leg and sacrum. She was given a treatment plan, but the Trust did not adhere to it. For example, Mrs B was not repositioned by nurses in a timely way • there are contradictions between the Trust's complaint response and Mrs B’s clinical records. The Trust's first response says Mrs B was stable and there was no deterioration. It acknowledges that she had breathing problems on two separate occasions but fails to acknowledge that she was on oxygen throughout this episode of care.

3. Mrs A says that as a result of the inadequate care that Mrs B experienced at the end of her life and the way in which the Trust dealt with her when she raised concerns, she has experienced multiple impacts. These include distress, being disregarded, trauma, betrayal, anguish, guilt, and dismay. A lack of transparency, openness, honesty, and consistency in the Trust’s complaint response only compounded Mrs A’s grief. She has had to have bereavement counselling to try and come to terms with everything that went wrong. Mrs A says she was a very well and happy person until her mother was admitted to hospital. Now, Mrs A says she is unhappy and it has been documented that she is suffering from depression.

4. As an outcome, Mrs A wants changes in procedure at the Trust so end of life care plans are initiated on admission to hospital when the patient has been admitted on an end of life or palliative pathway. Mrs A also wants assurances from the Trust that all staff working on a ward for rehabilitation and palliative care are suitably trained.

5. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

6. Mrs B was 87 years old. She had a clinical background of a thyroidectomy, horseshoe kidney, diverticular disease, and arthritis. She also had a permanent pacemaker in situ for heart block.

7. In March 2023, Mrs B began to develop an ischaemic ulcer on her right leg due to peripheral vascular disease. In November 2023, Mrs B was due to undergo a femoral bypass operation but was deemed unsuitable to have the procedure and discharged home for conservative management.

8. Mrs B was visited at home three times a week by nurses to have dressing changes for her debrided right leg ulcer. From March 2024, Mrs B suffered from loss of appetite and reduced dietary intake. She had a positive faecal occult blood test at this time. This resulted in significant weight loss and painful pressures sores on her elbows and sacrum. Mrs B was reviewed by her GP on 21 May 2024 and prescribed ‘just in case’ medications.

9. On 1 June 2024, Mrs B seemed fine but by 6pm, she was in significant pain and distress, mainly due to the pressure sore on her sacrum. A GP visited Mrs B at home and recommended that she be admitted to hospital to manage her pain which she agreed to. Mrs A says there was a 15-hour delay in Mrs B receiving the treatment she was admitted for, she was in a great deal of pain and was not monitored adequately.

10. Mrs A says her mother was deemed to be ‘stable’ on 1 and 2 June 2024 but suffered a rapid deterioration in her condition on 3 June 2024. Mrs B was placed on an end-of-life care plan and sadly died. The cause of Mrs B’s death was frailty of old age and peripheral vascular disease.

Assessment and oxygen therapy

15. Mrs A says the Trust failed to carry out an assessment of Mrs B before starting her oxygen therapy on 2 June 2024.

16. Firstly, having considered Mrs B’s records received from the Trust with support from our geriatrician adviser, some of Mrs B’s records for this episode of care are unclear and incomplete.

17. For example, a medical assessment form completed by a doctor is undated at the top of the form and no time is recorded. It is also noted that the oxygen prescription section on Mrs B’s Adult Prescription Chart was not completed, instead the oxygen was prescribed in the “as required” section, and there was no record on this chart as to when the oxygen was administered to Mrs B.

18. Therefore, based on Mrs B’s adult prescription chart, our geriatrician adviser says she was prescribed oxygen therapy on 2 June 2024 after being seen by a doctor rather than on 1 June 2024. This was due to Mrs B’s suspected COPD and was provided on an ‘as required basis.’ In other words, if Mrs B’s oxygen saturation level went below a certain level, oxygen therapy would commence.

19. According to Mrs B’s observation chart, she was on air (not on oxygen) at 10pm on 1 June 2024, and at 6.40am and 9.30am on 2 June 2024. After this, no observations are recorded on Mrs B’s observation chart.

20. As for whether the Trust carried out an appropriate assessment of Mrs B before starting her oxygen therapy, our geriatrician adviser says the NICE guidance regarding oxygen and palliative care – dyspnoea applies. This guidance indicates that oxygen therapy can be used on patients at risk of hypercapnic respiratory failure which is more likely in those with COPD which it was suspected Mrs B had. The NICE guidance also indicates that effective communication with the patient and other healthcare professionals is especially important including an individualised care plan.

21. Our geriatrician adviser says the records indicate that the admitting doctor had decided after discussion with Mrs B for “TLC only” and not for acute transfer. Therefore, oxygen was given to Mrs B in a palliative context to relieve her breathlessness. The nursing records on 2 June 2024 indicate that the nurse commenced Mrs B on oxygen at the rate of 4 litres per minute, as she was “very breathless”.

22. In summary, we consider that as oxygen was being given to Mrs B in a palliative context, an appropriate assessment was carried out by the clinical team prior to oxygen being started. This was in accordance with the relevant NICE guidance.

NEWS2 score and deterioration

23. Mrs A says that despite having a NEWS2 score of 8 on 2 June 2024, the Trust said in its complaint response that Mrs B showed no signs of deterioration at the time.

24. We note that the Trust’s complaint response of 27 September 2024 states that Mrs B was stable throughout 2 June 2024. The Trust’s complaint response of 25 March 2025 states that Mrs B’s NEWS2 score on 2 June 2024 was 8 which would indicate immediate medical review. Our geriatrician adviser says they have been unable to locate the relevant documentary evidence in Mrs B’s records to verify this but, assuming this score is correct, Mrs B received appropriate care.

25. The records indicate that Mrs B was assessed by a doctor who was aware of her NEWS2 score. It is documented that Mrs B was for care within a community hospital only and not for transfer to an acute setting. Given this and that Mrs B was not for any invasive treatment, our geriatrician adviser says a clinical decision was made to discontinue observations for her comfort.

26. It is documented in the contemporaneous records that Mrs B suffered a marked deterioration in her condition overnight from 2 to 3 June 2024. Our geriatrician adviser says Mrs B’s records paint a picture of a patient who was now sadly approaching the end of her life and she had been admitted to hospital for palliative care/symptom control purposes only of which she was aware. Having said that, the records also indicate that the Trust’s communication about this could have been clearer.

27. Mrs B did not want antibiotics and was not for escalation. Therefore, the records indicate that a clinical decision was made on the evening of 2 June 2024 to start end of life care when pathway medication commenced. The focus of this was about keeping Mrs B comfortable with nurse care and end of life medication. Ultimately, our geriatrician adviser says Mrs B’s high NEWS2 score on 2 June 2024, and subsequent deterioration triggered the Trust’s decision to start end of life care.

Pressure sores and treatment plan

28. Mrs A says Mrs B suffered from pressure sores on her leg and sacrum. She was given a treatment plan, but the Trust did not adhere to it. For example, Mrs B was not repositioned by nurses in a timely way.

29. Firstly, as regards Mrs B’s treatment plan, our geriatrician adviser says there is evidence of an appropriate treatment plan in Mrs B’s records, and the Trust broadly adhered to the plan throughout this episode of care. Broadly speaking, the Trust’s plan for Mrs B was that in event of a deterioration in her condition, end of life care would start in accordance with her wishes.

30. As for Mrs B’s pressures sores and her repositioning, our nurse adviser says the following NICE guidance applies:

1.1.9

‘Encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.’

1.4.9

‘Use high-specification foam mattresses for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface.’

31. The records indicate that when Mrs B was admitted to hospital on 1 June 2024, this was due to severe pain from a necrotic pressure ulcer on her sacrum. Our nurse adviser says that Mrs B was at high risk of pressure damage as she had multiple pressure sore/tissue damage, so she required pressure relieving equipment. Therefore, Mrs B was nursed on a Quattro air mattress from admission in accordance with the NICE guidance above.

32. Although the NICE guidance quoted above states that high-risk patients like Mrs B should be turned at least 4-hourly, our nurse adviser says it is documented within the records that there were constraints due to the amount of pain that Mrs B was in. Therefore, nurses slightly changed Mrs B’s position by rolling her.

33. Rounding charts in Mrs B’s records indicate that she was checked upon hourly. SKNN charts indicate that her skin was assessed at least 3 times daily during her admission. It is also noted that Mrs B was started on the end-of-life medications at 9pm on 2 June 2024, at which point our nurse adviser says the onus of Mrs B’s care would have been managing her symptoms and ensuring that she was comfortable.

34. Overall, although there is no evidence in the records that Mrs B was repositioned at least 4-hourly in accordance with the NICE guidance, our nurse adviser says the priority of the nursing team was to ensure that Mrs B was kept comfortable and as pain free as possible.

35. As above, Mrs B’s records paint a picture of a patient who was at the end of her life during this hospital admission. She had an ischaemic leg which means there was no blood reaching her leg. Mrs B had been offered amputation of her leg, but she did not want that. She was also in a great deal of pain from her pressure ulcers which the records indicate were unlikely to get any better. Given this, as above, the priority for nurses was to manage Mrs B’s symptoms and keep her comfortable.

36. Finally, while there is an argument that Mrs B’s end of life care could have started sooner than it did given her clinical background and high NEWS2 score on the afternoon of 2 June 2024, our geriatrician adviser says it is a difficult judgement call for clinicians to make. We note that Mrs B was started on end-of-life medication on the evening of 2 June 2024. Overall, we consider it was not unreasonable for the Trust to wait until then before commencing Mrs B’s end of life care.

Complaint response

37. Mrs A says there are contradictions between the Trust's complaint response and Mrs B’s clinical records. The Trust's first response says Mrs B was stable and there was no deterioration. It acknowledges that she had breathing problems on two separate occasions but fails to acknowledge that she was on oxygen throughout this episode of care.

38. We have considered the Trust’s first and second complaint response letters dated 27 September 2024 and 25 March 2025. As above, the Trust’s first response states that Mrs B was stable throughout 2 June 2024, but she suffered a rapid deterioration in her condition on 3 June 2024. There is no mention of Mrs B having a NEWS2 score of 8. This score would not indicate that a patient was stable. As above, it indicates that immediate medical review is required.

39. We concur that the Trust’s first response refers to Mrs B’s breathing difficulties but, as above, our geriatrician adviser says that Mrs B’s oxygen therapy did not start until 2 June 2024. Therefore, we cannot say that Mrs B was on oxygen therapy throughout this episode of care.

40. The Trust’s second response goes into more specific detail about Mrs B’s deterioration on 2 June 2024. It indicates that Mrs B was stable in the morning with a NEWS2 score of 4, but by the afternoon, further observations showed she had deteriorated with a NEWS2 score of 8. As before, our geriatrician adviser says they have been unable to locate the documentary evidence in Mrs B’s records to support her having a NEWS2 score of 8. However, assuming her score was correct, our geriatrician adviser has outlined above that appropriate care was provided.

41. We acknowledge that it could be argued the Trust’s first response is misleading or contradictory in terms of when Mrs B’s deterioration started on 2 June 2024, when compared to her contemporaneous medical records. In hindsight, it could have been clearer about when Mrs B’s condition started to change. However, we consider the Trust’s second response put this right with further detail and clarity provided about Mrs B’s deterioration on 2 June 2024. It is unfortunate that this level of detail was not provided in the Trust’s first response, but we do not consider this is enough to constitute maladministration. A satisfactory explanation was provided in the Trust’s second complaint response.

42. This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.

1. We have not seen any failings in the care provided to Mrs B by the Trust from 1 to 3 June 2024. We have not seen any failings in the Trust’s complaint response. We will therefore not uphold Mrs A’s complaint.