Medway NHS Foundation Trust

4. Mrs P complains about the following care and treatment provided to her late mother, Mrs T, at the Medway NHS Foundation Trust (the Trust), between 21 August 2023 to 6 September 2023:

Clinical issues: • The Trust did not give her mother an oxygen cylinder when it discharged her.

• The Trust did not check her mother’s heart condition before it discharged her.

Communication issues: • The Trust did not appropriately explain why it could not resuscitate her mother.

• The Trust did not tell her it gave and explain why it gave her mother morphine.

• The Trust did not tell her that her mother had heart failure until she later found out from a nurse.

5. As the Trust did not check her mother’s heart condition and give her an oxygen cylinder at the point of and before discharging her, it affected her mother’s breathing and she was not able to independently walk, use the toilet, or wash herself.

6. Mrs P said she had to give up her work to stay at home and look after her mother 24 hours a day since she could not move. As a result of the communication issues, it caused distress and frustration to the family at an already stressful and difficult time.

7. She would like an acknowledgement of failing, apology and financial remedy.

8. Mrs T was in her early 70s when her GP referred her to hospital on 21 August 2023 due to low oxygen saturation levels. This means the blood is not carrying enough oxygen to meet the body’s needs. She presented to the emergency department (ED) feeling generally unwell. Mrs P mentioned to the hospital Mrs T had increased worsening of breath since June 2023.

9. Mrs P said her mother had been struggling a lot as previously she could ‘do stairs’ and now she was getting more shortness of breath (SOB) on exertion. She had a nebuliser machine at home but had been getting wheezier. A nebuliser is medical equipment a person with a respiratory condition can use to administer medication quickly to the lungs.

10. The Trust diagnosed Mrs T with infrequent exacerbations of chronic obstructive pulmonary disease (IECOPD) and heart failure (HF). The NHS definition of COPD is the name for a group of lung conditions that cause breathing difficulties. It is a common condition that mainly affects older adults who smoke.

11. The breathing difficulties tend to get gradually worse over time and can limit normal activities. HF means the heart is unable to pump blood around the body properly. It usually happens because the heart has become too weak or stiff. This means it needs some support to help it work better and be controlled for many years.

12. It is mostly common in older people and is a long-term condition that tends to get gradually worse over time. The Trust discharged Mrs T on 6 September 2023. The hospital discharge summary said due to Mrs T’s chronic medical health she needed full time supervised care, which was currently provided by her daughter, Mrs P.

13. Mrs T sadly died on 25 February 2025.

Clinical issues

Oxygen cylinder

18. Mrs P complained the Trust did not give her mother an oxygen cylinder when it discharged her. She said the Trust said Mrs T would be connected to the oxygen if she was discharged to a care home. The Trust only gave her mother an oxygen cylinder in January 2024 after the community respiratory team assessed her at home. She said her mother was able to walk, wash and go to the toilet independently before her hospital admission.

19. Mrs P said she had to give up her work to stay at home and look after her mother 24 hours a day since she could not move. We recognise how this changed life for them both.

20. The Trust said Mrs T’s blood gases showed elevated carbon dioxide with low oxygen showing respiratory failure due to her lung disease. It said she had oxygen levels consistent with hypoxia (lack of oxygen supply in body tissues which causes confusion and changes in breathing and heart rate) throughout her admission.

21. It said she required supplementary oxygen to correct this and support her recovery. The Trust said it discussed Mrs T’s chronic hypoxia and the possibility of the requirement for long term oxygen on 5 September 2023. However, it considered it was unsafe due to smoking in the house.

22. It said the respiratory nurse explained its reluctance for concentrators due to smoking history, cognition, understanding of equipment and the risk factors. A concentrator is a device that extracts oxygen from the surrounding air giving a continuous supply of oxygen enriched air for patients.

23. The Trust said the outcome of the meeting was for Mrs T to be discharged home without oxygen as she was managing short distances and transfers without oxygen support whilst maintaining oxygen saturations within the target range set for her. The therapy team assessed Mrs T and arrangements made for a micro living (microenvironment) for her to manage once home.

24. Micro living refers to a patient living in a very small part of their home, usually one room, to support everyday recovery of movements or limited mobility, for example moving from bed to chair to toilet. We can see the physiotherapy (physio) records show the Trust’s plan was to wean Mrs T off the oxygen.

25. It completed regular physio assessments whilst she was in hospital which showed her ability to mobilise distances and transfers with assistance and an oxygen cylinder. The records support what the Trust said of its reluctance to discharge Mrs T home with an oxygen cylinder or long-term oxygen therapy (LTOT) as Mrs T and family members were smoking and vaping.

26. The nursing notes on 25 August 2023 showed Mrs T was breathless but did not always want oxygen as she was aggressive and anxious and in need of cigarettes. The records on 31 August 2023 said Mrs T was now weaned to room air at rest before and after mobilisation with no concerns on mobility. It said Mrs T was able to mobilise unaided or with Mrs P’s minimal support.

27. A clinical assessment on 1 September 2023 said Mrs T and Mrs P were both keen for Mrs T to go home. The Trust explained the reason for the continued stay was Mrs T required oxygen and once the requirement drops, she would be able to go home. It recorded that Mrs T was still smoking cigarettes. A physio assessment on 5 September 2023 said Mrs T had been using oxygen on and off when at rest last week.

28. We can see the records support what the Trust said that it had a meeting with the family on 5 September 2023. The Trust’s doctor recorded Mrs P was aware due to Mrs T’s active smoking history and other members vaping in the house, discharging her home with oxygen was a safety hazard.

29. The discharge summary of 6 September 2023 recorded the Trust said the community respiratory team could assess Mrs T at home and if she had not smoked and her cognition was better, she may be a candidate for home oxygen in the future. Our adviser referred to the BTS guidelines which provides detailed evidence-based guidance for the use of home oxygen for patients out of hospital.

30. They referred to page ten of the BTS guidelines about safety and home oxygen therapy, good practice points, which says, ‘The risks of prescribing oxygen to active smokers should be considered on a case-by-case basis.’ It further says, ‘Where there is reasonable doubt, the therapy should not be prescribed.’

31. They said a home visit, home oxygen assessment services involvement, and visit from a health professional undertaking a risk assessment in conjunction with the local fire service and/ or oxygen contractor would only be appropriate if the Trust considered home oxygen would be a serious option for Mrs T.

32. Our adviser observed in the records the Trust optimised Mrs T’s health condition to the point where it was able to discharge her with a micro living set up at home without the need for oxygen therapy. They could see the Trust completed an assessment for her to manage effectively at home within a microenvironment.

33. The discharge notes said the conclusion of the family meeting was to assess and arrange micro living setting. It said her medical condition meant she needed full time supervised care. It discharged Mrs T on 6 September 2023 with community follow up by the respiratory nurse for consideration by them in the future if needed. Our adviser referred to page 31 of the BTS guidelines which gives further information about smoking and home oxygen therapy.

34. It says there is an increasing recognition of the significant risks of fire and personal injury associated with smoking and the use of home oxygen therapy. They said Mrs T’s clerking admission records on 21 August 2023 recorded Mrs T had dementia and it was slowly getting worse. Our adviser said as Mrs T was an active smoker and had cognitive impairment there was reasonable doubt in the safety of her managing an oxygen cylinder at home.

35. They said it would have been a safety risk to her and others. Therefore, it was appropriate and in line with the BTS guidelines for the Trust to not give Mrs T an oxygen cylinder when it discharged her. We can see the records show the Trust explained the complexities of oxygen to the family and Mrs P and her husband felt Mrs T would not manage oxygen cylinders at home.

36. We can see the Trust considered the prescription of oxygen cylinder at home for Mrs T. We recognise the family were upset as it wanted the Trust to provide an oxygen cylinder to Mrs T upon her discharge from hospital. From review of the available information, we do not consider there are any indications of failings in this issue and the Trust acted appropriately in line with the BTS guidelines. Therefore, we shall not consider this issue further.

Heart condition

37. Mrs P complains the Trust did not check her mother’s heart condition before it discharged her. She said the doctor knew her mother had heart failure, but the Trust did not check her heart condition before sending her home. The Trust said Mrs T's electrocardiogram (ECG) showed she had a fast heart rate, likely to be atrial fibrillation (AF) triggered by her low oxygen and infection stressing her heart.

38. An ECG is a diagnostic tool that measures the electrical impulses of the heart. AF is an irregular heart rhythm which can cause symptoms of fatigue, heart palpitations, SOB and dizziness. The Trust said there was some thought the nebulised drugs used to open her airways might have worsened her heart rate. The Trust said it monitored this situation over the next few days, and it was settling at times.

39. It said on 24 August 2023 her heart rate was still variable and needed specific therapy with medication called bisoprolol to stabilise her heart rate. It confirmed Mrs T's heart returned to a normal rhythm. The Trust said Mrs T had chest X-rays on 10 and 21 August 2023 which showed she had chronic lung changes but no evidence of heart failure.

40. It said the X-rays do not exclude a diagnosis of infection/inflammation in the airways as is seen in an exacerbation of COPD which Mrs T had. This is because it does not show on Xrays. The Trust said on 25 August 2023 the working diagnosis was of right sided heart failure, secondary to chronic respiratory failure, due to her chronic obstructive airway disease.

41. The treatment for this was to keep her oxygen levels as stable as possible and treat the fluid retention. The Trust said as detailed in its first and second responses, it regularly checked and monitored Mrs T’s heart condition following her admission and before her discharge. We can see the Trust completed various investigations on Mrs T whilst she was in hospital. We could see the Trust completed an X-ray for Mrs T on 21 August 2023.

42. The records show Mrs T had leg oedema (swelling in the legs due to fluid buildup in the tissues often referred to as peripheral oedema). Our adviser said they could see the Trust appropriately checked and monitored Mrs T’s heart condition. They said they could see from the records Mrs T had a specific type of right sided heart failure called cor pulmonale.

43. This is when the right heart ventricle cannot effectively pump blood to the lungs, leading to blood backing up in the body. This causes symptoms like swelling in the legs, abdomen, liver congestion, fatigue and SOB. They said cor pulmonale can be acute or chronic depending on the severity of the lung condition. The basic treatment for this is focussing on the management of the lung condition.

44. They said they could see from the records this is what the Trust did in line with sections 1.2.77 and 1.2.78 of the NG115 guidelines. Section 1.2.78 of the NG115 guidelines says oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy.

45. Diuretic medication helps move fluid and salt out of the body which reduces swelling in the body. Our adviser said they could see the Trust appropriated treated Mrs T with furosemide, a diuretic medication, in line with sections 1.2.78 of the NG115 guidelines. The records show the Trust first administered this medication to Mrs T on 25 August 2023.

46. Section 1.2.77 of the NG115 guidelines says, ‘Ensure that people with cor pulmoale caused by COPD are offered optimal COPD treatment, including advice and interventions to help them stop smoking. For people who need treatment for hypoxia, see the section on longterm oxygen therapy.’

47. Our adviser said the Trust acted in line with section 1.2.77 of the NG115 guidelines in monitoring Mrs T’s heart condition as it treated it by optimising her treatment for an infective exacerbation of COPD. This treatment involved giving her salbutamol and ipratropium nebulisers and steroid tablets to treat her COPD condition on 21 August 2023.

48. Our adviser said the Trust appropriately gave Mrs T intravenous (administered directly into the bloodstream within a vein) antibiotic medication for a possible chest infection. The records show on 25 August 2023 the Trust ordered nicotine patches for Mrs T. We can see this shows it was encouraging her to quit smoking and reduce her cravings for it in line with section 1.2.77 of the NG115 guidelines.

49. Our adviser confirmed the Trust considered and administered oxygen therapy to Mrs T in line with the same section of the NG115 guidelines. In support of this they referred to a respiratory nurse specialist note of 23 August 2023. The respiratory nurse advised the medical team of the correct prescription of oxygen therapy and the target oxygen saturation aimed for 88 to 92% for Mrs T.

50. Target saturation is the specific oxygen saturation level aimed for patients during oxygen therapy. Our adviser referred to paragraph 15 a) of the GMP guidance, which says clinicians:

‘…must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient.’

51. Our adviser considered the records and confirmed the Trust appropriately checked Mrs T’s heart condition in line with the above GMC good medical practice guidance by checking her vitals (body’s basic functions to assess general health).

52. This included daily monitoring of her heart rate, blood pressure, breaths per minute, oxygen saturations, pain level, level of alertness and physically examining her and auscultating (listening to sounds) her lungs on ward rounds. We could also see regular entries of the Trust assessing Mrs T’s vital measurements.

53. Our adviser said this showed throughout her time in hospital her heart condition improved. Further, our adviser referred to a ward round note on 5 September 2023 which showed a doctor assessed Mrs T was not in any distress, able to speak in full sentences, chest was clear, no wheeze and respiratory rate was normal for the number of breaths per minute.

54. Our adviser said when Mrs T was first admitted to hospital on 21 August 2023 she required supplemental oxygen to breath comfortably. The records show the Trust’s plan was to wean Mrs T off the oxygen therapy to ensure her target saturation for it was 88 to 92%. By the time of her discharge Mrs T was managing to mobilise short distances without requiring oxygen therapy.

55. We can see on 5 September 2023 the physio assessed Mrs T mobilised unaided on room air. It said, ‘…offered patient to walk to sink from chair to trial short distance – mobilised unaided 12m on room air – practising pacing and deep breathing exercises…’ The Trust’s plan was to, ‘…maintain mobility and monitor saturations when mobilising short distance.’

56. The discharge notes on 6 September 2023 said throughout her stay Mrs T continued to improve and any SOB resolved. It said over the last three to five days, she had been mobilising unaided from her bed to the toilet and short trips with the physiotherapist and occupational therapist. It said her oxygen saturation dropped below 88% once.

57. From review of the available information, we can see there is no indication the Trust did not appropriately check Mrs T’s heart condition, and the records supported improvement in this condition, which was linked to her lung health.

58. Therefore, we consider the Trust acted in line with the NG115 guidelines and GMP guidance, in checking and treating Mrs T’s heart condition. We recognise it was a worrying and stressful time for the family. They were concerned with Mrs T’s health. We are pleased Mrs T’s heart condition and oxygen levels improved to an optimal level before her discharge.

Communication issues

Resuscitation conversation

59. Mrs P complained the Trust did not appropriately explain why it could not resuscitate her mother. In her complaint to the Trust she asked, ‘Why did the doctors keep saying whatever happens, they will not resuscitate my mother?’ She was not happy with the way the doctor communicated to her about not resuscitating her mother.

60. The Trust said resuscitation decisions form part of the treatment escalation plan, and decisions can be changed based on the patient’s clinical condition as treatment progresses.

It said decision not to resuscitate (do not attempt cardiopulmonary resuscitation (DNACPR)) Mrs T was made due to the severity of her lung disease (COPD) with its effect on the right side of her heart and lack of respiratory reserve, with chronically low oxygen levels.

61. It said this did not mean that active treatments would not be used to keep her as well as possible. It said further review of Mrs T’s medical records shows its decision of DNACPR was discussed with Mrs P on 22 August 2023 and no concerns were raised during or following the conversation.

62. It said resuscitation discussions are very difficult for patients, and their families and clinicians do try to explain the difference between attempting to re-start a heart should it stop and continuing all active treatment. We can see the treatment escalation plan (TEP) form dated 22 August 2023 at 10.43am completed by a doctor said they had a conversation with Mrs P.

63. There was a tick next to the following sentence in the document: ‘… (consider DNACPR if appropriate and whether patient should be for end-of-life care)?’ The doctor recorded that Mrs P had poor functional reserve and cardiopulmonary resuscitation (CPR) is unlikely to be successful and is not in her best interests.

64. During a doctor’s assessment on 21 August 2023 the Trust recorded, ‘Discussed DNAR (do not attempt resuscitation) with Mrs P and Mrs T, Mrs P has lasting power of attorney (LPA), agrees she should be for DNAR considering all co-morbidities and cognitive impairment.’

65. Our adviser confirmed functional reserve refers to a patient’s ability to recover to their cognitive and physical baseline function following an acute illness or other event causing physical or mental injury to the body such as a fall causing injury. They considered therefore it was the right decision, from a medical point of view, to not resuscitate Mrs T if her heart stopped.

66. Our adviser said from review of the records, they could not tell whether the Trust had an appropriate resuscitation conversation with Mrs P and Mrs T. They said they would usually expect a record of exactly what is said and discussed during a resuscitation conversation on a document separate from the resuscitation form.

67. They referred to paragraph 132 of the GMC guidelines for CPR which says decisions made in advance about whether CPR should be attempted must be based on the circumstances of the individual patient and consider their wishes and preferences.

68. It further says clinicians must approach discussions sensitively and bear in mind some patients or those close to them, may have concerns that decisions not to attempt CPR might be influenced by poorly informed or advanced age on the patient’s quality of life.

69. Our adviser said paragraph 142 of the GMC guidelines for CPR says any discussions with a patient, or with those close to them, about whether to attempt CPR, and any decisions made, should be documented in the patient’s record and any advance care plan.

70. Our adviser said the Trust could have explained having a DNACPR decision does not mean it will not give other appropriate treatment to improve Mrs T’s condition, caring for her the best it could to enable her to return home. They said the Trust should have explained this, and ensure their understanding, or any questions from Mrs T and/ or Mrs P documented.

71. This is to ensure it explained the DNACPR issue sensitively to them in line with the GMC guidelines for CPR. We consider this is a shortcoming as it does not fall so far short to be an indication of failing. This is because we were not present during the conversation to know what was discussed at the time to be certain the Trust were not being sensitive in the discussion.

72. We can see the Trust clearly documented that it discussed the reasons why it considered CPR was not in Mrs T’s best interests due to her multiple health conditions and cognitive impairment.

73. We recognise it would have been a difficult, distressing and unpleasant topic to discuss. We are reassured the post take ward round notes the next day, on 22 August 2023, shows the Trust continued active treatment to assist in improving and recovery of Mrs T’s health condition. Therefore, we shall not consider this issue further.

Morphine

74. Mrs T complains the Trust did not tell her it gave and explain why it gave her mother morphine. In her complaint to the Trust, she said she found out her mother was on morphine every day and the nurse told her it was helping her breathing. She said she received a call back from the community respiratory team on 1 September 2023 where she asked if it was appropriate for her mother to receive morphine.

75. She said she was again told it was fine as it helped with her breathing and slowed her heartbeat. The Trust said it prescribed and administered a low dose of morphine as a symptomatic treatment, if Mrs T became short of breath, distressed and uncomfortable due to her lung disease and low oxygen saturations. Symptomatic treatment is treatment that only affects symptoms and not the underlying cause of it.

76. It said low dose morphine can often be considered for patients to relieve the symptoms of breathlessness which can be very distressing. The records show the Trust gave medications as prescribed with no concerns during Mrs T's admission. The records show a medication reconciliation document which included morphine. It said this medication was to be given as required for SOB and the start date was 25 August 2023.

77. As mentioned above we could see the nursing notes on 25 August 2023 said Mrs T was breathless but did not always want oxygen as she was aggressive and anxious. Our adviser said the use of small doses of morphine is appropriate to relieve breathlessness in patients undergoing palliative care.

78. Mrs T was not under the care of the palliative team in hospital however, the underlying principle of administering a small dose of morphine to ease the distress and anxiety caused by being SOB would still apply in her case. They said this is because it was clear Mrs T’s lung condition, COPD, was progressing and causing her to become more breathless.

79. Our adviser said when Mrs T was first admitted to hospital on 21 August 2023 and for a good part of her admission, she required supplemental oxygen to help her to breath. As mentioned above, she had physical signs such as fluid in her legs, associated with her heart condition. They said this occurs as the COPD progresses and becomes more severe.

80. Therefore, although Mrs T was not formally referred to the palliative care team, it would have been reasonable to treat her breathlessness in the same way to make sure she was as comfortable as possible. Our adviser said breathlessness can trigger anxiety by activating the body’s fight and flight response which can create a feedback loop of not getting enough air which intensifies fear and panic. This can present as aggression.

81. Our adviser referred to paragraph 49 of the GMP guidelines which says clinicians must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including a) their condition, its likely progression and options for treatment, including associated risks and uncertainties.

82. They said in line with these guidelines, they would expect the clinician give information about the potential benefits and side effects of the morphine medication, for example, confusion, constipation, drowsiness. This would have made Mrs P aware of the medication prescribed for her mother and put her mind at rest about her mother’s care.

83. We can see Mrs P had LPA to discuss issues about her mother’s healthcare. We could see no indication the Trust told Mrs P it gave or explained why it gave her mother morphine in line with paragraph 49 of the GMP guidance.

84. We are an Ombudsman provided for, and funded by, the public. We need to ensure that we maintain a balance between supporting those who complain to us to get a remedy for the injustice they have experienced, while ensuring we use our resources to achieve the most impact.

85. We do so under our own ‘public value model’ to do this. This means that in some circumstances we will only consider cases at the higher end of severity, or where we can see our involvement will have a wider public impact. To do so, we consider injustice against our own severity of injustice scale. It is available on our website.

86. This is a transparent scale of six bandings that provide the Ombudsman the opportunity to consider the impact of severity ranging from low bandings of inconvenience, frustration up to level six where often we see loss of life or profound impacts such as permanent disability. Mrs P said the impact of this issue caused distress and frustration to the family at an already stressful and difficult time.

87. She seeks an apology, service improvements and a financial remedy. Although we acknowledge the frustration and distress when the family later found out the Trust were giving Mrs T morphine, we consider the level of impact to the family would be at a lower level, a level one, on our severity of injustice scale.

88. This is because the indication of failing in the lack of communication about the morphine medication is a one-off incidence where we would reasonably expect the effect on them is of short duration, and where there are no other adverse effects or ongoing wider impact.

89. For this reason, under our approach to public value we will take no further action on this issue. Nevertheless, we are reassured and pleased the Trust openly acknowledged it could not be sure if it explained about the morphine medication to the family, and apologised if it had not as it should have done.

Heart condition

90. Mrs P complains the Trust did not tell her that her mother had heart failure until she later found out from a nurse around 2 September 2023. The Trust said the records confirm there was a discussion with the ward doctor on 1 September 2023 when Mrs T had more leg swelling, lung crackles and right sided heart failure was discussed. It said it considered the swelling of her legs was due to the right sided heart failure.

91. The Trust said at the family meeting on 5 September 2023 Mrs P was very much aware of her mother’s long-term lung and heart condition (heart failure). Her heart was managed by furosemide (diuretic medication to treat heart failure) which is one of the medications noted in her discharge summary.

92. The Trust said it is unclear from the records why Mrs P did not understand her mother had heart failure. However, it accepted her feedback she was not aware until a nurse told her and explained. We could see a ward round note on 1 September 2023 which showed the clinical assessment said Mrs T had possible heart failure with IV (intravenous) furosemide.

93. We could see no record of what Mrs P said that she only found out from a nurse around 2 September 2023 that her mother had heart failure. We can see the Trust’s multidisciplinary meeting (MDT) with the family on 5 September 2023 shows Mrs P was very much aware of her mother’s long term lung condition called COPD and poor heart called heart failure.

94. It recorded overall, the family were happy with the meeting and had no further questions. Our adviser reviewed the MDT family meeting of 5 September 2023. They said, although the records do not show the Trust told Mrs P of the specific type of heart failure her mother had, it indicates it gave and discussed information about her mother’s heart failure.

95. They said therefore, the Trust acted in line with paragraph 33 of the GMP guidelines which says, ‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’

96. From review of the available information, we consider the Trust was sensitive and responsive in giving Mrs P information about her mother’s health condition. The records reflect Mrs P was aware of her mother’s heart and lung condition.

97. We understand it was a very difficult and stressful time, and we do not underestimate how challenging it was for Mrs P and the family dealing with Mrs T’s health issues. We can see no indication of failing in this issue and shall not consider it further.

98. We thank Mrs P for bringing her complaint to us.

1. We have carefully considered Mrs P’s complaint about Medway NHS Foundation Trust (the Trust). We consider we will take no further action on the communication issue for morphine medication due to the level of severity against our public value model. We decided we have seen no indication anything went seriously wrong on the other complaint issues.

2. We acknowledge it was an extremely worrying and frustrating time for the family during Mrs T’s hospital admission in August to September 2023. We understand Mrs T and the family had been through a difficult experience.

3. We do not underestimate how challenging it was for the family when the Trust discharged Mrs T and they had to care for her. We recognise this decision will be very disappointing for Mrs P and we hope this statement clearly explains how we have considered her complaint and the reasons for our decision.