University Hospitals of North Midlands NHS Trust

5. Mrs M complains that between 25 May and 22 June 2024 the University Hospitals of North Midlands NHS Trust (the Trust) did not: • provide her mother, Mrs T, with appropriate medication • diagnose her mother’s sepsis earlier • put a ReSPECT form in place appropriately • provide adequate food and fluid for her mother • record her mother’s fall correctly.

6. Mrs M says the Trust caused her mother pain and contributed to her mother’s death. She says this also caused her severe distress. Mrs M wants an apology and service improvements.

7. The Trust admitted Mrs M on 25 May 2024 with constipation lasting around a week, abdominal pain, chest pain and a fever. The Trust gave her medication to manage her symptoms.

8. Mrs T suffered a fall on 16 June in which she injured her left knee. A ReSPECT a DNACPR order was put in place on 22 June at 8.16pm. Mrs T passed away on 22 June.

Medication 11. Mrs M complains the Trust did not provide adequate pain relief medication to Mrs T during her admission. She also says the Trust failed to provide her with medication relief for her constipation.

12. NICE guidelines say if a patient has a NEWS score of one to four then they should be assessed by a ward nurse for monitoring and potential escalation. It says scores of five to six should be assess by a ward doctor to decide if escalation to critical care team is needed. It also says scores of seven or over should be escalated to the critical care team. GMC guidelines say to take steps to alleviate pain and distress when this is identified.

13. Records show the Trust gave Mrs T 60mg nefopam (a non-opioid pain relief) three times a day. Mrs M told us she was concerned the Trust gave her mother nefopam as she had kidney disease and this can be impacted by that medication.

14. Our physician adviser explained that nefopam should not be given to patients with end stage kidney disease. They explained end stage kidney disease is indicated by an estimated glomerular filtration rate (eGFR) of less than 15. The Trust recorded Mrs T’s eGFR as 50 on 15 June and 30 on 18 June and it declined to 20 on 20 June. They explained that while this was decreasing during her admission, Mrs T was not considered to be at end stage of kidney disease so the use of nefopam was not considered dangerous and could still be used as a form of pain relief.

15. BNF guidelines say usual dosages of nefopam in the elderly are between 30 and 90mg three times per day. Mrs T was given 60mg, therefore it appears the Trust provided pain relief within the appropriate dosages.

16. The records also show the Trust provided Mrs T with paracetamol two to three times a day. It also gave her codeine on 18, 19 and 20 June.

17. The medical records show Mrs T had a NEWS score of six and seven for a period of four hours on 26 May. The Trust also scored her NEWS as five on 13 June, five on 20 June and six on 21 June.

18. Mr T’s high NEWS score on 26 May was due to a high heart rate and high respiratory rate (breaths per minute). Her high score on 13 June was due to oxygen saturation levels and her high scores on 20 and 21 June appear to be due to issues with her blood pressure levels. It does not appear that any of the occasions in which Mrs T had a high NEWS score were in relation to a high pain score.

19. From the records we can see Mrs T complained of pain on 11, 15, 17, 18, 19 and 20 June. On each occasion staff noted they gave her pain relief to manage this.

20. Mrs M says the Trust also failed to provide Mrs T with medication to treat her constipation.

21. NICE guidelines on constipation say this is generally defined as bowel movements occurring less than three times a week. It says to reduce laxatives once a person is producing soft stool at least three times a week.

22. Medication records show the Trust gave Mrs T Movicol (a laxative) between 27 May and 3 June and then from 15 June. The Trust appears to have stopped the Movicol on 3 June due to concerns about sores developing on Mrs T’s buttocks and potential health issues as it is noted ‘send blood sample if still loose stool’.

23. From the records we can see Mrs T was having several bowel movements per day up until 10 June when these started to reduce and she was started with the laxative again from 15 June.

24. Based on the evidence we have it appears the Trust acted in line with NICE guidelines when it made the decision to remove laxatives from Mrs T’s medication as she was having regular bowel movements. Once it appeared her bowel movements were slowing down the Trust made the decision to provide her with laxatives again.

25. It appears the Trust provided Mrs T with pain relief throughout her admission and provided her with additional pain relief in the form of paracetamol and codeine when the medication she was receiving did not provide enough pain relief in line with NICE, GMC and BNF guidelines. It also appears it managed her constipation medication in line with NICE guidelines on this.

26. We appreciate that it must have been difficult for Mrs M to witness Mrs T in distress however we have not identified any failings in her care in relation to medication provided for pain relief and constipation. Our decision is not intended to undermine Mrs M’s concerns and we hope this gives her some closure on these events.

DNACPR 27. Mrs M complains the Trust pushed for a ReSPECT form to be completed and part of this included a DNACPR.

28. RCUK guidelines say ReSPECT plans are for anyone however they have more relevance for patients with complex health needs and patients at risk of deterioration.

29. BMA guidelines say when a patient lacks capacity and a DNACPR is put in place the patient’s family should be informed. If they are not immediately contactable then a decision must be made in the patient’s best interest. It also says where possible these discussions should not be made over the phone.

30. The Trust discussed putting a ReSPECT plan in place with Mrs T and Mrs M during her admission, although it is not clear when exactly this discussion took place. This was discussed as Mrs T had previously had a ReSPECT plan in place on her previous admission which was two months earlier in April.

31. The Trust noted both Mrs T and Mrs M did not want a plan put in place and the Trust did not put one in place at that time. This appears to be in line with RCUK guidelines as their decision was respected.

32. Mrs T suffered a cardiac arrest at 8.05pm on 22 June. The Trust initiated CPR for six minutes and provided adrenaline. The duty doctor decided to stop CPR due to other medical issues that she had and a ReSPECT form was created which included the decision that she was DNACPR. This was done as Mrs T no longer had capacity and it was decided it would be better for her to keep her comfortable until she passed. Unfortunately, she passed at 8.15pm.

33. Our adviser explained that in practice, due to the short length of time between Mrs T’s cardiac arrest and her passing it would not have been practical, or emotionally appropriate, to try to contact Mrs M to discuss the ReSPECT and DNACPR decision with her at the time to make the decision.

34. The records show Mrs M and her sister were advised to come into the Trust as Mrs T was deteriorating however it is not recorded when exactly this was done.

35. Based on the evidence we have seen it appears the Trust acted in line with RCUK and BMA guidelines as it originally respected Mrs T’s decision not to have a ReSPECT form put in place however when it was a medical emergency and necessary to do so, the Trust put one in place in line with her best medical outcome in mind. It would have been better to discuss this decision with Mrs M and let her know about it, however it does not appear this was possible at the time. We appreciate that Mrs M may have found this distressing and our decision is not intended to undermine her feelings regarding these events.

Sepsis 36. Mrs M complains Mrs T’s death certificate listed sepsis as a cause of death however this was not identified or communicated to her or her family whilst Mrs T was alive. She is concerned that the Trust never swabbed Mrs T’s open wound to test for infection.

37. NHS guidelines list common symptoms of sepsis as: slurred speech, shivering, muscle pain, difficulty breathing, pale skin, high temperature and no peeing for at least 18 hours.

38. NICE guidelines say when assessing a patient for potential sepsis clinicians should identify a possible source of infection, factors that increase the risk of infection and any new abnormalities which could indicate sepsis. It also says NEWS2 scores can be used as a possible indicator of sepsis with any single score of 3 requiring further investigation.

39. On Mrs T’s admission on 26 May she scored seven and six on the NEWS2 score between 9.47am and 1.54pm before it dropped to four and then one by 2.41am. Mrs T’s NEWS2 score next caused concern on 13 June at level five however no single score was above three.

40. Mrs T’s NEWS2 score was three at 11.58am on 18 June with this score coming from her blood pressure. Her NEWS2 score was then five at 5.31pm and 5.59pm on 20 June with three points coming from blood pressure. This was the case again at 3.48pm on 21 June.

41. There are times at which Mrs T’s NEWS2 score could have indicated sepsis however her NEWS2 scores appeared to be consistently below any threshold, and this would therefore not support a diagnosis of sepsis throughout her admission.

42. Our physician adviser explained there are other tests that could indicate a diagnosis of sepsis.

43. Mrs T’s white cell count remained consistently in the expected range (4-11 cells per microliter (µL)) until 10 June where it fell below the expected level. Our adviser explained that in cases of sepsis they would expect to see white cell levels above the expected range as the body is fighting infection.

44. Mrs T’s C-reactive protein (CRP) levels were above the expected levels (0-5mg/l) throughout her admission. On 26 May her CRP level was recorded as 344 however that had reduced to 73 by 31 May. It remained between 96 and 141 between 1 and 19 except on 15 June where it peaked at 210. It rose to 207 on 19 June before lowering slightly to 192 on 21 June.

45. Our adviser explained in cases of sepsis we would expect to see large increases in both white blood cell levels and also CRP levels. Mrs T’s CRP level was above the expected level however it remained fairly consistent after her initial admission. The spike on 15 June does not coincide with Mrs T’s fall on 16 June when Mrs M believes sepsis infection could have occurred.

46. From the blood results we have there does not appear to be anything that indicates a diagnosis of sepsis rather than a general viral or bacterial infection. The Trust was already treating Mrs T for community acquired pneumonia with Cotrimoxazole (a general antibiotic). Our adviser explained this antibiotic could have been used to treat sepsis however it would depend on the focus of the infection.

47. Mrs M believes the Trust should have swabbed the wound on Mrs T’s left leg for possible infections.

48. BMJ guidelines say swabs of wounds should only be taken when there is evidence that a wound is infected or if the wound is deteriorating.

49. The records show the dressings on Mrs T’s wound were changed regularly, although on occasion she did refuse to have the dressing changed. On some occasions staff recorded that the wound was bleeding, but our adviser explained this does not in itself indicate infection and there is no indication of an infection at any point. Therefore now swabbing the wound appears to be in line with BMJ guidelines.

50. Based on the evidence we have seen it appears the Trust acted in line with NHS and NICE guidelines in how it considered sepsis as there did not appear to be any indication from the test results we have before her sad death, that Mrs T had sepsis. It also appears the Trust acted in line with BMJ guidelines in its decision not to swab Mrs T’s wound.

51. As sepsis was identified as a cause of death it is understandable that Mrs M would be concerned that the Trust missed this whilst Mrs T was alive. We therefore hope she is reassured that we have not seen any indication that this was present from the test results that took place. We hope this gives Mrs M some reassurance that the Trust could not have done more in its care for Mrs T to identify sepsis.

Nutrition 52. Mrs M says the Trust failed to provide Mrs T with adequate oral nutrition and fluid intake.

53. NICE guidelines say patients should be screened for malnutrition when patients are admitted to hospital and then again weekly unless there are further concerns. CQC guidelines say care providers should have a food and drink strategy that addresses the nutritional needs of people using the service.

54. Food chart records show Mrs T’s food intake was low for multiple days. In order to support her intake, the Trust prescribed her with nutritional supplements (ensure compact). Despite this there is evidence that Mrs T refused to drink these supplements on multiple occasions and the frequency was changed from twice to three times a day around 11 June. It is noted that she continued to refuse this on multiple occasions.

55. Our adviser explained it would have been expected that if Mrs T was refusing to take the supplements, then other options should have been explored to support her nutritional needs.

56. Records from 28 May request ‘strict input and output’ recording. However fluid management records are inconsistent with multiple days showing no input or output throughout the day.

57. This does not appear to be in line with CQC guidelines as we are not able to identify that options were explored to support Mrs T’s food and fluid intake during her admission.

58. The Trust used a Malnutrition Universal Screening Tool (MUST) to assess Miss T’s risk of malnutrition upon her admission and determined she was at low risk of malnutrition. There are no records that indicate another MUST assessment was carried out during her admission.

59. Mrs T’s weight is recorded as 71.3kg on 5 June and then again on 12 June as the basis for a prescription of dalteparin (an anticoagulant). It is then recorded as 70.3kg on 21 June. It is also noted Mrs T’s weight not being able to be recorded, either due to refusal or her condition, on 28 May, 1 June, 8 June and 17 June.

60. An ulcer risk assessment tool from 13 June recorded that she had lost between 5 and 10kg, although it is not clear over what period of time this weight loss took place. This weight loss is not recorded on the same tool between 27 May and 2 June.

61. The Trust does not appear to have recorded Mrs T’s weight on a regular basis during her admission between 25 May and 22 June 2024. It appears the Trust failed to complete weekly MUST assessments and weigh ins which is not in line with NICE guidelines.

62. Based on the evidence we have seen it appears the Trust did not act in one with NICE or CQC guidelines in how it assessed Mrs T’s risk of malnutrition and in how it recorded and managed her food and fluid intake. The impact of this failing will be discussed below.

Fall assessment 63. Mrs M complains the Trust did not properly assess Mrs T following her fall on 16 June. She says the Trust failed to photograph the wound, caused skin tears after the fall when handling Mrs T and also did not properly take care of her wounds.

64. NMC guidelines say is important to keep timely and accurate records of events. It also says to identify when a patient’s physical health may be deteriorating and refer the patient to a qualified professional.

65. NHS guidelines say following a fall the patient should be checked for fractures or spinal injuries before being moved, safe handling methods should be used where a risk of a fracture is considered, neurological observations should be carried out if there is a risk of head injury and a medical examination should be arranged to assess the patient following the fall.

66. IMI guidelines say consent should be gained before a photograph is taken of a wound. GMC guidelines say doctors should keep accurate medical records.

67. The medical records show on 16 June Mrs T suffered a fall. This was documented as ‘patient said she felt dizzy and placed herself on the floor, landing on the floor with legs’. The fall was witnessed by nurses, as they were transferring her from a chair to her bed, and an incident form was completed. Both Mrs T’s family and a doctor were informed of the fall. A skin tear is recorded following the fall.

68. It appears the Trust followed both NMC and NHS guidelines in how it recorded the fall. Record of the fall was entered into the medical records shortly after the fall and as the fall was witnessed there was not a fear of fractures or head injury.

69. Our physician adviser has identified that no clinical examination of the wound is in the medical records which would be expected to have happened after the fall. Based on other medical records, such as a senior house officer (SHO) referring her for an X-ray on 17 June, we can see doctors did assess Mrs T. It appears these assessments were not properly recorded. This is not in line with GMC guidelines.

70. Mrs M has provided photos of the wound Mrs T sustained. She does not know why the Trust did not take photographs at the time of the fall.

71. Our nursing adviser explained there is no requirement for a fall to be photographed, and consent should be sought before any photographs are taken.

72. Medical records from 17 June show the Trust’s clinical photographer sought consent, however Mrs T refused. This appears to be in line with IMI guidelines.

73. The photographs provided show a large wound close to Mrs T’s left knee. The medical records show the Trust regularly changed Mrs T’s dressings on her wounds although she did refuse to have them changed on multiple occasions including 20 June.

74. The Trust also referred her to its ‘plastics’ department, presumably to further address the wound and for more complex care. This was done on 20 June, and she was seen by them on 21 June. This appears to be in line with NMC guidelines as the Trust referred her for more specialist care when it felt it was necessary.

75. Based on the evidence we have seen it appears the Trust acted in line with NICE and NHS guidelines in how it handled Mrs T’s fall and how it cared for the wound after the fall. It also appears the Trust acted in line with IMI guidelines by respecting Mrs T’s refusal to have her wounds photographed. It appears the Trust did not act in line with GMC guidelines in how it recorded the assessment of Mrs T’s wound following her fall. We will discuss the impact of this failing below.

Impact 76. Mrs M says the Trust’s actions caused her mother pain, distress and contributed to her death. She also says it caused herself and her family severe distress. We can say that on the balance of probabilities the Trust’s failings in how it recorded the assessment of Mrs T’s wound and how it provided food and fluid to her may have led to some of the impact Mrs M is suggesting.

77. We cannot say the failings contributed to Mrs T’s sad death. She was very ill with several existing long term health conditions and had previously been admitted to the Trust in April. Neither can we say the Trust caused unnecessary pain to Mrs T as we have found the Trust provided pain relief when she needed it.

78. When we spoke to Mrs M, we asked the outcomes she wanted to achieve from her complaint. She said she wanted an apology and service improvements.

79. Our Principles say where something has gone wrong or poor service has led to an injustice or hardship, the organisation responsible should take steps to provide an appropriate and proportionate remedy. This is what Mrs M has said she wants from making this complaint.

80. On 18 May the Trust agreed it would provide an apology letter for Mrs M that outlines the failings we have identified above in how the Trust handled Mrs T’s nutrition and how it assessed her after her fall on 16 June, apologises for these failings and explains steps is has taken to improve the service to avoid this happening in the future.

81. As the Trust has agreed to demonstrate learning has been taken from this complaint, and apologise for the failings and distress caused, we believe the Trust has done enough to address the failings. Based on the above we are satisfied that the agreed actions address what went wrong in Mrs T’s care and provides Mrs M with some reassurance following her complaint and has given her the one outcome she told us she wanted, and consider her complaint resolved.

82. We recognise Mrs M suffered unnecessary distress due to the Trust’s actions. We would also like to thank her for bringing her complaint to us. We hope the agreed actions will provide Mrs M with some reassurance following her complaint and achieves what she is seeking.

1. We have carefully considered Mrs M’s complaint regarding the care and treatment University Hospitals of North Midlands NHS Trust (the Trust) provided to her late mother, Mrs T. We were very sorry to hear of the concerns she raised regarding how the Trust handled her medication, how it created a do not resuscitate (DNACPR) for her, how it investigated her sepsis, how it handled her food and fluid intake and how it handled her fall. We can clearly see this has caused her a lot of distress at a time when she was already experiencing severe distress.

2. We have carefully considered all the evidence available from Mrs M and the Trust. It appears the Trust acted in line with relevant guidelines in how it handled Mrs T’s medication, how it created a DNACPR for her and how it investigated her sepsis. It appears the Trust did not act in line with relevant guidelines with how it handled her food and fluid intake and how it handled her fall. Mrs M says this caused her severe distress and also caused pain to Mrs T.

3. Based on our findings and the outcomes Mrs M told us she wanted, the Trust has agreed to provide a letter of apology which outlines the actions the Trust has taken to improve based on her complaint. We are satisfied the Trust has agreed to take action to put right what went wrong, and the impact caused which we will explain further below.

4. We hope the agreed actions will provide Mrs M with some reassurance about what happened and achieves the outcomes she told us she was seeking. We hope the explanations below explain how we have fully considered her complaint.