Medway NHS Foundation Trust

5. Mrs H complains about aspects of care and treatment provided by the Trust, to her mother between 28 January and 6 February 2024. She says the Trust did not provide meaningful clinical input to her mother until 1 February. Specifically, she says the Trust: • did not diagnose and treat her mother as early as it should have • delayed her mother’s catheter insertion • did not investigate the cause of her mother’s delirium • did not provide oxygen as early as it should have.

6. She says her mother suffered unnecessary pain and her death could have been avoided had the Trust diagnosed and treated her earlier than it did. She also says she and her family experienced psychological trauma as a result of watching her suffer.

7. Mrs H would like service improvements to prevent the same issues from recurring and financial redress. She would also like the Trust to acknowledge and take responsibility for what went wrong and the impact this had on her mum and family.

8. This background is a brief overview of events to provide context. It does not include everything that happened.

9. Mrs J initially attended hospital as she had lost the use of her legs. She arrived at the Emergency Department (ED) at 10.30am on 28 January. The Trust managed her ED care in a corridor due to a lack of beds.

10. The Trust admitted Mrs J to a ward on 30 January with a suspected UTI. A UTI is an infection that can affect any part of the urinary system including the bladder, kidneys, ureters and urethra. It transferred her to two wards over the course of her admission.

11. The Trust diagnosed Mrs J with urinary sepsis and worsening kidney function. Her condition deteriorated further and the Trust informed family she may need end of life care on 5 February.

12. Mrs J sadly died from sepsis and multi organ failure on 6 February.

Diagnosis and treatment

18. Mrs H complains the Trust did not diagnose or treat her mother for sepsis as early as it should have. She says it did not provide meaningful clinical input to her mother until 1 February.

19. Mrs J attended the ED on 28 January by ambulance and the Trust booked her in at 10.30am. Her NEWS 2 score was ‘2’. The National Early Warning Score 2 is a standardised scoring system used by clinicians to identify patients at risk of clinical deterioration. The Trust carried out a triage assessment shortly afterwards and marked her as ‘urgent - yellow’ category.

20. The Trust carried out blood tests at 11.21am and a urine test at 2.34pm. The latter test showed signs of a UTI. Mrs J’s blood test results were available at 2.04pm. The ED clinicians referred her to the medical team at 2.47pm with a diagnosis of stage one AKI (acute kidney injury refers to a sudden episode of kidney failure or damage).

21. The Trust prescribed fluids and antibiotics which it gave to Mrs J at 3.13pm.

22. Our ED adviser explained the Trust assessed Mrs J in a timely manner. Specifically, if a patient is categorised as urgent the Trust should assess them within 60 minutes which it did. The Trust triaged Mrs J, carried out appropriate tests, took her observations and a doctor reviewed her soon after. This was in line with NHS England’s, ‘Guidance for emergency departments: initial assessment’.

23. On her presentation to ED, Mrs J’s NEWS 2 score was not high enough to suggest sepsis, and she was already receiving antibiotics for a UTI. Based on this and her other test results, our ED adviser helped us to understand there was no obvious indication for the Trust to provide antibiotics within the hour.

24. Our ED adviser noted Mrs J met one moderate to high criteria for sepsis in the form of loss of function of her legs. NICE’s ‘Sepsis: recognition, diagnosis and early management’, says clinicians should manage this by arranging a clinical review within the hour and they should also arrange blood tests. The Trust did this.

25. The Trust also noted Mrs J’s past medical history of sepsis. Our ED adviser helped us to understand that overall, the Trust managed Mrs J’s clinical symptoms appropriately on 28 January.

26. We have not found failings in the Trust’s ED management of Mrs J’s symptoms. We have found it followed the above NICE and NHS England guidelines.

27. Our physician adviser helped us to understand what happened when the Trust admitted Mrs J. The Trust carried out a medical assessment of Mrs J and completed a management plan. This included oversight from a senior decision maker.

28. The GMC’s ‘Good Medical Practice’ says doctors 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.’

29. The Trust suspected Mrs J was suffering from an E-coli UTI and provided treatment through antibiotics. She had also received antibiotics from her GP before her admission. Our physician adviser explained, this was the correct treatment course for this type of infection.

30. Mrs J’s microbiology results came back on 4 February, and they did not show E-coli growth. Our physician adviser explained this does not mean she did not have it. They explained the Trust provided timely antibiotics and had also considered Mrs J’s test results from her December inpatient stay when she suffered from sepsis.

31. The Trust also diagnosed Mrs J with an AKI. Following this, it consulted with a specialist renal team at another Trust. It followed the advice given by the renal team which was appropriate. This was in line with NICE’s ‘Acute kidney injury’ guidelines.

32. Mrs J’s test results also showed features of liver and kidney failure. Specifically, her liver tests were abnormally high. Our physician adviser explained it is likely her infection escaped the control of the antibiotics her GP and the Trust had correctly prescribed her. Therefore, her deterioration was unavoidable and there was nothing further the Trust could have done to change the sad outcome for Mrs J and her family.

33. We recognise how difficult this would have been for Mrs J and for her family to witness as she deteriorated quickly and unexpectedly.

34. Overall, during this period the Trust ordered relevant tests and actively considered Mrs J’s symptoms in line with the above NICE guidelines. Therefore, we have not found failings in this part of the complaint.

Investigating the causes of delirium

35. Mrs H complains the Trust did not investigate Mrs J’s underlying delirium and this contributed to her and her family’s distress. In its complaints response, the Trust said it could have done more to address the underlying causes of Mrs J’s agitation.

36. We appreciate how distressing this would have been for Mrs J and her family to witness.

37. Our physician adviser helped us to understand how the Trust considered the cause of Mrs J’s delirium. Mrs J’s medical notes show the Trust considered her delirium and documented episodes of agitation.

38. Our physician adviser explained a common cause for delirium is a bowel obstruction. During our investigation, we have seen evidence the Trust considered this and prescribed laxatives. Our adviser explained this was the most appropriate treatment for a bowel obstruction.

39. We have also seen that doctors provided nicotine patches to Mrs J. Our physician adviser explained another possible cause of the delirium was nicotine withdrawal and the Trust provided appropriate treatment for this in the way of patches.

40. Whilst we acknowledge the Trust says there was more it could have done to investigate the causes of Mrs J’s delirium, we have found the Trust followed NICE’s ‘Delirium: prevention, diagnosis and management in hospital and long-term care’ which says clinicians must: ‘In people diagnosed with delirium, identify and manage the possible underlying cause or combination of causes.’

41. We have found the Trust looked for causes of the delirium and sought to treat these causes in line with the above NICE guidelines. Therefore, we have not found a failing here.

Catheter insertion

42. Mrs H says the Trust should have inserted a catheter 30 hours earlier than it did. She says this caused her mother to suffer a distended stomach and unnecessary discomfort. She also complains the Trust could not locate a bladder scanner which contributed to the delays.

43. The Trust diagnosed Mrs J with an AKI and she needed intravenous fluids (fluids through her veins). Our physician adviser explained these are both indications to place a urinary catheter.

44. They went on to explain, the purpose of the catheter is to allow the clinical staff to monitor the kidney output closely (usually this would be checked hourly). They explained the catheter does not in itself improve or treat the condition. It is recommended for monitoring to allow clinical staff to have a detailed and real time understanding of how well the kidneys are responding to treatment.

45. Our physician adviser further explained, the placement of a catheter in an acute injury is not an absolute requirement if alternative methods are being used to monitor kidney function. Some mobile, alert and self-caring patients prefer to offer urine measurement from bottles. However, in frailer patients a catheter is usually the preferred option.

46. Mrs J’s medical notes show she was frail with multiple comorbidities, and she used a wheelchair for mobility. She had impaired mobility when she came to hospital and was confused.

47. Our physician adviser explained the Trust should therefore have catheterized her as soon as it confirmed she had an AKI and needed intravenous fluids. This was necessary in line with the UK Renal Association’s, ‘Clinical Practice Guidelines Acute Kidney Injury’ and NICE’s ‘Intravenous fluid management guideline’.

48. The above NICE guideline emphasises monitoring of fluids. Our physician adviser explained this would have been best done through a catheter. The Trust diagnosed Mrs J with an AKI on the afternoon of 28 January. It did not catheterise her until around 5am on 30 January, around 40 hours later.

49. Our physician adviser explained a bladder scan is recommended prior to insertion of a urinary catheter but is not essential. The purpose of a bladder scan is so that staff can assess if there was any retained urine in the bladder. This is helpful in considering if the urinary system is blocked.

50. They went on to explain that the placement of a catheter itself can assess the presence or absence of urinary retention by checking the amount of urine that immediately drains out of the bladder. Therefore, the Trust should not have delayed placing a catheter because of the absence of a bladder scanner.

51. We have found the Trust did not place a catheter as early as it should have in Mrs J’s admission, and this was a failing. We go on to consider the impact of this later in our report.

Provision of oxygen

52. Mrs H complains the Trust did not put in place oxygen as early as it should have (when Mrs J was assessed in the ED). Mrs J suffered from chronic obstructive pulmonary disease (COPD) and suffered from shortness of breath. COPD is the name for a group of lung conditions. They cause breathing difficulties caused by long-term lung damage.

53. In its complaints response, the Trust acknowledged it should have offered oxygen whilst Mrs J was in the ED.

54. Our physician adviser agreed with both Mrs H and the Trust and explained the Trust should have followed NICE’s ‘Chronic obstructive pulmonary disease in over 16s: diagnosis and management’ and offered oxygen when she attended the ED. The guidelines state clinicians should prescribe oxygen to keep oxygen saturation within the patient’s individual target range.

55. Mrs J’s medical records show when it admitted her, the Trust provided oxygen in line with the above guidelines.

56. We have found the Trust should have offered oxygen (in line with the above NICE guidelines) when it became aware Mrs J suffered from COPD. This would have been during her initial triage. It should also have offered oxygen when it became clear she was short of breath whilst in the ED.

57. We have found failings in the Trust’s provision of oxygen whilst Mrs J was in the ED. We have found the Trust did not follow the above NICE guidelines. We go on to consider the impact of this on Mrs J later in our report.

Impact

58. So far in our investigation we have found failings in the Trust not placing a catheter as soon as it should have. We have also found failings in its initial management of Mrs J’s oxygen.

59. We first considered when Mrs J should have had a catheter and the impact this had on her. Our adviser explained Mrs J should have had a catheter on the afternoon of 28 January. She did not have one fitted until around 5am on the 30 January. This was a delay of approximately forty hours.

60. We next considered what the impact of that was on Mrs J’s comfort. Her medical records show the Trust asked her if she had passed urine in the past four hours at each nursing review. The first entry that shows she had not passed urine within the last four hours and that she had an increased pain score as a result, (five) was at 11.52pm on 29 January.

61. Mrs J had a bladder scan early on 30 January. This showed she had one litre of fluid in her bladder (600-800mls should be the highest level of urine held in the bladder). The Trust then catheterised Mrs J shortly after this at around 5am on the morning of 30 January.

62. Looking back, we can see the last nursing entry in which Mrs J reports she has passed urine in the last four hours was recorded at 3.38pm on 29 January. This entry also states her pain score was zero.

63. Therefore, we have found the time she was unable to pass urine for was between six and eighteen hours. The nursing records suggest she had not been in discomfort for all of this period and that her discomfort was likely between six and fourteen hours.

64. Our physician adviser explained this delay in catheterisation would not have contributed to Mrs J’s AKI or sepsis. Additionally, they went on to say it would not have contributed to her deterioration or her sad death.

65. Mrs H explained in her complaint that her mother’s stomach became distended and that she shared her mother’s discomfort with staff during this period and nothing was done. We acknowledge the distress this caused both Mrs H and her mother.

66. The Trust has not accepted any failings in this part of the complaint. We go on to make recommendations to address this later in our report.

67. We next considered the impact of delayed oxygen on Mrs J. Our adviser explained Mrs J should have been offered oxygen when she attended the ED on 28 January. The Trust provided oxygen following her admission when it managed her oxygen well.

68. Our physician adviser explained the lack of oxygen could have contributed to Mrs J’s delirium. They explained, it is not possible to be sure it did, as there were many other possible contributing factors to the delirium.

69. Our physician adviser went on to say that they had not seen evidence the temporary lack of oxygen contributed to Mrs J’s deterioration or her sad outcome. There were other factors in her condition which were more relevant to this. They further explained, it is very unlikely that Mrs J’s outcome would have been altered by giving oxygen earlier.

70. We can see Mrs J suffered from shortness of breath during her time in the ED and that this became worse due to the delay in catheterisation. We have found this caused her and her family unnecessary distress at a time when she was very unwell. We have also found the family will never know if the lack of oxygen contributed to Mrs J’s delirium and this in itself is distressing to understand.

71. We next considered what the Trust has already done to put right the failings we have found. As a remedy our ‘Principles for Remedy’ say organisations should ensure complainants receive:

• ‘an assurance that lessons have been learnt • an explanation of changes made to prevent maladministration or poor service being repeated.’

72. In its complaints response, the Trust apologised and explained it had reminded all staff to ensure medical conditions are noted and oxygen if needed is given to a patient as soon as possible. It also said it had introduced the fundamentals of care into its ED through which all staff are allocated to attend individual patients to ensure their basic needs are met.

73. We have not seen evidence the Trust has addressed catheterisation in its fundamentals of care. Therefore, we have made recommendations to address this later in our report.

74. We consider these actions to be in line with our ‘Principles for Remedy’ and that they should prevent the same failings we have found in the lack of oxygen provision, from recurring. We do not consider there are any further service improvements it should make.

75. We acknowledge, the Trust has not offered a financial remedy and so we have made recommendations to address this later in our report.

1. Mrs H complains about aspects of care and treatment provided by Medway NHS Foundation Trust (the Trust), to her mother, Mrs J.

2. We have not found failings in the Trust’s diagnosis or treatment of Mrs J, or in its investigation of her delirium. We have identified failings including delays in Mrs J’s catheterisation and in the Trust offering her oxygen. We have found the failings led Mrs J to experience unnecessary pain and discomfort and caused significant distress to her family who witnessed this.

3. We have found there is more the Trust can do to put right the impact on Mrs H. It has made changes to prevent delays with offering oxygen, but not regarding delays with catheters. We have therefore decided to partly uphold the complaint overall.

4. We recommend the Trust complete an action plan regarding the catheterisation and that the Trust pays Mrs H £600 to put right the overall impact of the failings we have found.