County Durham and Darlington NHS Foundation Trust

4. Mrs I complains about the aspects of care and treatment she received from the Trust in July 2024.

5. Specifically, Mrs I said the Trust: • did not properly administer paracetamol • did not carry out appropriate observations on Mrs I • did not care for her appropriately and neglected her.

6. As a result of the claimed failings Mrs I did not receive appropriate treatment on 16 July. Her temperature had spiked to 40.6°C which increased her risk of serious complications. She was extremely concerned about her wellbeing. Mrs I told us she is traumatised from the events at the Trust and is terrified in the event she ever has to return to the ward she was admitted on.

7. She is looking for an apology and service improvements.

8. Mrs I was on holiday abroad and became unwell. She was admitted to hospital because of an infection. She was prescribed IV antibiotics. When she returned home, she was still unwell.

9. In July 2024, Mrs I attended the Trust after she had symptoms of abdominal pain and diarrhoea. The Trust did a computed tomography (CT) scan, which showed she had a mass, polycystic kidneys and a renal stone. A CT scan takes detailed pictures of the inside of the body. Polycystic kidneys is a disorder where fluid filled sacs develop in the kidneys. Renal stones are hard solid lumps formed from concentrated minerals and salts within the kidneys or urinary tract.

10. The Trust also did blood tests which showed high inflammatory markers. High inflammatory markers show the body is fighting an infection. The Trust referred Mrs I to the surgical day unit to have repeated blood tests and a review of her symptoms. The Trust told her to come back in two days, to the surgical day unit.

11. Two days later, Mrs I attended the Trust’s surgical day unit. The Trust did her observations. These are routine and regular measurements of a patient’s physical health such as blood pressure, heart rate, temperature and breathing rate. Observations track recovery, identify deterioration and determine if a patient needs urgent care.

12. The Trust admitted Mrs I as an inpatient because of her results from the CT scan and blood tests from 10 July. It prescribed Mrs I with intravenous (IV) antibiotics. This is antibiotic medication, which is inserted into the vein.

13. The Trust diagnosed Mrs I with abdominal sepsis. This is a life-threatening extreme response to an infection within the abdominal cavity. The Trust prescribed her more IV antibiotics. Throughout the day Mrs I’s temperature would rise. The Trust prescribed her with paracetamol, and her temperature would lower. This cycle continued throughout the day.

14. The Trust placed Mrs I in a side room because she had Clostridioides difficile (C. Diff) and was infectious. C.Diff is a bacteria causing severe diarrhoea and intestinal inflammation. It is highly contagious. The side room call bell did not work. Mrs I asked for a nurse because she was experiencing rigors. This is uncontrollable shaking when an individual is unwell. At around 6.28pm Mrs I asked a Trust nurse for paracetamol. The Trust did not prescribe any. It said she had already had her prescribed limit.

15. At around 6pm, Mrs I began to experience an increase in her blood pressure and heart rate. Her oxygen levels lowered.

16. At 9.50pm, Mrs I’s temperature spiked to 40.5°C. The Trust moved Mrs I to a different room which had a working call bell and provided her with a fan to bring her temperature down. The Trust asked for the doctor to review Mrs I because of her temperature spike.

17. At 11.24pm, the Trust prescribed Mrs I more IV antibiotics.

18. In mid July 2024, The Trust completed blood cultures. Mrs R (Mrs I’s sister) visited her at the Trust. Mrs I told her sister about the events that evening. Her sister verbally complained to the staff. She spoke with the nurse in charge, and the Trust told her they were short staffed.

19. Three days later, The Trust discharged Mrs I.

The Trust not properly administering paracetamol.

23. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indication that anything has gone wrong with part of Mrs I’s complaint.

24. Six days into her admission, at around 6.28pm, Mrs I asked a Trust nurse for paracetamol. The Trust did not prescribe any. It said she had already had her prescribed limit.

25. Mrs I told us she believes she should have been prescribed more paracetamol at 7:11pm, but this did not happen. She said that because she wasn’t prescribed the paracetamol at this time, her temperature rose to 40.5°C.

26. The Trust said Mrs I had already been prescribed the maximum daily allowance of four doses of paracetamol within a 24-hour period. It said this was why she could not have any more when she asked at 6.28pm. The Trust also said that a portable fan could have been offered to help manage her temperature and apologised if this was not done at the time.

27. NICE guidance on paracetamol says doctors should check when paracetamol was last administered over a 24-hour period before administering. It also says that an adult’s dose is every 4-6 hours with a maximum dose of 4g per day.

28. The Trust gave Mrs I paracetamol at 7.11pm, and 23.19pm the evening before. The Trust also gave her paracetamol at 10.06am and 13.26pm the next day. As paracetamol can only be given in four doses within a 24-hour period, when she requested another dose at 6.28pm, she was informed that she had already reached the maximum allowed dosage.

29. Our adviser said the Trust was correct in not giving her more paracetamol at 6.28pm as she would have exceeded her daily dose within the 24-hour window.

30. Our adviser said the Trust could have given Mrs I more paracetamol at 7.11pm. Mrs I’s medical records show that she did not have paracetamol until the night staff arrived on shift at 10pm. Our adviser explained the delay in the paracetamol was most likely because the high number of patients needing urgent care. This was also explained in the Trust response. Our adviser said the Trust may not have had time to give her the dose at 7.11pm because the number of patients needing care.

31. From what we have seen, we are satisfied the Trust acted in line with NICE guidance when administering Mrs I’s paracetamol. Although the Trust were late in administering paracetamol at just after 7pm, the Trust gave it to her shortly after. It is unavoidable that the patients needing care was high at the time Mrs I was due her next dose of paracetamol. We do not underestimate how this would have caused her distress.

32. As there are no signs that anything went seriously wrong, we will not look at this part of the complaint any further.

The Trust not caring for Mrs I appropriately and neglecting her.

33. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so, we have decided the Trust has already done enough to put right the impact in this part of Mrs I’s complaint.

34. The Trust placed Mrs I in a side room because she had C. Diff and was infectious. The side room call bell did not work. Mrs I asked for a nurse because she was experiencing rigors.

35. Mrs I said she found using the commode extremely undignified. She said she asked for the commode to be removed after using it, but it was not taken away for two hours.

36. Mrs I also said the call bell in her side room was not working, which caused her significant anxiety. She said she was worried about how she would alert someone if she needed help. She added that she was left attached to an empty IV antibiotic bag for around four hours.

37. The Trust said removing used commodes should always be a priority and apologised for the delay in this instance. It acknowledged that it would have been unpleasant for Mrs I, and for that, it apologised as well.

38. Regarding the call bell in the side room, the Trust explained that these rooms do not have hard-wired call bells like the rest of the Trust. It said the fault with the call bell was reported, but hospital engineers were unable to fix it, so an external supplier had to be brought in, which caused delays. The Trust said, ideally, it would have moved Mrs I to another room, but this was not possible at the time, as the ward was full. The Trust said it moved her as soon as it was able to do so. It also said that nurses are regularly present nearby, and carry out routine checks on patients to address their needs.

39. The Trust explained the IV bag was left empty due to pressures on the ward, as staff were prioritising care for unwell patients, which meant that some non-urgent tasks, such as changing IV bags, were delayed. It assured Mrs I that an empty IV bag did not pose a safety risk, as the integrity of the seal remained intact. It acknowledged being left attached to an empty IV bag would have been inconvenient, particularly as it restricted movement. It apologised for this. The Trust also explained healthcare assistants are not permitted to remove IVs, which added to the delay.

40. The Trust said it has created an action plan to address the issue of used commodes and bedpans not being removed promptly. It said staff would be reminded to ensure these items are taken away as quickly as possible in the future.

41. NICE guidance on patient experience in adult NHS services says that healthcare workers should listen to and address and health beliefs, concerns and preferences. It also says that patients’ personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. Address their needs at the time of asking and ensure maximum privacy.

42. From the evidence we have seen, the Trust did not follow this guidance. Mrs I was placed in a side room where the call bell did not work. She expressed these concerns to the Trust. Mrs I also used her commode, which was not emptied for around two hours, despite her asking. Mrs I was also left attached to an empty IV bag for around four hours. This is an indication of a failing.

43. Mrs I said during this time she felt she did not receive appropriate care which raised concerns about her wellbeing. She said she is traumatised from the events at the Trust and is terrified if she ever needed to return to the ward. We recognise the impact was distressing for Mrs I and would have been unpleasant for her. We do not underestimate the impact of this.

44. Mrs I said she is seeking an apology and service improvements as an outcome of bringing her complaint to us.

45. Our principles of remedy say an appropriate range of remedies may include an apology, explanation and acknowledgment of responsibility and remedial action.

46. The NHS complaint standards say organisations should offer fair remedies and put things right and identify errors and learn from them to improve the service.

47. Our severity of injustice scale says a level 1 injustice will usually be an injustice such as annoyance, frustration, worry or inconvenience, arising from a single (one-off) incident of maladministration or service failure, where the effect on the individual is of short duration, with no adverse effects or wider impact. This is an incident that impacts a person for a period of no more than two weeks.

48. We believe this part of Mrs I’s complaint falls within level 1 on the severity of injustice scale. The Trust’s failings with the commode, call bell and empty IV bag were of a short duration. We believe this caused short-term distress and discomfort. These events occurred over a relatively short period of time, specifically over four days. There is no evidence of any significant or lasting harm as a result. Mrs I told us she is looking for an apology and service improvements.

49. The Trust responses acknowledged Mrs I’s concerns about her call bell not working, being left attached to her IV antibiotic bag for some time and not removing the commode straight away. It has apologised and taken steps to avoid these errors happening again. We can also see that the Trust has provided an action plan and have communicated it to staff to remind them to remove items such as this away, as soon as possible.

50. We are satisfied the Trust’s remedies are in keeping with what we usually expect to see with this level of complaint and what Mrs I had asked for. We believe it has done enough to put things right. We consider the Trust has acted in line with our principles for remedy. We will not consider this further.

The Trust not carrying out appropriate observations of Mrs I.

51. Mrs I said she was diagnosed with abdominal sepsis but felt she was not monitored any differently. She said she was only given ‘general observations’ and believes she should have been checked more frequently. She said that not being prescribed paracetamol at around 7.10pm, combined with only having general observations, caused her temperature to rise to 40.5°C. Mrs I said she felt like she was going to die because of what she described as neglect in her observations. She also said the Trust should have taken her blood cultures sooner than it did.

52. The Trust has apologised to Mrs I for if she felt it had not done enough to prevent her rigor and high temperature. It explained she had already received the maximum dose of paracetamol at the time, the spike in temperature happened. The Trust said it reviewed her condition and made a clinical decision to switch from oral antibiotics to intravenous antibiotics.

53. The Trust said blood cultures are only taken if an infection is suspected or there is a change in the patient’s clinical condition. It added Mrs I’s blood cultures were taken on the morning, following her temperature spike, during the doctors’ routine rounds. They are typically not considered unless a patient’s temperature exceeds 39°C.

54. RCP guidance on Clinical response to the NEWS trigger threshold shows how often a patient should have their observations monitored based of their National Early Warning Score (NEWS). NEWS is a clinical scoring system used in hospitals to standardise the assessment of a patient’s illness severity and quickly identify those at risk of sudden health deterioration. Depending on what score a patient is, depends how frequently they should have their observations checked and monitored and also what clinical response they need.

• NEWS 0: Minimum 12 hourly observations. The clinical response is to continue routine NEWS monitoring • NEWS 1-4: Minimum 4-6 hourly observations. the clinical response is to inform registered nurse who must assess the patients and registered nurse decides to whether increased frequency of monitoring or escalation of care is required • NEWS 3 in a single parameter: Minimum one hourly. The clinical response is to inform the medical team caring for the patient, who will review and decide whether escalation of care is necessary.

55. From the medical records we have seen the Trust completed observations on Mrs I.

• day one of admission, 6.27am, NEWS score 0 • 10.26am, NEWS score 2 • 14.32pm, NEWS score 0 • 6.28pm, NEWS score 2 • 9.50pm NEWS score 4 • Day two of admission, 1.33am, NEWS score 0.

56. As Mrs I’S NEWS score was 0 at 6.27am on day one, the Trust should have completed her observations 12 hourly as a minimum. We can see the Trust completed Mrs I’s observations three times within a 12 hour period. This is more than the appropriate level of observation needed for someone who has a NEWS score of 0.

57. When Mrs I’s NEWS score increased to 2, at her 6.28pm observations, the Trust changed to four hourly observations. Again, the Trust completed her next set of observations within the four-hour period, at 9.50pm. At this point, her NEWS Score was 4. This also required a minimum four hourly observation period.

58. When Mrs I’s temperature raised to 40.5°C, the Trust raised an urgent escalating for a review of her condition, retook her observations, gave her paracetamol and requested for blood cultures were completed. These were taken the following morning.

59. From what we have seen, we are satisfied the Trust acted in line with RCP guidance on clinical response to the NEWS trigger threshold and completed Mrs I’s observations in line with minimum observation times.

60. As there are no indications anything went wrong. We will not look at this part of the complaint any further.

61. We recognise how difficult it can be to make a complaint. We would like to thank Mrs I for bringing her concerns to us.

1. We have carefully considered Mrs I’s complaint about Country Durham and Darlington NHS Foundation Trust (the Trust). We were very sorry to hear about what happened to Mrs I and the pain and distress it caused her.

2. We have seen no indication anything went wrong with the Trust administering paracetamol, or when the Trust completed Mrs I’s observations.

3. We did see an indications of failings in the Trust caring for Mrs I. Specifically, the Trust leaving the commode in her room and the call bell in the side room not working. It is our view the Trust has done enough to put the impact of this right.