Manchester University NHS Foundation Trust

2. Miss N complains about the care and treatment provided by Manchester University NHS Foundation Trust (the Trust) to her father, Mr R, in February and March 2024. She says the Trust:

• Did not act quickly enough to assess her father and make a decision on surgery after he was transferred to Hospital A on 23 February 2024 • Failed to provide the care and treatment needed to improve his condition in preparation for his surgery • Failed to identify and treat MSSA infection • Failed to maintain his nutrition • Failed to maintain his mobility • Failed to bring him out of sedation appropriately following surgery • Failed to identify and treat the build-up of fluid he experienced following surgery

3. Miss N says as a result of the failings her father’s surgery was delayed and this contributed to his death. She says as a result of the failings in the care after his surgery the Trust missed an opportunity to provide additional care which may have helped improve his condition and prevent his death.

4. She says the death of her father and the circumstances under which he died caused her a great deal of distress and had a huge impact on her life which she still struggles with today. Miss N would like the Trust to acknowledge the failings and apologise. She would also like the Trust to put in place significant service improvements.

5. Mr R had a medical history of heart problems. He had tests carried out in 2022 and 2023 to assess his cardiac condition and he was referred for heart valve replacement in 2023. Mr R decided against valve replacement surgery at that time as he had concerns about the risk of such major surgery.

6. He was admitted to Hospital on 15 February 2024 due to a deterioration in his condition. During his admission he was assessed for possible transcatheter aortic valve implantation procedure (TAVI, a procedure where the aortic valves are replaced using a narrow flexible tube passed through a blood vessel towards the heart) or surgery to replace two of his heart valves that were failing.

7. He was transferred to Hospital A on 23 February 2024 and the two possible options to replace his heart valves were reconsidered and the Trust decided he was not suitable for TAVI and required surgery. Mr R was transferred to Hospital B for surgery on 26 March 2024. He sadly died on 31 March 2024.

Did not act quickly enough to assess her father and make a decision on surgery after he was transferred to Hospital A on 23 February 2024

11. Miss N says the decision had already been made on which surgical approach to take before he was transferred to Hospital A but the Trust decided to reassess him again rather than moving forward with the surgery immediately.

12. The GMC guidance says:

‘You 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, their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs

In providing clinical care you must:

• prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence • consult colleagues where appropriate • respect the patient’s right to seek a second opinion

You must be satisfied that you have consent or other valid authority before you carry out any examination or investigation, provide treatment.’

13. The NICE TAVI guidance says:

‘Patient selection should be carried out by an experienced multidisciplinary team. The multidisciplinary team should determine the risk level for each patient and the TAVI device most suitable for them. During the consent process patients should be told about all treatment options and their advantages and disadvantages.’

14. The NICE heart valve disease guidance says:

‘Discuss the possible benefits and risks of interventions with adults who have an indication for valve intervention. Include in the discussion:

• the benefits to quality of life (both in the short and long term)

• prosthetic valve durability

• the risks associated with the procedures

• the type of access for surgery (median sternotomy, minimally invasive surgery or, for people at high surgical risk, transcatheter)

• the possible need for other cardiac procedures in the future.

When surgery is agreed, base the decision on the type of surgery (median sternotomy or minimally invasive surgery) on patient characteristics and preferences.

Aortic valve disease

• Offer surgery, if suitable (by median sternotomy or minimally invasive surgery), as first-line intervention for adults with severe aortic stenosis, aortic regurgitation or mixed aortic valve disease and an indication for surgery who are at low or intermediate surgical risk.

• Offer TAVI, if suitable, to adults with non-bicuspid severe aortic stenosis who are at high surgical risk or if surgery is unsuitable.’

15. The records indicate Mr R had two failing heart valves (his mitral valve was failing due to mitral regurgitation, where the valve does not completely close and his aortic valve was failing due to aortic stenosis, where the valve has become narrowed causing the heart to pump harder to push blood through it). Our cardiologist adviser said the records support the view Mr R had severely weakened heart function as a result of these problems and the only possible treatment was to attempt to replace the two valves and ease the pressure on his heart.

16. Our cardiologist adviser said the combination of conditions Mr R attended with posed a very high risk of death, however the treatment he required also posed a very high risk of death. There are no set guidelines that dictate a timeline for the consideration of treatment to replace heart valves and our cardiologist adviser said such decisions are based on clinical judgement and consideration of the combination of conditions and the risks of the treatment.

17. The records indicate by the time he was admitted to Hospital A on 23 February 2024 Mr R was in a critical condition with both heart and kidney failure. Our cardiologist adviser said it is important to appreciate that for Mr R to have any chance of survival he required two heart valve replacements (mitral and aortic valve). Our cardiologist adviser said this is a very complex situation to manage as the heart has four valves and when two fail at the same time it causes significant complications and makes the surgery much more complicated.

18. Mr R had bicuspid aortic valve which is an important factor when considering the appropriate procedure to perform. Bicuspid aortic valve is a congenital heart defect where the aortic valve (between the left lower heart chamber and the body's main artery, the aorta) only has two cusps (thin, flexible flaps that make up the valve) instead of the normal three.

19. Our cardiologist adviser said this requires additional consideration of the potential effectiveness of the surgery, especially when considering TAVI, due to a range of structural attributes of the bicuspid valve that might increase the probability of complications during or after the procedure.

20. Prior to his transfer Mr R’s condition was discussed in the TAVI multidisciplinary team meeting and the Trust concluded TAVI was not suitable and that surgery was his best option. Our cardiologist adviser agrees with this view and said due to the severity of his condition and the morphology (size, shape and structure) of his aortic valve, TAVI was not an appropriate procedure and the only option was surgery.

21. Following his transfer to Hospital A on 23 February 2024 the Trust discussed surgery with Mr R however the records indicate he didn’t agree and wanted to be reconsidered for TAVI. Our cardiologist adviser said at this time Mr R was not fit enough to undergo any kind of surgical intervention, including TAVI and the plan of care put in place was to optimise his condition, perform further investigations and reassess him for TAVI in line with his wishes.

22. The records indicate during the period that followed the Trust arranged for pre-operative investigations including repeat echocardiogram, a CT scan, pulmonary function tests, repeat angiogram, carotid doppler scans, a dental X-ray and subsequent plans for teeth extractions. The records also indicate the Trust provided treatment aimed at stabilising his heart failure and optimising his condition.

23. After further review by the TAVI multidisciplinary team and exploring Mr R’s request to be reconsidered for TAVI, the Trust confirmed its view on 19 March 2024 that there was no other medical way to improve his heart function other than surgery. This was discussed with Mr R and his family and he agreed to proceed.

24. There is no evidence in the records which would support the view the Trust did not act quickly enough to assess him and make a decision on his surgery following his transfer to Hospital A on 23 February 2024. The records indicate Mr R had a complex combination of conditions and risk factors which needed to be considered before surgery could be agreed.

25. The records indicate he also needed time for his condition to be optimised to ensure he was fit enough to undergo investigations and then major surgery with as reduced a risk as possible. There is no evidence to indicate the decision on his surgery could have been made sooner by the Trust.

26. The Trust’s view that surgery was the most appropriate option is evident in the records from the date of his transfer to Hospital A. However surgery can only be planned for and carried out with the patient’s consent. The records indicate Mr R did not initially agree to surgery and wanted to be reconsidered for TAVI following his transfer.

27. We carefully considered Miss N’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Trust did not act quickly enough to assess her father and make a decision on surgery after he was transferred to Hospital A on 23 February 2024. We found the Trust acted in line with the GMC guidance, the NICE TAVI guidance and the NICE valve disease guidance.

Failed to provide the care and treatment needed to improve his condition in preparation for his surgery

28. Mr R was in a critical condition when he was transferred to Hospital A with a combination of significant problems which had progressed during the previous two years. He had two failing heart valves and complicating kidney failure. Our cardiologist and anaesthetist advisers both said Mr R presented very late for such significant problems and by the time he was admitted to hospital surgery was the only option and his condition was not going to improve without it.

29. Our anaesthetist adviser said there is no evidence to indicate there was anything more the Trust could had done to optimise his condition for surgery given how unwell he was, the combination of problems he had and the degree of surgery he required. Our anaesthetist adviser said the records support the view there was no aspect of Mr R’s condition that could be improved without the surgery.

30. Our cardiologist adviser said given the severity of his condition it would have been equally reasonable following his transfer to Hospital A for the Trust to decide against surgery and refer him for best supportive care or palliative care instead. Our cardiologist adviser said the records indicate the Trust decided to attempt surgery to give Mr R the best possible chance of survival.

31. The records indicate although his condition fluctuated and he was frail throughout his admission, the surgery was performed and completed without any complications. The surgery was performed on 27 March 2024 and Mr R was transferred to the Cardiac Intensive Care Unit (CICU) immediately afterwards for treatment to stabilise his blood pressure and heart function. Following his transfer to the CICU he suffered with fluid build-up, atrial fibrillation and increasing oxygen requirements. His condition deteriorated in the days that followed and he suffered multi-organ failure. He died on the evening of 31 March 2024.

32. Our cardiologist adviser said the records support the view the severity of his heart failure was too significant for the surgery to resolve it. The records indicate the difficulties he experienced both before his surgery and after it were due to the severity of his heart failure rather than inadequate or inappropriate care from the Trust to prepare him for surgery.

33. We carefully considered Miss N’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received. We acknowledge that Mr R was critically ill during this period and that his care was extremely difficult for the Trust to manage.

34. We found no evidence to indicate the Trust failed to act in line with the GMC guidance or provide the care and treatment Mr R needed to prepare him for surgery. The records support the view the surgery was able to be successfully completed without any complications.

Failed to identify and treat MSSA infection

35. The records do not indicate Mr R contracted either MSSA or MRSA infection during this admission. The records show nasal swabs were taken by the Trust at several points and the swab taken on 27 March 2024 returned a positive result for MRSA bacteria on 30 March 2024.

36. Our cardiologist adviser said a positive nasal swab does not confirm an infection, it only means that the patient carries the bacteria in their nose or on their skin without experiencing any symptoms. MRSA often resides in the nose, groin and skin in hospitalised patients without causing a systemic infection.

37. The records indicate as a precaution the Trust moved Mr R to a side room on the CICU and provided treatment with antibacterial cream for his nose and antibacterial wash for his skin to prevent any infection from developing. The records indicate the Trust considered providing antibiotic medication for MRSA as a further precaution but decided against this as it felt his condition at this time was due to multi organ failure rather than infection. Our cardiologist adviser said the records provide no evidence to indicate any additional symptoms of infection were identified during this admission.

38. We carefully considered Miss N’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received. We found no evidence to indicate the Trust failed to identify and treat MSSA or MRSA infection.

39. The records support the view the Trust tested for infection and provided treatment aimed at preventing it. We found the Trust acted in line with the GMC guidance and we found no evidence to indicate Mr R contracted an infection during this admission.

Failed to maintain his nutrition

40. The NMC Code says nurses must make sure to deliver the fundamentals of care and work in partnership with people to make sure care is delivered effectively. The NMC Code says nurses must keep clear and accurate records, identify any risks or problems and the steps taken to deal with them. The NMC Standards say nurses should observe, assess and optimise nutrition and hydration status and determine the need for intervention and support.

41. The NICE malnutrition guidance says to screen patients for malnutrition or risk of malnutrition if there is a clinical concern, such as unintentional or unplanned weight loss. If a person is identified as low or medium risk of malnutrition it says to arrange repeat assessment and screening depending on the person's risk factors, needs, and treatment goals.

42. The Trust has accepted there was an incident in Mr R’s nutritional care that was inappropriate. This was the breakdown in communication which led to the attempt to feed him solid food after the decision had been made to provide a liquid diet. We acknowledge the Trust has acted on this to reduce the risk of such incidents happening again in future.

43. The records indicate the Trust performed a malnutrition universal screening tool (MUST) for Mr R on admission and then at several points later. However, the records of the MUST assessments and nutritional care plans provide very little detail of Mr R’s nutritional needs and the interventions required to ensure they were met. The MUST assessments and nutritional care plans in the records are also not completed consistently.

44. The records include daily food charts to record Mr R’s nutritional intake however they are poorly completed and our nurse adviser said they lack sufficient detail to inform us of what food he was able to eat, how often and how much.

45. The initial MUST assessment completed shortly after he was admitted indicated Mr R was at low risk of malnutrition (risk score is recorded as 0). Based on this assessment we think it was in line with the NMC Code and NICE nutrition guidance for the Trust to proceed without putting any specific measures in place to assist Mr R with his nutrition.

46. His weight on admission (23 February 2024) is recorded as 78.1kg and it fluctuated slightly but remained stable until 6 March 2024. The records indicate at this point Mr R’s weight began to decrease and is recorded as 76.9kg on 12 March 2024 and 73.9kg on 19 March 2024 where the MUST assessment carried out by the Trust increased his risk of malnutrition (risk score is recorded as 1).

47. Our nurse adviser said there is no evidence in the records to indicate the Trust put in place a nutritional care plan for Mr R when his weight started to decrease. There is no evidence to indicate his individual nutritional needs were assessed by the Trust, recorded and subsequent changes made to help improve his nutritional intake at this time. There is no evidence in the records to indicate the Trust referred him to the dietician on or before 19 March 2024 despite his decrease in weight of just over 4kg in the preceding 2 weeks.

48. Our cardiologist adviser said there is no evidence to indicate the nutritional care had an impact on the cause of his condition (heart and kidney failure) or the plans for his surgery. The records show Mr R was frail throughout his admission and this was taken into consideration by the Trust when making plans for treatment and surgery. Our cardiologist adviser said the records indicate he was optimised sufficiently to enable the surgery to go ahead without complications.

49. We carefully considered Miss N’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge that Mr R was critically ill during this period and that his care was extremely difficult for the Trust to manage.

50. We found once Mr R began to lose weight the Trust should have assessed and record his dietary needs and put a plan in place, with input from a dietician, to support him with his nutrition. We found the Trust did not act in line with the NMC Code and Standards or the NICE malnutrition guidance to appropriately manage Mr R’s nutrition and act on his weight loss or increased risk of malnutrition.

51. Although we did not find this contributed to Mr R’s outcome, managing his nutritional care appropriately would have ensured he received the nutritional support he needed at this time.

Failed to maintain his mobility

52. The Trust has said Mr R was mobile and independent following his admission however it accepts he was referred by nurses for a physiotherapy review twice but was not reviewed by the physiotherapy team on either occasion. The Trust said:

‘On 19 March 2024, your father was referred for a physiotherapy assessment as he was complaining of 'weak lower limbs'. He was not assessed by the physiotherapy team on this day, as he was in theatre for a tooth extraction. The following day, 20 March 2024, the Nurse documented that your father was mobile and independent and that he was awaiting a date for surgery.

It was documented by the Nurse on 25 March 2024 that a physiotherapy review for your father had been requested. Your father was then transferred to Hospital B on 26 March 2024 the same day as his surgery. It is unclear as to the reason for the referral and there is no documentation of an assessment being undertaken by a physiotherapist.

We are very sorry that the physiotherapy team did not assess your father, while he was on Ward F5. We acknowledge that in hindsight the physiotherapy team should have undertaken an assessment following the referral being received on 19 March 2024. This was when your father had been complaining of his legs being weak and having already being an inpatient for three weeks before his surgery.’

53. Our principles say good practice with regard to remedies means:

• Getting it right • Being customer focused • Being open and accountable • Acting fairly and proportionately • Putting things right • Seeking continuous improvement.

54. We do not uphold points of complaint which have already been upheld by the organisation involved and where we can see appropriate action has been taken to address the failings. We acknowledge the Trust has identified this failing, apologised for the impact it had and made improvements to reduce the risk of it happening again in future. We will look to see if this failing had an impact on Mr R’s condition and also provide a view on the support provided by the Trust to assist him with his mobility.

55. The records indicate the Trust nursing team assessed Mr R regularly throughout his admission and his mobility and support needs were recorded. The assessment carried out on admission (23 February 2024) states that he is ‘independently mobile’. The assessment on 25 February 2024 states he is ‘independent, assisted when needed.’ Our nurse adviser said the records support the view Mr R’s mobility decreased over the following days and the assessment on 3 March 2024 notes he is ‘independently mobile under supervision’.

56. The records indicate Mr R was normally independent and mobile but as he would get out of breath while walking, support was provided by the nursing team as and when required. Additional support was provided with the use of a wheelchair to assist him to the toilet if needed. Our nurse adviser said this level of support is in line with the NMC code when assisting a patient who is usually independently mobile but has fluctuating needs.

57. On 19 March 2024 the records state Mr R ‘has been slowly mobilising to bathroom but complains legs feel very weak’ and the nursing team make the initial referral to the physiotherapy team for an assessment. It is at this point the Trust has acknowledged the physiotherapy team should have assessed Mr R’s needs. Despite this the records show he continued to be independently mobile in the days that followed with supervision and support from the nursing team.

58. Mr R’s mobility did decrease and as his admission went on he would remain in his bed for long periods. Our cardiologist adviser said there is no evidence to indicate the lack of a physiotherapy review had an impact on his condition or the plans for his surgery or treatment. Our cardiologist adviser said it is important to appreciate Mr R was critically unwell with significant heart and kidney conditions during this admission which had an impact on his ability to mobilise.

59. Our cardiologist adviser said a physiotherapy review would have been beneficial in understanding his needs but it is difficult to comment on any additional care that could have been provided to improve his mobility while he was suffering such significant heart failure and complicating kidney failure. The treatment he required for his condition to improve was the replacement of his two heart valves.

60. We carefully considered Miss N’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received. We acknowledge the Trust has recognised it did not carry out the physiotherapy reviews requested by the nursing team and we think it has taken appropriate action, in line with our principles, to address this failing.

61. We found no evidence to indicate the Trust failed to maintain Mr R’s mobility. We acknowledge there were aspects of care that could have been improved however we have not seen that the failings identified by the Trust had the impact of decreasing Mr R’s mobility. The records support the view his mobility decreased as a result of the progression of his illness and the severity of his heart failure and not as a result of any failings in care from the Trust.

Failed to bring him out of sedation appropriately following surgery

62. After his surgery was completed Mr R remained under sedation until 9.45pm. As he awoke he became agitated and the Trust re-sedated him overnight. The Trust attempted to bring hm out of sedation again at 9.45am the next morning and once again he became agitated and was re-sedated. At 4pm that afternoon the Trust reduced his sedation and it was discontinued at 4.30pm. On this occasion Mr R woke up appropriately.

63. Our anaesthetist adviser said following surgery it is preferable for patients to be woken up and taken off ventilation as soon as possible. However, as Mr R was a high risk patient it is not surprising that it was a challenge to bring him out of sedation after such significant surgery.

64. Our anaesthetist adviser said respiratory distress when coming out of sedation is not a rare occurrence and the risks are increased when the patient has such significant underlying issues as chronic heart and kidney failure. A patient experiencing respiratory distress would be re-sedated until it was safe to bring them round. Our anaesthetist said it would have been unsafe after such significant surgery not to re-sedate Mr R when he experienced distress when waking up.

65. Our anaesthetist adviser said there is no evidence in the records to indicate the difficulty bringing Mr R out of sedation was due to failings on the part of the Trust. The records support the view the difficulties were due to the severity of his condition.

66. We carefully considered Miss N’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received.

We found the Trust acted in line with the GMC guidance when attempting to bring Mr R out of sedation following his surgery.

Failed to identify and treat the build-up of fluid he experienced following surgery

67. Miss N says the fluid build-up her father experienced after his surgery was an indication of the multi-organ failure he was suffering at that time which ultimately caused his death. She says the Trust could have done more to prevent it if it had identified sooner after his surgery.

68. Our cardiologist adviser said the records indicate Mr R had fluid build-up from the outset. He was admitted to Hospital on 15 February 2024 with pulmonary oedema (build-up of fluid around the lungs) and he had swelling in his legs (evidence of fluid build-up in the legs). Our cardiologist adviser said this fluid build-up was a direct result of the heart and kidney failure that prompted his admission. Fluid build-up in a patient with both heart and kidney failure is not easy to reverse with medication and the treatment itself poses significant risk to the patient.

69. The BNF guidance recommends treatment with furosemide medication for fluid build-up. The records indicate the Trust identified his fluid build-up early in his admission and provided frusemide medication in an attempt to reduce it. Our cardiologist adviser said there is no evidence in the records to indicate the care the Trust provided for his fluid build-up was inadequate or that there was more that the Trust could have done to treat it.

70. Our cardiologist adviser said it is important to understand the significance of Mr R’s illness and the combination of his conditions. He had both heart and kidney failure which by their nature cause significant difficulty in the patient’s ability to remove excess fluid from the body. By the time Mr R attended his conditions were advanced, there was no treatment option other than surgery and no aspect of his condition would improve without it.

71. Our cardiologist adviser said the records indicate all appropriate treatment options were considered and applied by the Trust. There is no evidence in the records to indicate there was any further treatment that could have been provided by the Trust or that Mr R’s death could have been prevented.

72. We carefully considered Miss N’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received.

We found no evidence to indicate the Trust failed to identify and treat Mr R’s fluid build-up. We think the Trust acted in line with the GMC and BNF guidance.

1. We have decided to partly uphold this complaint. We partly uphold a complaint when we find failings in some aspects of care but not in others. We found the overall care provided by the Trust was in line with the guidance and standards in place. However, we found failings in the nutritional care provided by the Trust.