Northern Lincolnshire and Goole NHS Foundation Trust

3. Mrs A complains about the care provided to her husband, Mr B, by Northern Lincolnshire and Goole NHS Foundation Trust (the Trust) on 15 and 16 April 2023. Specifically:

• Mr B was given inadequate care to treat his conditions when he was in hospital • a doctor attempted to place a Do Not Attempt Resuscitation (DNAR) order on Mr B when he was delirious and lacked capacity to understand this process.

4. Mrs A says that her husband died unexpectedly after suffering a stroke the day after he went into hospital with shortness of breath.

5. As an outcome, Mrs A wants changes in procedure, so relatives are accurately updated about patients’ conditions when they are in hospital. Mrs A also wants a financial remedy from the Trust.

6. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

7. Mr B was 77 years old. He was taken to Scunthorpe Hospital which is part of the Trust on 15 April 2023 with a history of worsening shortness of breath, deteriorating exercise tolerance and reduced oral intake. A chest examination revealed that he had reduced air entry to both lower zones of his lungs but no overt evidence of any signs to suggest that he was experiencing any heart failure.

8. Mr B’s venous blood gas analysis had shown that, due to his COPD, he was a retainer of carbon dioxide and was deemed to require his saturations to be maintained at a certain level to stop the carbon dioxide from building up in his system. There was no evidence of infection at the time (2pm approx. on 15 April 2023). As Mr B had recent poor oral intake, he was commenced on IV fluids to rehydrate him.

9. Mr B’s chest x-ray showed the severity of his COPD. He was treated for his COPD and remained stable throughout the rest of 15 April 2023. Mr B was seen at 10am on 16 April 2023 where he was thought to have a non-infective exacerbation of his COPD. Due to his general frailty and progression of his COPD, the Trust suggested the completion of a Do Not Attempt Resuscitation order (DNAR).

10. At 4.50pm on 16 April 2023, Mr B was noted to be drowsy. An hour later, he was noted to be stable but to require slightly more supplemental oxygen to maintain his recommended level of oxygen saturation. By 7.30pm, Mr B had declined. He was unable to speak; he was confused and had right-sided upper limb weakness. It was thought that he had suffered a stroke.

11. Further examination found Mr B to be unresponsive. As it was thought that he had suffered a stroke before becoming unconscious and stopping breathing, the Trust decided that Mr B would not be amenable for resuscitation. He was kept comfortable but deteriorated further and sadly died at approximately 10pm on 16 April 2023. The cause of Mr B’s death was exacerbation of COPD.

Care on 15 and 16 April 2023

16. Mrs A says that her husband was given inadequate care by the Trust to treat his conditions when he was in hospital.

17. Having considered the relevant records, our A&E adviser says that on 15 April 2023, Mr B was brought to the emergency department (ED) by ambulance. He had low oxygen saturation, fast heart rate and was struggling to breathe. Mr B was initially assessed by an ED consultant as part of rapid assessment and triage to initiate treatment and investigations.

18. Mr B’s past medical history including his COPD was noted and our A&E adviser says that a management plan was formulated. Mr B had a blood gas taken that showed chronic retention of carbon dioxide (a sustained rise in carbon dioxide over a period of time due to impaired gas exchange in lungs, seen in COPD patients). Mr B was further reviewed by a junior doctor in ED who referred him to the medical team for further review and optimisation. Our A&E adviser says this was in accordance with the RCEM guidance for initial assessment of ED patients which states:

There are three main objectives of good quality initial assessment:

1. Improving safety 2. Identifying acuity to ensure that the most time-critical patients are treated by the right service within appropriate time frames, and that appropriate prioritisation occurs for the remainder.

3. Improving efficiency in the system to ensure that patients do not wait unnecessarily for investigations or diagnostic decision making.

19. Our A&E adviser also says this was in accordance with sections 14 and 15 of the GMC guidance which states:

‘You must recognise and work within the limits of your competence.

You must have the necessary knowledge of the English language to provide a good standard of practice and care in the UK.

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 (including the symptoms and psychological, spiritual, social, and cultural factors), 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.’

20. Overall, we consider that Mr B was provided with appropriate care by the Trust, in accordance with relevant guidance, when he was in the ED on 15 April 2023.

21. On 16 April 2023, responsibility for Mr B’s care was transferred to the medical team. Our physician adviser has considered this episode of care and says the records indicate that Mr B was given oxygen (scale 2), antibiotics, nebulisers, and his diuretics continued. He was also given food and drinks confirmed in the nursing records due to his poor oral intake. All this was appropriate management for his conditions.

22. However, as it was thought that Mr B had suffered a stroke, our physician adviser says that section 1.3.2 of the NICE guidance on Stoke and transient ischaemic attack in over 16s applies. This states:

‘Perform brain imaging immediately with a non-enhanced CT for people with suspected acute stroke if any of the following apply:

• on anticoagulant treatment.’

Also, section 37 of the GMC guidance on communicating with those close to a patient states:

‘You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.’

23. Our physician adviser says that Mr B was on Rivaroxaban, which is an anticoagulant, but there is no evidence in the records that a CT brain scan was considered for Mr B or discussed with him or his family when it should have been. Therefore, we consider this is a failing by the Trust contrary to the NICE and GMC guidance. We have made recommendations about this.

24. In terms of impact, our physician adviser says Mr B had a high Clinical Frailty Score of 7 related to his comorbidities including severe COPD. Therefore, even if a CT brain scan had been carried out in accordance with NICE guidance, Mr B would likely only have been for conservative management rather than neurosurgical intervention. Nevertheless, this still should have been discussed with Mr B and his family and documented in the records as a CT brain scan would have helped to confirm the cause of his neurological deterioration, as well as informing discussions with Mr B’s family about his future care.

DNAR and mental capacity

25. Mrs A says a doctor attempted to place a Do Not Attempt Resuscitation (DNAR) order on Mr B when he was delirious and lacked capacity to understand this process.

26. Firstly, our A&E adviser says the completion of ResPECT forms and DNAR forms separately depends on individual hospital policy. In Mr B’s case, we have not seen any DNAR forms in the records, but there are two ResPECT forms, both dated 16 April 2023, which contain conflicting evidence about his mental capacity. Both our advisers concur that these forms contain conflicting evidence about Mr B’s mental capacity at the time.

27. One of the ResPECT forms indicates Mr B did not have capacity, but it does not have any specific timings attached to it. The other ResPECT form indicates Mr B did have capacity. It is timed at 14.00 on 16 April 2023, but the form appears to have been ‘crossed out’. Neither form is fully completed. Mrs A has told us that she feels her husband lacked capacity throughout his time in hospital.

28. Our physician adviser says that section 24 of the GMC guidance about supporting patients to make decisions about treatment and care applies. This states:

‘All patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able to. You must start from the presumption that all adult patients have capacity to make decisions about their treatment and care.’

29. Given the discrepancies in both forms and the conflicting information about Mr B’s mental capacity, we cannot be sure if Mr B or his family were involved in the decisions about his care and resuscitation status. We consider this to be a failing by the Trust contrary to the GMC guidance above. We have made recommendations about this.

30. However, having considered Mr B’s wider medical records from 16 April 2023, our physician adviser says he is noted as ‘alert’ by nursing staff earlier in the day. This indicates that Mr B had capacity up until approximately 7.15pm when a documented deterioration in his condition is noted. While we acknowledge Mrs A’s recollection that her husband lacked capacity throughout this episode of care, on the balance of probabilities, we consider Mr B had sufficient capacity to understand and make his own decisions about care during most of 16 April 2023 until a noted decline in his condition that evening.

31. Mr B’s deterioration was reported as being due to ‘cognitive problems.’ We acknowledge that delirium is a cognitive impairment, but our physician adviser says there is no specific evidence in the records that Mr B suffered from delirium during this episode of care.

32. In summary, we consider the Trust could have better managed aspects of Mr B’s care experience such as communication with him and his family, offering CT scan after his suspected stroke, and documenting all this more appropriately in the records. This is reflected in our findings as outlined in this report.

33. Nevertheless, our physician adviser says there is no evidence in the records that Mr B’s death was avoidable. He had suffered a suspected stroke and had severe COPD amongst other comorbidities which resulted in a high Clinical Frailty Score. Sadly, this meant that his death on 16 April 2023 was an expected and predictable outcome. We recognise that this was a tragic event and no doubt greatly distressing for Mrs A. Hopefully, our finding that there is no evidence Mr B’s death could have been avoided will provide Mrs A with some reassurance.

34. As regards the ultimate clinical decision by the Trust that Mr B was not recommended for resuscitation attempts, our physician adviser says this was a reasonable decision, considering our balance of probabilities view that his condition deteriorated later on 16 April 2023 to the point that any resuscitation attempts would have been futile.

1. We have seen failings by the Trust regarding its management of Mr B’s care when he was in hospital on 15 and 16 April 2023. As it was thought Mr B had suffered a stroke, we consider he should have been offered a CT brain scan. This should have been discussed with Mr B and/or his family and documented in the records. Similarly, as regards Mr B’s mental capacity and resuscitation status, we consider this should have been more thoroughly clarified in his records. We consider this causes Mrs A uncertainty and emotional distress about some of her husband’s care.

2. Therefore, we partly uphold Mrs A’s complaint about the Trust. These are our recommendations:

• the Trust should acknowledge its failings in Mr B’s management, as summarised in paragraphs 23 and 29. It should apologise to Mrs A for the uncertainty and emotional distress this causes her about her husband’s care • the Trust should develop an action plan to address the failings summarised in paragraphs 23 and 29. It should identify any specific reasons for these failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, as well as how these will be monitored • the Trust should pay Mrs A £150 as a personal remedy in view of the uncertainty and emotional distress caused to her by the failings in her husband’s care.