University Hospitals Coventry and Warwickshire NHS Trust

6. Mrs B complains about the care and treatment the Trust gave her father (Mr A) during his admission between 8 August and 2 October 2022. Specifically, it:

• did not inform, discuss or agree with Mr A’s family a do not resuscitate (DNR) status decision made on 2 October 2022 • gave Mr A oramorph between 8 and 13 August 2022 when his family asked the Trust not to and suggested an alternative • did not maintain or replace Mr A’s fluids after Mr A fasted (nil by mouth -NBM) before procedures the Trust then cancelled • did not do enough to maintain his nutritional intake • did not do enough to prevent pressure sores from forming.

7. Mrs B says Mr A was in pain and distress and not in the right state of mind to agree to the DNR and his family should have been involved. Mr A died and his family were not there, which has been devastating for them. Mrs B said the Oramorph caused Mr A to suffer severe diarrhoea and says he was severely dehydrated due to the Trust not replacing or maintaining his fluids causing him to have an acute kidney injury. Mrs B says the Trust did not do enough to prevent Mr A losing 33lbs weight during his admissions. Mrs B says Mr A developed sores causing him distress. Mrs B says witnessing her father’s deterioration from these issues still causes her distress.

8. Mrs B wants an independent view. She wants Trust acknowledgement for failings identified an apology and service improvement to prevent this happening again.

9. Mr A was admitted to the Trust on 9 August 2022 serious health conditions including colorectal cancer, and peripheral vascular disease with critical limb ischemia (CLI - a severe blockage in the arteries of the legs that reduces blood flow). Mr A had previously suffered a heart attack and undergone a coronary bypass, both indicating he had ischaemic heart disease (narrowing of the arteries supplying the heart muscle with blood).

10. Mr A was scheduled for surgery to prevent major leg amputation on 11 August 2022. The Trust abandoned this as unsafe. Mr A underwent lower limb amputation on 1 September 2022.

11. On 16 September 2022 the Trust identified Mr A with bleeding in his lower and upper gastrointestinal tracts. The Trust identified a recurrence of previous rectal cancer.

12. On 2 October 2022 Mr A sadly died after experiencing sudden cardiac arrest following a sudden bout of vomiting.

DNR status decision on 2 October 2022

17. The GMC standard on end-of-life practice says, ‘to be for or not for resuscitation is a medical decision’.

18. The NHS website on DNACPR decisions says ‘DNACPR is a medical treatment decision that can be made by your doctor even if you do not agree’. It says, ‘If you lack capacity to decide about CPR, doctors should first check to see if you have an Advance Decision to Refuse Treatment (ADRT) that says that you do not want CPR. They should also check to see if you have a Lasting Power of Attorney (LPA) for health and care decisions’.

19. It goes on to say ‘If you do not have an advanced decision to refuse treatment (which says that you do not want resuscitation) or an LPA (with life-sustaining treatment decision-making powers) then a best interests decision is made by the senior doctor’.

20. Mr A started vomiting at 4.10am on 2 October 2022 and shortly after went into sudden cardiac arrest. The Trust attempted CPR eight times and achieved a return of spontaneous circulation (a sustained palpable pulse) but Mr A was making no attempt to breathe on his own and his blood pressure (BP) did not stabilise.

21. The Trust clinicians treating Mr A made a collective decision not to start CPR if Mr A rearrested after identifying no reversible cause for his cardiac arrest.

22. Our physician adviser said the Trust DNR decision was clinically sound and in line with guidance. Though the Trust achieved the return of Mr A’s pulse this did not mean he was out of danger. Mr A was sadly very unlikely to survive, irrespective of any course of action.

23. GMC Good Medical Practice says doctors must be sensitive and responsive in giving those close to the patient information and support. Our physician adviser said in a situation like this. if a patient goes into cardiac arrest and his family are not present the expectation is the Trust make efforts to speak with them as soon as possible.

24. At 9.30am The Trust completed a RESPECT (Recommended Summary Plan for Emergency Care and Treatment) form stating DNR. This is an NHS form created through conversations between patients and clinicians, outlining preferences for emergency care if a patient cannot express their wishes.

25. The Trust acknowledged Mr A lacked capacity due to his poor clinical state at the time and his clinical team made the DNR decision. After making the decision the Trust called Mr A’s family, discussed what DNR meant, and called them into the hospital.

26. In summary, clinicians are responsible for making DNR decisions, sometimes at short notice. The guidance above is clear and supports the Trust’s actions here. The Trust did not have to have obtain agreement from the patient or family before making a clinical decision to DNR. It should endeavour to speak with the family as soon as possible about this, which is what it did here.

27. We are sorry to learn how the timing of the events meant Mrs B was unable to get to the hospital in time to be there for Mr A’s death. This no doubt continues to be very difficult for her.

Oramorph

28. NICE CG147 says on ‘Management of critical limb ischaemic pain’:

• ‘1.6.7. Offer paracetamol, and either weak or strong opioids depending on the severity of pain, to people with critical limb ischaemic pain.’

29. Mr A had critical limb ischaemia and severe peripheral arterial ischaemia. The Trust prescribing Oramorph (a liquid form of morphine which is an opioid) for his pain was in line with NICE guidance.

30. The BNF does not list diarrhoea as a side effect of morphine. Our physician adviser said the BNF will list side effects as rare as 1 in 10,000. Our physician adviser said opioids are well known to cause constipation rather than diarrhoea.

31. In summary Trust prescribing of Oramorph was in line with guidance.

Replacement of Mr A’s fluids

32. NICE CG138 says Trusts should:

• ‘ensure a patients’ nutrition and hydration is adequate at all times’.

33. The Trust monitored Mr A’s hydration using fluid balance charts that were consistently completed. From these charts, it appears that his fluid intake was adequate most of the time and the documentation around this was good.

34. Our nurse adviser said the Trust monitored and manged Mr A’s fluid levels in line with the guidance above. Mr A’s acute kidney injury was short lived, and after identifying it the Trust treated Mr A with IV fluids. Treatment was stopped on 23 August 2022 after it was successful. His renal function then remained stable and recovered until his sudden cardiac arrest.

35. From the records, it appears that Mr A was nil by mouth on around five of the days of his admission. On two of these days the Trust administered IV fluids. We found evidence of the Trust doing this on 9, 10 and 11 August 2022 and on on 8 September 2022.

36. There is evidence that Mr A was only intermittently NBM (therefore not entirely without fluid) on these days as it is documented that he was eating and drinking apart from when he was pre-operative.

37. Our nurse adviser was satisfied from Mr A’s clinical notes the Trust did follow guidelines in ensuring adequate hydration when Mr A was nil-by mouth.

38. In summary, the Trust provided Mr A with appropriate hydration and monitored this. We are sorry to learn from Mrs B how many times her father’s procedures were cancelled or postponed. This no doubt increased her worry about his hydration and there would have been times when Mr A could not drink.

Nutritional intake

39. NICE CG32 says:

• ‘1.2.2 All hospital inpatients on admission […] should be screened [for malnutrition and risk of malnutrition] • ‘1.3.1 Nutrition support should be considered in people who are malnourished’.

40. A Trust nursing assessment document completed on admission stated Mr A had not had any unintentional weight loss and was not eating less than usual. The Trust weighed Mr A on admission and nine days later on 18 August 2022. He weighed 87kg on both occasions.

41. On 13 August 2022 the Trust record Mr A as ‘can have diet and fluids’.

42. The Trust weighed Mr A again on 31 August 2022 and he weighed 82kg.

43. The NICE guidance indicates the Trust should have screened Mr A for risk of malnutrition on admission. Trust should do this using a validated tool such as MUST assessment (Malnutrition Universal Screening Tool (MUST) is a validated 5-step, evidence-based tool used to identify adults who are malnourished, at risk of malnutrition, or obese).

44. The Trust first completed a MUST assessment on 1 September 2022, at which point Mr A had lost 5kg in three weeks. The Trust gave Mr A a MUST score of 2 (high risk). A MUST score of 2 should prompt the Trust to try to improve and increase nutritional intake. The Trust did this by providing Mr A with supplement drinks (recording Mr A had aa 50% intake of these) and starting food charts.

45. But a MUST score of 2 should also prompt a referral to a dietician or similar. The Trust did not refer Mr A to a dietician in line with the guidance above. Nor were the food charts consistently completed.

46. In line with the guidance and MUST assessment, the Trust should also have assessed Mr A’s risk of malnutrition on admission, and then at least weekly following this.

47. We cannot say how much of Mr A’s weight loss can be attributed to any potential Trust failings or how much was due to his clinical condition. Nevertheless, Mrs B sought acknowledgements and service improvements.

48. In its response of August 2023, the Trust acknowledged it did not monitor Mr A’s nutritional intake in line with relevant guidance. It shared Mrs B’s complaint with ward staff and reiterated the importance of putting all patients with reduced intake on the MUST pathway, that nutrition charts are to be completed and reviewed daily, and that dietician referral should be made if no improvement is seen. The Trust also reminded staff of the importance of weighing patients weekly.

49. The Trust said it would continue to monitor MUST compliance to ensure improvements are embedded.

50. In summary there are indications the Trust did not escalate concerns about Mr A’s nutritional intake as it should have. The Trust has acknowledged this, apologised and outlined the service improvement it has made. We hope Mrs B takes some reassurance that her complaint will help ensure patients in similar circumstances are escalated when there are concerns with their nutritional intake. This is what Mrs B wanted and for that reason we will take no further action here.

The Trust did not do enough to prevent pressure sores from forming

51. NICE CG179 says on repositioning:

• ‘1.1.8 Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every six hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.’

• ‘1.1.9 Encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.’

• ‘1.1.18 Consider using a barrier preparation to prevent skin damage in adults who are at high risk of developing a moisture lesion or incontinence-associated dermatitis, as identified by skin assessment (such as those with incontinence, oedema, dry or inflamed skin).’

52. The Trust completed a skin assessment on Mr A’s admission on 9 August 2022. The Trust documented Mr A being able to initially to relieve his own pressure areas (9 August 2022 and 13 August 2022). It provided him with a quattro air mattress and air cushion on 14 August 2022.

53. The Trust later said Mr A needed to be checked and repositioned two-hourly after it noted he had a red blanching area. There were some instances where the Trust did not reposition two-hourly. We noted on 11 September 2022 Mr A was repositioned four-hourly. On 15 September 2022 there was a six-hour gap between repositioning.

54. The Trust record Mr A’s pressure areas as intact on two separate checks on 9 August 2022. The Trust recorded skin checks on 10 August 2022 and 11 August – skin checked and documented (twice daily). On 10 August 2022 and 18 August 2022, the Trust noted Mr A had a natal cleft (pressure area to bottom) and then grade 2 pressure ulcer on his left buttock.

55. Mr A did have a rash over his back and right leg from 15 August 2022. There is no indication this was due to a Trust failure to reposition Mr A. The Trust treated Mr A’s rash with antihistamines and referred him to its dermatology team for review. The Trust dermatology team said Mr A had a dry rash more consistent with Mr A’s acute kidney injury and a hypersensitivity reaction. The Trust gave Mr A topical ointment and regular emollient was suggested. The Trust could not say exactly why the rash started but we know it discharged Mr A from the dermatology service on 26 August 2022 and discontinued the treatment (suggesting this was resolved).

56. Mrs B said this was only provided in reaction to Mr A developing bed sores and not as a preventative measure and the Trust was not moving Mr A on a regular basis to prevent further deterioration. As we said above, the is no indication this rash was a bed sore.

57. Other than on the two dates mentioned above. there is good evidence in Mr A’s clinical record of the Trust complying with the two hourly repositioning plan. Our nurse adviser said the Trust assessed Mr A’s need for repositioning in line with the NICE guidance above.

58. In summary, we are sorry to hear about how Mr A developed a rash. There are several possible reasons for that. We were reassured to see Trust treatment resolved the problems. We are satisfied the Trust assessed Mr A’s repositioning needs and in the main complied with moving him every two hours (except on two occasions) and for that reason will take no further action here.

1. We have carefully considered Mrs B’s complaint about the care and treatment her father (Mr A) received at University Hospitals Coventry and Warwickshire NHS Trust (the Trust). We are sorry to hear of Mr A’s poor experience and the ongoing traumatic impact this has had on his family. They have our condolences for their loss.

2. The Trust decision to place Mr A on a ‘do not resuscitate’ (DNR) order was in line with standards and guidance. We are satisfied the Trust told Mrs B as soon as it could after making the DNR decision. We are sorry to learn Mrs B did not have time to get into hospital to be with her father before he died.

3. We have seen no indication the pain relief (Oramorph) the Trust gave Mr A was not in line with guidance, or that it caused his diarrhoea. Likewise, there is no indication the Trust failed to provide provided Mr A with hydration in line with standards, or failed to do enough to prevent pressure sores.

4. The Trust accepted it should have done more to monitor Mr A’s nutritional intake. We looked at what actions the Trust has taken to provide Mrs B with what the service improvement she seeks. We are satisfied these should prevent this happening again.

5. We explain our decision below