York and Scarborough Teaching Hospitals NHS Foundation Trust

5. Mrs F complains the Trust did not escalate her father, Mr J’s breathing difficulties and administered a saline nebuliser on two occasions when it should not have done during his admission from March to his sad death in April 2024. She also says it did not regularly review her father during the same admission, which she says led to him developing painful bedsores.

6. She says her father lost his life and his last days were spent suffering. She explains she is tormented by the thought that he could have had a painless and comfortable death. Instead, he was alone and afraid. She says her and her family are struggling to come to terms with what happened. She wants an acknowledgement of failings, service improvements and a financial remedy.

7. Mr J had a history of lung cancer and chronic obstructive pulmonary disease (COPD), a progressive, long-term lung condition that makes it hard to breathe. In early March 2024 he attended the Trust’s emergency department (ED) with abdominal pain. It admitted him and treated him for acute colitis (sudden inflammation of the large intestine).

8. In mid-March the Trust noted Mr J reported breathlessness, this continued intermittently throughout his admission. It carried out a chest X-ray which was normal. The Trust treated him for an exacerbation of COPD. It gave him medication and oxygen therapy to support his breathing. Mr J sadly died in mid-April. The Trust noted his cause of death as an infective exacerbation of COPD.

Breathlessness escalation 11. Mrs F complains the Trust did not escalate her father’s breathing difficulties during his admission between March and April 2024. Understandably, she is concerned as she feels her father died prematurely and his last days were spent suffering. We are sorry to hear she feels tormented by the thought he could have had a comfortable death with his family around him.

12. NMC guidelines say nurses must accurately identify, observe and assess signs of normal or worsening physical health in the person receiving care. It goes on to say they must make a timely referral to another practitioner when any action, care or treatment is required.

13. Mr J attended the Trust’s ED with abdominal pain in mid-March. It admitted him the day after and treated him for acute colitis.

14. A few days into his admission, Mr J first reported breathlessness during a medical examination. The medical team documented a likely exacerbation of COPD and prescribed steroids and saline nebulisers to manage this.

15. Later that day, Mr J continued to experience shortness of breath, which nursing staff escalated to the medical team. The medical team assessed him and noted a high secretion burden with no sign of infection. A high secretion burden refers to an uncomfortable build-up of mucus in the airways and lungs. It is a symptom often associated with COPD which can cause breathing difficulties.

16. They prescribed carbocisteine, a medication used to make mucus less sticky and easier to cough up. That same day, nursing staff escalated him to the medical team again when he required oxygen. Medical staff assessed him three times on this day, and he reported feeling comfortable with oxygen therapy overnight.

17. In early April, Mr J experienced a sudden onset of breathlessness. The Trust carried out an X-ray and blood tests, which showed no serious issues. Mr J remained stable throughout the day. The medical team recommended the gradual reduction of oxygen. He reported improvement. However, a few days later, his oxygen requirements increased, which nursing staff escalated.

18. The medical team reviewed him and noted a saline nebuliser had improved his symptoms. They continued treatment for his COPD using steroids and nebulisers. A week later, nursing staff again escalated his care to the medical team, when he complained of increased secretions.

19. The medical team assessed him and noted he had scattered crackles all over his chest with secretions that could be heard. They planned to continue with carbocisteine and saline nebulisers to relieve his symptoms. Mr J sadly died the morning after.

20. Based on the evidence we have seen, it is our view the nursing team’s actions were in line with NMC guidelines. We can see they identified Mr J’s breathlessness and escalated him to the medical team on each occasion. Our nurse adviser says there is evidence the nursing team escalated Mr J each time his breathing worsened or symptoms changed. Therefore, it does not appear the Trust missed an opportunity to escalate Mr J when his breathing worsened.

21. In reaching this decision, we are in no way underestimating the impact Mr J’s death had on Mrs F or their family. We are sorry we cannot take further action on this part of her complaint and acknowledge how disappointing this will be for her.

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Saline nebuliser 22. We understand Mrs F’s concerns about the Trust’s use of saline nebulisers in April, as she told us her father, almost choked while using one in March. She believes the Trust should not have continued using them after this incident.

23. Our physician adviser explains there are no national guidelines specifying when saline nebulisers should or should not be used. However, they referred us to a BMC study, which supports the use of saline nebulisers to assist mucus clearance in patients with COPD who have difficulty coughing up mucus.

24. The records show the Trust gave Mr J a saline nebuliser in mid-March, then again in early April, and the day before he died in mid-April. There is no indication in the records that Mr J did not tolerate nebulisers during these instances.

25. This differs from Mrs F’s understanding, as she believed the Trust would not use saline nebulisers again after the difficulties her father experienced in March. This has understandably caused her worry, particularly as the Trust administered one shortly before he died, and she feels it may have contributed to his death.

26. We have not been able to find evidence in the records to suggest Mr J experienced any side effects such as choking when it gave him the saline nebulisers on both occasions in April. We hope this reassures Mrs F. However, we recognise her recollection of events may differ from the records. We are sorry we cannot provide further clarity about any communication that led her to believe the Trust had decided to stop administering saline nebulisers.

27. Our physician adviser explains saline nebulisers are not considered to cause irritation and are not likely to have caused Mr J to deteriorate or contribute to his death.

28. In summary, we can see no indication the Trust got anything wrong when it gave Mr J a saline nebuliser. While there are no specific guidelines for their use, the BMC study supports their role in symptom management for patients with COPD. The Trust’s primary intention in using saline nebulisers was to help Mr J manage his symptoms, which is consistent with best practice.

29. For this reason, we will not take further action. We hope Mrs F takes comfort in the fact we did not find the Trust got anything wrong when it gave her father a saline nebuliser and there is nothing to suggest it contributed to his death.

Pressure sore care 30. Mrs F says the Trust did not regularly review her father during his admission between March and April. She says this led him to develop bedsores which caused him to suffer in pain.

31. In the Trust’s response to her complaint, it acknowledged it did not follow its own plan to reposition Mr J every two hours, maintaining a four-hourly schedule throughout his admission. It also acknowledged it could not establish the care provided for Mr J’s vulnerable sacral skin (skin at bottom of the spine) during the first six days of his admission and identified eight missed opportunities for skin checks.

32. NICE guidance says organisations should assess patients for pressure ulcer risk upon admission. For individuals identified as being at high risk, regular skin assessments should be provided. Patients should be encouraged to reposition frequently, at least every four hours, or helped if they are unable to reposition themselves. Additionally, barrier creams should be used to protect the skin from moisture-related damage, such as that caused by incontinence.

33. The records show when the Trust admitted Mr J, it carried out a pressure ulcer risk assessment, in line with the NICE guidance. It identified Mr J was at risk of pressure ulcers. It put a prevention plan in place, which included twice daily skin assessments and four hourly position changes.

34. Six days into his admission the Trust identified Mr J had a pressure sore on his sacrum. It moved him onto an air mattress to help relieve pressure to his sacrum. In early April it identified his pressure sore had worsened and a tissue viability nurse (TVN) assessed him. A TVN is a nurse with advanced training in skin health and wound care. They recommended to reposition him every two hours, however this did not happen, and it carried on with four hourly checks.

35. Mr J suffered from faecal incontinence, which put him at risk of moisture associated damage to the sacral area. Our nurse adviser says barrier cream should have been used to protect his skin but there is limited evidence to confirm regular application during his admission.

36. Based on the evidence we have seen, it appears the Trust did not fully follow NICE guidelines. It assessed pressure ulcer risk on admission and implemented a plan, but it missed eight skin checks and did not change its plan to reposition Mr J every two hours, as the TVN recommended. Additionally, there is limited evidence barrier creams were used regularly. This indicates the Trust got something wrong.

37. Our nurse adviser explains Mr J’s pressure ulcer may not have been completely preventable, as he was very frail and cachexic. Cachexia is often called wasting syndrome, characterised by extreme weight loss and it is caused by an underlying illness such as COPD. However, they say the ulcer may not have worsened if the Trust had consistently followed NICE guidelines.

38. We understand Mrs F feels the Trust missed opportunities to review her father and prevent him from suffering from painful pressure ulcers. She says she is tormented by the fact he could have had a painless comfortable death.

39. There is evidence Mr J experienced pain related to his sacral pressure sore on two occasions earlier in his admission. There is also information within Mr J’s records that he preferred to lie on his back and declined to be repositioned on occasion.

40. Based on this information, it is possible even if the Trust had fully followed the guidance, Mr J may still have developed a pressure ulcer due to his reluctance to reposition. We understand Mr J’s hesitancy to engage with the Trust as he was worried that changing his position may affect his breathing.

41. Our Principles for Remedy says to put things right organisations should provide an apology and take proportionate actions to address any failings.

42. Taking the above into account, we cannot conclude with certainty that Mr J’s pressure ulcer and associated pain were fully preventable. The records also do not indicate Mr J experienced ongoing severe pain or suffering associated with his pressure sore.

43. In its final response the Trust apologised it did not fully follow its pressure ulcer prevention plan. It also put together an action plan which specifically outlines the actions it has taken to address the gaps in pressure ulcer care it provided Mr J with, in response to Mrs F’s complaint. This includes additional training on pressure sore prevention and management. It also has a new system to ensure outstanding care tasks such as repositioning are reported on, in real time and can be acted on. We can see it intends to continue to audit this and monitor the results.

44. We are satisfied the actions the Trust has taken since Mrs F raised her complaint are in line with our principles and remedies this part of her complaint. These actions demonstrate the Trust’s commitment to improving its service because of the issues Mrs F highlighted.

45. In view of the action the Trust has already taken, we do not think it would be proportionate to consider this part of her complaint further, when the Trust has already taken appropriate action. We hope this reassures her the Trust has taken her complaint seriously and will take comfort in the steps it has taken to prevent the same thing from happening to someone else.

1. We have carefully considered Mrs F’s complaint about York and Scarborough Teaching Hospitals NHS Foundation Trust (the Trust). We were deeply sorry to hear of Mrs F’s concerns about the care and treatment the Trust provided to her father. We would like to thank her for the time and effort she has taken to explain her complaint to us.

2. We have reviewed the evidence provided by Mrs F and the Trust. It appears the Trust followed relevant guidelines when it escalated his breathlessness several times during his admission.

3. We consider the Trust did not fully follow relevant guidelines for Mr J’s pressure area care. We cannot see this led Mr J to experience an ongoing or severe impact. The Trust acknowledged it missed opportunities to check Mr J’s skin and reposition him. It apologised for the errors it made in Mr J’s pressure sore care and provided an action plan to explain the changes it made to prevent the same errors from happening again.

4. We saw no indications of failings with the Trust’s decision to give Mr J a saline nebuliser (a device used to loosen mucus in the lungs) on two occasions in April. For these reasons we will not be taking further action on this complaint. In coming to our decision, we are not diminishing the impact Mr J’s death has had and continues to have on Mrs F and their family. We hope our explanation below clearly explains our decision.