St George's University Hospitals NHS Foundation Trust

4. Mrs F complains about the treatment the Trust provided to her daughter, Ms E, from early February 2023 to mid-March 2023. She complains the Trust placed her in a side room and failed to adequately monitor Ms E during her admission. Furthermore, she complains the Trust failed to treat Ms E’s cardiac arrest as soon as it should have in mid-March 2023.

5. Mrs F says the Trust’s delay caused Ms E significant injury which led to her death. She considers the Trust could have prevented her death. Mrs F adds that Ms E’s loss emotionally impacted her two children and her wider family.

6. Mrs F is seeking service improvements to prevent these matters occurring again in the future.

7. In June 2022, Ms E had a stroke which caused brain damage. Following her stroke, Ms E needed a wheelchair to mobilise.

8. In mid-July 2022, the Trust found Ms E had bacteria in her bowel which could cause infection and spread. Because of this, the Trust decided whenever it admitted Ms E to its care, it should always treat her from a side room for infection control.

9. In September 2022, Ms E was diagnosed by her GP with Type 2 diabetes. This is when the body does not produce enough insulin, or the insulin does not work properly, and can lead to blood sugar levels becoming too high. This was controlled with diet rather than prescribed medication.

10. In December 2022, the Trust found Ms E had a different bacteria in her bowel that also required her to be isolated in a side room.

11. At the time of the events complained about Ms E was a resident at a hospital which provides rehabilitation and long-term care for patients with neurological disabilities. She had a number of health issues including:

• sickle cell disease, which affects the red blood cells and causes painful episodes • stage three kidney failure for which she relied on a nephrostomy tube (catheter) attached to a drainage bag • diabetes • she was fed through a tube called a Percutaneous Endoscopic Gastrostomy (PEG), which is a tube that is inserted directly through the abdominal wall into the stomach • she had a tracheostomy tube, which is a tube inserted into the windpipe through an opening in the neck o establish a direct airway when breathing is blocked, restricted, or requires long-term mechanical assistance.

12. At the beginning of February 2023, the Trust found her catheter had become blocked and she had a urine infection which had spread to her bloodstream called urosepsis. The Trust admitted Ms E to its intensive care unit (ICU) under the care of its urology team. The following day, the Trust transferred her to a side room in a specialist surgical ward.

13. Whilst in its care the Trust noted Ms E had recurrent episodes of a raised body temperature. Despite its investigations the Trust could not identify the cause of her fever.

14. In early March 2023, the Trust found Ms E had a blood clot in her lung. It started her on a course of blood thinning medication to treat the clot.

15. One morning in mid-March 2023, the Trust found Ms E had had a cardiac arrest. After 11 minutes of cardiopulmonary resuscitation (CPR) the Trust was able to get Ms E’s heart to restart. CPR is an emergency procedure used when the heart stops, or someone stops breathing, to maintain circulation. The Trust transferred Ms E to ICU. Despite treatment, Ms E’s condition deteriorated and led to multiple organ failure. Ms E sadly died two days later.

20. 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 seen any indications that something has gone wrong.

Side room

21. Mrs F told us she is specifically concerned about the Trust’s decision to treat Ms E from a side room. She feels that due to Ms E having impaired communication due to her tracheostomy tube, this decision put her at risk.

22. The Trust said Ms E was nursed in a surgical ward which specialises in surgical patients who need airway management. The Trust confirmed it placed Ms E in a side room when it transferred her to the surgical ward. It explained this was for infection control reasons due to a previous finding of Ms E having a multi drug resistant bacteria in her bowel.

23. HSA framework and WHO guidelines both stipulate that patients who have been screened for or have confirmed Carbapenemase-producing Enterobacterale (CPE) should be managed in a single room. Enterobacterales are a group of bacteria which live harmlessly in the gut. Some of these bacteria have become resistant to antibiotics. Carbapenems are an important, powerful group of antibiotics that can only be given in hospital through an intravenous drip.

24. Most of the time CPEs are harmless, however, if they get from the gut into other parts of the body e.g., the urine, a wound or the blood, they can cause an infection and will need treatment. Infections caused by CPE can be very difficult to treat as the bacteria can produce chemicals which destroy most antibiotics, including carbapenems. Therefore, it is important to prevent the spread of CPE.

25. We can see from Ms E’s clinical records that in mid-July 2022 the Trust noted ‘side room isolation essential for this patient whenever in hospital’ after a positive screening result for Klebsiella pneumoniae. Klebsiella pneumoniae is the specific CPE Ms E had at this time. Furthermore, we can see that in December 2022, the Trust identified Ms E had a different CPE known as Citrobacter Koseri following a swab from a leg wound.

26. In adults, Citrobacter Koseri often leads to urinary tract infections, respiratory infections, and rarely, skin or musculoskeletal infections, typically in those with multiple comorbidities. If the strain in question is highly resistant, hospitals may mandate strict isolation to prevent further spread.

27. We can see that upon her admission in early February 2023, the Trust admitted Ms E to its ICU as it had no suitable tracheostomy beds available. Due to the previous CPE infections, Ms E was nursed in a side room within the ICU. The Trust then transferred her to side room on a specialist surgical ward.

28. Our adviser explained that Klebsiella pneumoniae is a very contagious infection that can also exist without causing symptoms. They said Ms E was at risk of carrying this infection because of her other health issues, like having a tracheostomy tube. They explained that, according to guidelines from the World Health Organisation, patients with infections like this must be cared for in separate rooms to stop the infection from spreading to other patients or staff.

29. Furthermore, our adviser explained that as the Trust did not have any suitable tracheostomy beds available, a bed in ICU was appropriate. They explained that staff in ICU are trained to monitor patients who require tracheostomy care.

30. Our adviser has said that besides ICU, there are a very limited number of wards available with tracheostomy care trained nursing staff. They therefore said that the Trust’s decision to move Ms E to a specialist surgical ward was appropriate as this ward had appropriately trained staff.

31. We understand why Mrs F has concerns regarding the Trust’s decision to treat Ms E from a side room. Our consideration of this decision has found it was in line with the HSA framework and WHO guidelines. This is because she was identified as having CPE infections.

32. We hope Mrs F will be reassured we have carefully considered her concern here. Because we have seen no indication something has gone wrong, we will not be considering this part Mrs F’s complaint further.

Observations

33. Mrs F complains the Trust failed to adequately monitor Ms E during her admission.

34. The Trust said it provided Ms E with appropriate daily airway monitoring by a multidisciplinary team. It said it had documented it monitored Ms E’s National Early Warning Score (NEWS) observations at least every four hours during her admission on the surgical ward and she was stable. It also documented its urology team were reviewing Ms E daily with input from other specialisms such as microbiology, infectious diseases and haematology.

35. The NMC Code says nurses should make sure that people’s physical needs are assessed and responded to. To do this, the nursing staff used the Royal College of Physicians (RCP) NEWS framework. This is a scoring system for assessing whether a patient is at risk if deterioration. It uses physiological measurements, such as breathing rate, heart rate, temperature and blood pressure to generate a score. This then forms the basis for the level of observations and clinical response.

36. NEWS framework states that a NEWS of zero requires observations to be completed at least every 12 hours whereas a NEWS of between one and four requires observations at least every four to six hours. A NEWS of three in a single vital sign or a NEWS totalling five or six, requires observations every hour. Additionally, a NEWS of seven requires continuous observations.

37. Furthermore, depending on the overall NEWS, the level of escalation and the action required changes:

• an overall score 1 to 4 requires prompt assessment by ward nurse to decide on change to frequency of monitoring or escalation of clinical care.

• an overall score of 3 in any single parameter requires urgent review by ward-based doctor to determine cause and to decide on change to frequency of monitoring or escalation of clinical care.

• an overall score 5 to 6 requires urgent review by ward-based doctor or acute team nurse to decide on escalation to critical care team.

• an overall score of 7 or over requires emergency assessment by critical care team, usually leading to patient transfer to higher-dependency care area.

38. From reviewing Ms E’s medical records, we can see that during her admission, the Trust completed multiple observations recording her vital signs and NEWS. We can also see from the records that the Trust’s monitoring of Ms E’s condition was in line with her recorded NEWS. This includes responding appropriately when her NEWS increased on several occasions throughout her admission, therefore resulting in more frequent observations.

39. For example, the records show that over a two-day period in early March 2023, the Trust recorded Ms E as having a NEWS of 4 in the early hours one morning. Over the next 36 hours and 48 hours, we can see the Trust completed 8 sets of observations, noting her NEWS as 3 and 4, with longest period between observations being 4 hours and 48 minutes and the shortest being 2 hours and 51 minutes.

40. With the set of observations taken in the morning on the second day, we can see that a nurse from the specialist surgical ward contacted the critical care outreach team (CCOT) as she had a NEWS of 8. The CCOT completed a review of Ms E’s condition and made the decision to keep her on the specialist surgical ward. They also requested a review by a urology specialist registrar as Ms E was still under the care of the urology team.

41. Additionally, we note the Trust frequently checked Ms E’s capillary blood glucose (CBG) levels during her admission to monitor her type 2 diabetes. Her capillary blood glucose levels were under 10 most of the time during her hospital stay, so within the normal range.

42. Our adviser identified that there were no issues with Ms E’s tracheostomy during her admission and therefore said it was appropriate for the Trust to provide ward level support with ward level frequency of observations. Additionally, Ms E’s medical records show the infection control team and microbiology team were heavily involved in her care.

43. We have carefully considered the evidence available to us. We think the Trust completed the necessary level of observations in line with her recorded NEWS. We consider there is no indication it has failed to act in line with relevant framework.

44. We acknowledge Mrs F’s concerns about the Trust not adequately monitoring Ms E. As we have seen no indication something has gone wrong here, we will not be considering this part of Mrs F’s complaint further.

Cardiac Arrest

45. Mrs F complains the Trust failed to treat Ms E’s cardiac arrest as soon as it should have in mid-March 2023.

46. In its complaint responses, the Trust stated it promptly assessed Ms E when she was discovered to be unresponsive. It said it put out a cardiac arrest call whilst the nursing and medical team started emergency resuscitation measures.

47. RCUK Guidelines state that if a person is found to be unresponsive and not breathing normally then a call to either the resuscitation team or an ambulance should be made. They also state that cardiopulmonary resuscitation (CPR) should be started with the ratio of 30:2, which means 30 chest compressions followed by two rescue breaths.

48. A defibrillator/monitor should be attached and the person’s heart rhythm assessed. If the type of cardiac arrest is assessed to be non-shockable, such as PEA, then CPR should be immediately resumed for two minutes. The cycle of assessing the person’s heart rhythm and resuming CPR for two minutes should be continued until the return of spontaneous circulation (ROSC) occurs, which is when the person’s heart resumes a sustained beating rhythm on its own.

49. From reviewing Ms E’s medical records, we can see the Trust completed observations on Ms E at 5.38am on the day of her cardiac arrest. We note that all her sats were in line with previously recorded observations and her NEWS was 2. With a NEWS of 2, the Trust were not due to complete any further observations until 9.38am at the earliest.

50. The records show the Trust then discovered Ms E was unresponsive at approximately 8.45am and put out the arrest call at 8.45am, with the crash team arriving at 8.50am. The Trust completed a rhythm check at 8.48am and noted her cardiac arrest was a Pulseless Electrical Activity (PEA) type of arrest.

51. A PEA arrest is when a person’s heart still has electrical activity, but it is not mechanically pumping strongly. It is classified as a non-shockable rhythm, meaning that a defibrillator will not help.

52. Due to the electrical activity continuing during a PEA arrest, heart monitors may show a seemingly normal rhythm, or a slow rhythmic baseline. This is because heart monitors read the electrical signal within a patient’s heart and not the mechanical pumping of blood. Therefore, when a patient experiences a PEA arrest in hospital, this may not trigger an alarm to alert staff to their declining condition.

53. Ms E’s records detail that ward staff started CPR immediately. After four cycles of CPR and a dose of adrenaline at 8.52am, her heart resumed beating on its own after being in arrest for 11 minutes. We can see the crash team attended to Ms E for 50 minutes before the Trust transferred her to ICU at 10.25am.

54. Our adviser explained that Ms E’s observations at 5.38am on the day of her cardiac arrest document her general status as satisfactory with a NEWS of 2. They noted the details of the cardiac arrest describe it as PEA. Furthermore, they noted her observations at 8.51am show a drop in her oxygen saturation levels, a systolic blood pressure of 58 and an increase in her heart rate up to 131. Our adviser explained these observations suggest that Ms E was breathing and her heart was pumping, rather than her being in complete cardiac arrest at the time. Our adviser explained the decline in Ms E’s observations between 5.38am and 8.51 could have been gradual or spontaneous nearer to 8.51am.

55. Our adviser said the Trust took the appropriate steps calling for the cardiac team and transferring Ms E to ICU where it could provide her with specific drugs to improve her blood pressure. They said the support given on ICU was not delayed as her observations at 5.38am did not require any ICU support.

56. We understand that Mrs F has concerns regarding the Trust responding to Ms E’s cardiac arrest. Our adviser said medical records suggest the decline in Ms E’s condition was due to her not responding to the treatment the Trust had provided and her systems were failing. We acknowledge this was and continues to be a very distressing series of events for Mrs F and her family.

57. With all the above in mind, we consider the Trust acted in line with RCUK Guidelines when responding to Ms E’s cardiac arrest in mid-March 2023. As we have not seen any indication of failings regarding the care and treatment the Trust provided to Ms E during her admission, we are unable to consider Mrs F’s complaint further.

58. We would like to thank Mrs F for providing us with the opportunity to consider her concerns about the care and treatment the Trust provided to Ms E from early February to mid-March 2023. We hope that our investigation reassures Mrs F and her family that it provided Ms E with the appropriate level of care.

1. We have carefully considered Mrs F’s complaint about the treatment St George's University Hospitals NHS Foundation Trust (the Trust) provided to her daughter, Ms E.

2. We are sorry to learn of the death of Ms E. We do not doubt that the circumstances of the complaint have been and continue to be very difficult and upsetting for Mrs F and her family. We would like to extend our deepest condolences for their loss.

3. We have decided not to consider Mrs F’s complaint further. This is because we have been unable to see any indication that something went wrong with the care and treatment the Trust provided to Ms E. We go on to explain our decision below.