Northern Care Alliance NHS Foundation Trust

5. Miss R complains on behalf of her father, Mr R, about the Trust. She says he was left without adequate oxygen and the Trust delayed treatment to clear his chest secretions in January 2024. She says Mr R was left without adequate nutrition in March 2024.

6. Miss R says as a result, her father’s condition deteriorated. She says Mr R’s oxygen levels dropped, and he was left undernourished. She says this was distressing for her and the rest of the family to witness.

7. Miss R is seeking acknowledgement of failings.

8. This background is only intended to place the key events related to this complaint in context, not to provide a full, chronological account of everything that happened.

9. Towards the beginning of January 2024, Mr R very sadly suffered a major stroke and was admitted to the Trust. Mr R received inpatient care for effects of stroke on the stroke ward. Just over two weeks later, towards the end of January, Mr R contracted pneumonia. The Trust treated Mr R with antibiotics and oxygen.

10. At the beginning of March, the Trust fitted a nasogastric (NG) tube for Mr R. An NG feeding tube is inserted in the nostril and carries nutrition via the oesophagus (food pipe) and into the stomach. The Trust provided Mr R with a low sodium feed.

11. Eight days later, Mr R’s low sodium feed had run out. Two days after this, Mr R had a percutaneous endoscopic gastrostomy (PEG) fitted. A PEG is a feeding tube inserted directly into the stomach through the abdominal wall. Following this procedure, the Trust restarted Mr R’s feed.

Secretions and oxygen

16. Miss R says the Trust delayed performing chest secretions on Mr R and left him without adequate oxygen in late January 2024.

17. 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 looking at what should have happened with what did happen. We have done this, and we have seen no indication something has gone wrong here. We have explained why below.

18. The BTS’s ‘Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings’ provides guidance on oxygen saturation levels. The guidelines recommend target saturation range for acutely ill patients not at risk of respiratory failure is 94–98% and for those with other known risk factors for respiratory failure, a target saturation range of 88–92%.

19. From the records, we can see the Trust was treating Mr R on the stroke ward and he had contracted pneumonia. We can see overnight, his oxygen saturation levels were dropping intermittently. We understand this must have been very distressing for Mr R and extremely concerning for Miss R.

20. The records show in the early hours, Mr R’s oxygen saturation levels had dropped to 80%, and he was receiving 35% oxygen through a face mask.

21. This prompted the Trust to increase the oxygen Mr R was receiving to 60% oxygen delivered at 15l per minute through a non-rebreather oxygen mask. We can see Mr R’s oxygen saturations were then noted to be back within the target range at around 97% at 2.30am.

22. From the records, we can see at 4.00am Mr R was reviewed by an ICU doctor, and it was noted his oxygen saturations were at 88%. The Trust’s plan was for Mr R to continue to receive oxygen on the stroke ward.

23. Miss R believes Mr R should have been admitted to ICU and given increased oxygen. We understand why she felt this way. It must have been very frightening to see his oxygen levels fall and to worry that he was not receiving enough support.

24. The FICM’s ‘Care at End of Life’ provides guidance on admissions to ICU. It says decisions to admit to ICU include consideration of a patient’s capacity to recover, balancing the benefits and burdens of treatment, and balancing the likely outcomes with and without intensive care support.

25. The FICM’s guidelines say escalation of treatment to ICU is a complex decision and the factors to be considered are the ability of a ward to deliver necessary treatment and the need for treatment that cannot be delivered on the ward.

26. Our ICU adviser said the ward team and ICU doctor considered these factors in the context of Mr R’s stroke and significant impairment in addition to the development of pneumonia. Our ICU adviser said Mr R was responding well to the use of the non-rebreather oxygen mask at 15l per minute. From the records, we can see his oxygen saturations improved and were within target levels.

27. Our ICU adviser said the next level of treatment used in ICU to improve oxygen saturations would have been high flow nasal oxygen or CPAP (continuous positive airway pressure). However, as Mr R was responding well to ward level treatment this was not necessary.

28. Our ICU adviser added CPAP has the potential to cause gastric inflation and a risk of regurgitation of stomach contents. There is a higher risk in patients with poor swallow and gag reflex as in Mr R’s case.

29. We hope this can reassure Miss R that it was not necessary to admit Mr R to ICU, and it would not have been suitable to provide other oxygen treatments as this would have increased the risk of complications for Mr R.

30. From the records, we can see at 8.30am Mr R’s oxygen levels dropped to 79%. However, this was when the Trust had to remove his oxygen mask to perform chest suctioning to help clear his secretions. We can see Mr R’s oxygen levels then returned to within target range of 92% once oxygen was readministered at 15l per minute.

31. From the records, we can see it was noted at 10.04am the ward team would discuss with ICU about chest physiotherapy to help clear secretions and it was noted ICU nursing staff could provide deep suctioning after 4.00pm.

32. NICE’s webpage ‘Palliative care – secretions’ provides guidance on managing chest secretions. The guidelines recommend use of antimuscarinic medications such as hyoscine, and glycopyrronium bromide to manage secretions. The guidelines also recommend the use of chest suctioning to help clear secretions.

33. From the records, we can see the Trust had prescribed Mr R hyoscine patches and glycopyrronium bromide to help manage and clear his chest secretions. We can then see it was noted at 12.00pm Mr R was having regular hourly chest suctioning. This is in line with NICE’s recommendations.

34. The records show at 2.30am on the following day, the oxygen needed to maintain Mr R’s target saturations was lower than 9l per minute. This indicated an improvement as per the plan following the ICU review.

35. We recognise how worrying it was for Miss R to witness her father struggling with secretions, and to see his oxygen saturation levels falling. After balancing all the evidence, we consider the Trust managed Mr R’s oxygen levels and chest secretions appropriately, and we cannot see any indications the Trust did not follow clinical guidelines.

Nutrition

36. Miss R says Mr R was left without adequate nutrition for four days in March 2024. From the records, we can see up to the first day Miss R is concerned about, the Trust was feeding Mr R was a low sodium feed (Nepro HD) through an NG feeding tube.

37. In its final response, the Trust said the low sodium feed ran out on the first day Miss R is concerned about. It said the low sodium feed was not kept as standard stock and had to be ordered from its pharmacy. It said its dietitian ordered the low sodium feed three days earlier, but due to a communication error in its pharmacy, it was not sent to the ward during the weekend in March.

38. We have explored whether the Trust should have therefore switched or sourced a different feed during the weekend in March.

39. The BDA’s ‘Manual of Dietic Practice’ recommends using a low sodium feed if sodium levels are elevated. From the records, we can see Mr R’s sodium levels were elevated. We can see the Trust was focused on trying to reduce Mr R’s sodium levels, hence why it provided a low sodium feed.

40. From the records, we can see Mr R was due to have a PEG fitted on the third day Miss R is concerned about. Our dietitian adviser said the priority was to lower Mr R’s sodium levels to allow for the PEG to be fitted.

41. Our dietitian adviser said if the Trust had switched to a standard feed, this may have kept Mr R’s sodium levels elevated, which would have delayed the PEG procedure. The priority was therefore to have the PEG fitted as Mr R appeared to be distressed by the NG tube.

42. From the records, we can see unfortunately the low sodium feed ran out over the weekend, when the Trust dietitian was not present. Our dietitian adviser said in the absence of the dietitian, it was unsafe to provide a different feed without the volume, rate, and fluids being calculated by a dietitian first. For that reason, we do not consider there was a safe alternative feed the Trust could reasonably have provided at that point.

43. From the records, we can see Mr R was then able to have the PEG fitted on the third day Miss R is concerned about. The Trust’s local guidelines recommend a patient should be kept nil by mouth (NBM) for six hours prior to a PEG insertion. We therefore consider Mr R would have had to have been kept NBM for a period anyway on that day.

44. NICE clinical guideline 32 recommend patients to then be kept NBM for at least four hours post-PEG insertion. From the records, we can see the Trust restarted Mr R’s nutrition approximately six hours post-PEG insertion.

45. On balance, the evidence indicates a communication error within the Trust meant Mr R’s feed was not available during the weekend in March. We consider this is an indication of a failing. The Trust had ordered the low sodium feed, but a communication error meant it was not sent to the ward. This left Mr R without the feed that the Trust had prescribed for him.

46. We understand why this caused Miss R significant concern, especially given how unwell Mr R was at the time. We will now consider the impact this may have had on Mr R and Miss R.

47. Our dietitian adviser explained that, although Mr R went without feed for around three days, this would not usually meet the clinical definition of starvation, which starts after five days of little or no nutrition.

48. We understand this may not reflect how distressing it was for Miss R and her family to see Mr R without his usual feed. That said, the advice we received is that Mr R continued to receive fluids, and the short period without feed was unlikely to have had a significant effect on his nutritional health or long-term prognosis.

49. That said, we appreciate this must have been really distressing for Mr R, Miss R, and the rest of the family. We acknowledge this must have added to their concern during a very worrying time.

50. We will now consider what action has been taken by the Trust to try to put things right and learn from this.

51. The Ombudsman’s ‘Principles for Remedy’ say what organisations should do to put things right, when a failing has led to an injustice. It says an appropriate range of remedies can include an apology, explanation, remedial action, or an acknowledgement of responsibility.

52. We were pleased to see the Trust raised a clinical incident shortly after these events. From the incident report, we can see the Trust highlighted the communication breakdown and put actions in place for clearer communication in its pharmacy.

53. We can see from the Trust’s final response, it acknowledged a communication error led to Mr R’s feed not being available and offered its apologies. This is in line with our ‘Principles for Remedy’.

54. We have considered whether more should be done to put this right. The Trust has acknowledged the communication error, apologised, raised a clinical incident and identified action to improve communication within pharmacy.

55. We understand this will not remove the distress Miss R and her family experienced. However, we consider these actions address the failing we have identified and are in line with our ‘Principles for Remedy’ and we would not ask it to take any further action.

Conclusion

56. We appreciate this has been an extremely upsetting and distressing time for Miss R and her family. Our decision is not intended to lessen the impact this complaint has had on Miss R and her family.

57. In summary, we have not seen indications that the Trust failed to manage Mr R’s oxygen levels or chest secretions appropriately. We have identified a failing in the way the Trust managed the availability of Mr R’s prescribed feed. However, we consider the Trust has acknowledged this, apologised, taken learning and acted in line with our ‘Principles for Remedy’.

58. For these reasons, we will not take any further action on Miss R’s complaint. We hope we have clearly explained the reasons for our decision and where possible reassured Miss R with our explanation of the care provided by the Trust. We would like to thank Miss R for giving us the opportunity to consider her complaint.

1. We have carefully considered Miss R’s complaint about Northern Care Alliance NHS Foundation Trust (the Trust). We were very sorry to hear about Mr R’s stroke, and we recognise how frightening and distressing this period must have been for him, Miss R and the wider family. We understand Miss R’s concerns come from what she saw and experienced during an extremely difficult time.

2. Based on the evidence, we cannot see any indication the Trust did not manage Mr R’s oxygen levels or chest secretions appropriately in January 2024.

3. Based on the evidence, we can see indications of a failing around the management of Mr R’s nutrition in March 2024. After careful consideration, we consider the Trust has taken enough action to put things right.

4. For the reasons explained below, we have decided not to take further action on the complaint. We appreciate this may be disappointing for Miss R. We hope our explanation helps her understand how we reached our decision, and why we consider the Trust has already taken enough action in response to the failing we identified.