The Royal Wolverhampton NHS Trust

6. Mrs O complains there were significant failings in the quality of care her mother received from the Trust between 21 June and her death on 23 June 2022. Specifically, she complains the nurses: • failed to administer oxygen and did not escalate for a medical review with a doctor during the night of 21 June • failed to maintain her hydration and nutrition at optimum levels.

She complains the clinical team: • failed to transfer her to the Intensive Care Unit (ICU – a special hospital ward for severely ill patients) on 21 June and 22 June • acted short of recommendations with the use of anticipatory medication by giving midazolam after morphine on 23 June.

7. Mrs O believes that if those failings had not occurred, Mrs K would not have died.

8. The outcomes she is seeking is an apology and a financial remedy.

9. The Trust admitted Mrs K on 18 June due to a leg injury. She had multiple recent admissions to hospital. The Trust started the sepsis pathway as she had a National Early Warning Score (NEWS – a points-based medical tool used to track a patient’s vital signs and identify clinical deterioration) of seven (scores seven or above are high risk).

10. Mrs K had a positive test for COVID-19 shortly after her admission.

11. The notes from 21 June reflect that Mrs W became increasingly agitated and she was removing her oxygen mask. The doctor prescribed a small dose of lorazepam (a medication used to treat anxiety and relax people) to try to calm her down. Mrs K was agitated, did not tolerate her mask and her oxygen saturations (the measure of oxygen in the blood) remained poor during the night.

12. The Trust prescribed morphine (a pain relief medication) on 22 June and then midazolam (a medication used for sedation and to manage agitation) the next day.

13. Mrs K continued to decline and sadly died on 23 June.​

Nursing care and escalation on 21 June

19. Mrs O says during the night of 21 June, the Trust failed to keep an oxygen mask on her mother, despite her oxygen saturation being low. She thinks the Trust should have used lorazepam to help with this and the nurse should have escalated for a medical review due to an increased NEWS. We recognise that the situation was extremely distressing for both Mrs O and her mother.

20. The notes from 21 June show Mrs K was very unwell and significantly confused. She was agitated throughout the day and had refused interventions which made it difficult for Trust staff to provide care.

21. In the night of 21 June Mrs K’s NEWS score had risen to four due to her low oxygen saturation. The low oxygen saturation levels accounted for three of those points. RCP guidance tells us generally a NEWS of four is low risk, but if any individual parameter is three or above it should be escalated to the medical team. The nurse escalated this increase to a doctor in line with this guidance.

22. Following escalation from the nurse, a doctor reviewed Mrs K who noted she, ‘removed [oxygen] mask and is physically aggressive when trying to place it back’. The oxygen mask was in place to help with her respiratory issues. It is clear Mrs K, in her confused state, would not keep the oxygen mask on.

23. To calm Mrs K and help her accept wearing the mask, the doctor prescribed 0.5mg of lorazepam. However, notes from the following morning indicate that despite the nurses' efforts and the medication, Mrs K would not wear the mask during the night.

24. Our nurse adviser explained there was very little the nurse could have done once Mrs K continued to remove the mask. The doctor had prescribed a one-off dose of lorazepam and so the nurse was not able to administer any further doses of this medication. In balancing Mrs K’s distress and agitation against the goal of improving her oxygen levels, the nurse decided it was in Mrs K’s best interest to leave the mask off.  Given the mask was to help with her breathing, we understand why it would ultimately have been counter-productive to keep trying to put it on when Mrs K was fighting against it.

25. We think the nurse made this decision having weighed up the best option based on Mrs K’s circumstances. We think this is in line with the NMC code which says nurses must always act in the best interest of patients.

26. Around one hour later, the nurse repeated Mrs K’s NEWS score, which remained at four. Her oxygen saturation levels continued to account for three of those points. The doctor had left a note for nurses to contact them if further concerns arose. Despite this, the nurse did not escalate the second set of observations for review, which we think they should have done given the doctor’s instructions and RCP guidance.

27. With the help of our physician adviser, we have considered what might have happened had the nurse escalated to a doctor and whether the indicated failure to do so had any impact on Mrs K. We know Mrs O believes her mother’s low oxygen levels might have contributed to her deterioration and death.

28. We consider there was very little a doctor could have done had they seen Mrs K for a second time. Mrs K needed the oxygen mask to improve her low oxygen saturation but would not allow it to remain in place. By forcing the mask on her, it is likely to have caused additional distress and worsened, rather than solved this problem.

29. An additional dose of lorazepam was unlikely to have been appropriate for Mrs K. Lorazepam is used in very small doses in frail and elderly patients. A side effect of the medication is respiratory depression (where breathing becomes too slow or shallow to adequately exchange oxygen and carbon dioxide in the lungs). Therefore, given her respiratory symptoms, the Trust would have been concerned about prescribing too high a dose of lorazepam to Mrs K.

30. Our physician adviser gave their opinion that the low oxygen saturation did not contribute to Mrs K’s overall deterioration or death. Her poor oxygen saturation and respiratory problems were symptoms of her very poorly condition, rather than the cause of it.

31. In summary, while we think the nurse should have escalated to a doctor during the second instance of poor oxygen saturation, we cannot see this would have changed the outcome. We will therefore not take further action on this point.

32. We do not wish to diminish that it would have been upsetting for Mrs O to think there were issues with her mother’s care.

Nutrition and hydration

33. NICE guidance on the care of adults in the last days of life says to support the person with drinking, if they are able, but to consider if there are risks of swallowing problems. It therefore acknowledges the patient might be too unwell, and so nurses must assess whether it is appropriate in their circumstances.

34. Mrs K was very unwell on admission and continued to deteriorate. On 21 June, we can see she was significantly unwell and was very sadly in the final days of her life. The fluid and nutrition charts show that other than a cup of tea, a small sip of water and few mouthfuls of porridge Mrs K declined or was unable to eat or drink anything between 21 and 23 June. The written notes support she was too unwell with an entry on 22 June saying, ‘Dr made aware as patient too drowsy + agitated. Not tolerating food + fluid’.

35. Our nurse adviser explained patients in Mrs K’s condition should not be given any food or fluids as there is a significant risk of aspiration (where food, liquid, vomit, or saliva enters the airway and lungs, causing suffocation) and choking. While Mrs O was able to feed her mother a few mouthfuls of porridge on 22 June, we can see the doctor explained the risks of choking to her.

36. NICE guidance supports that patients should only be given drink when they are able to do so safely. We think the nurses acted in line with this in the management of her fluid.

37. We consider Mrs K was too unwell to eat safely. We think the nurse considered her condition and acted in line with NMC guidance which says to deliver care in the best interests of the patient.

38. We do not wish to diminish how concerning it must have been for Mrs O to see her mother being unable to eat and drink during this time.

Failure to transfer her to ICU

39. Mrs O believes the Trust should have pre-emptively transferred her mother to ICU on 21 or 22 June when it became clear she was seriously unwell. She believes it failed to give her the best opportunity to get better.

40. The medical notes indicate that upon admission to hospital, the Trust determined that Mrs K was not suitable for ICU or non-invasive ventilation (NIV). NIV is a form of breathing support involving a machine and face mask to push pressurised air into the lungs. Based on the advice we have received, it is clear that due to Mrs K’s frailty, overall condition, and her very poor prognosis from the outset, ICU was not a suitable option for her care.

41. Our physician adviser explained that a transfer to ICU would not have prolonged Mrs K’s life as she was very unlikely to recover; it would only have only extended her suffering in the final stages of her life. We do not think ICU would have been beneficial or a viable option for Mrs K.

42. The Trust decided not to pursue further treatment in ICU because it would not have served Mrs K’s best interests. We consider this aligns with GMC guidance, which emphasises that doctors must provide treatment only where it serves the patient’s needs.

43. We do acknowledge how upsetting it must have been for Mrs O and know she wanted her mother to have the best care possible.

Anticipatory medication

44. Mrs O is concerned with the use of morphine and midazolam in the last days of her mother’s life. She says these medications can cause respiratory depression and might have contributed to her deterioration and death.

45. As we have said above, by 21 June Mrs K was deteriorating and was approaching the last days of her life.

46. The records reflect Mrs K experienced pain and discomfort during this time. On 21 June she was in significant pain with the blister on her leg which she refused to allow hospital staff to touch. Morphine is used to manage pain, and the Trust prescribed it in an attempt to alleviate Mrs K’s suffering.

47. As detailed above, Mrs K was also significantly agitated throughout her admission. Terminal agitation is a severe state of distress that frequently occurs in the last days of life. Midazolam is used to prevent agitation and provide relief during end-of-life care.

48. Having discussed the management of Mrs K’s medication with our physician adviser, we know doctors must use an individualised approach based on the patient’s symptoms when prescribing anticipatory medication. We have seen evidence the Trust considered Mrs K’s needs and gave her treatment to address them in line with GMC guidance. GMC guidance says clinicians must assess a patient and provide suitable treatment when necessary.

49. We know Mrs O is concerned that the medications in combination might have caused respiratory depression in her mother. It must have been very difficult for her to see her mother in respiratory distress during these last few days.

50. Our physician adviser explained in the doses prescribed to Mrs K the medications would not have caused her respiratory issues or contributed to her overall decline. We consider the medication helped manage the unfortunate symptoms she experienced at end of her life and have seen no evidence they contributed to her deterioration.

51. We acknowledge how awful it must have been for Mrs O to see her mother in such a poorly condition during this time. We hope our consideration gives her some answers regarding the care, and the reasoning behind the decisions the Trust made.

1. We have carefully considered Mrs O’s complaint about Royal Wolverhampton NHS Trust (the Trust). She is concerned about the care it provided to her mother, Mrs K, in the days before she died. We were very sorry to learn about Mrs K’s death and would like to pass on our sincere condolences to Mrs O.

2. Regarding the care on 21 June, we think the nurse should have requested a doctor see her mother during the night. Having carefully considered this, we do not think this caused any impact on Mrs K’s deterioration or death.

3. Regarding the other points Mrs O raised, we have not seen indications anything went wrong with Mrs K’s care.

4. We have therefore decided we will not take further action on the complaint.

5. We do not wish to diminish the impact on Mrs O and how distressing these events were for her. We hope our comments and consideration bring her some answers about the care her mother received.