Medway NHS Foundation Trust

3. Miss O complains about aspects of the care and treatment the Trust provided to Mrs A between 19 November 2023 and 19 January 2024. She specifically complains the Trust failed to:

• promptly test Mrs A for COVID-19 and respond to her call bell when she was isolated due to COVID-19 and her oxygen saturation level was very low • ensure Mrs A’s nutritional needs were met, including ensuring she had an adequate intake of food • provide appropriate end-of-life care • promptly insert a cannula, causing a five-day delay providing intravenous antibiotics • communicate effectively with Mrs A and her family, including a failure to tell her family she had been placed on end-of-life care.

4. Miss O says these failings caused her mother to die sooner than she should have and she suffered unnecessarily prior to her death. She also says these failings caused her family a lot of distress.

5. She would like the Trust to take steps to improve its service and compensate her family for the distress caused.

6. Mrs A was a 61-year-old woman with a history of chronic obstructive pulmonary disease (COPD). COPD is a long-term and progressive lung disease which makes it difficult to breathe. She was taken to the emergency department (ED) of a hospital, run by the Trust, via ambulance on 19 November 2023 due to a cough and shortness of breath.

7. When reviewed by a doctor in the ED they suspected a chest infection was exacerbating her COPD and she was prescribed antibiotics. Mrs A was observed to be very frail and was not medically fit to be discharged home. She was admitted to hospital for further monitoring and treatment on 21 November.

8. Mrs A was assessed by the ward consultant who noted she had general cachexia, which is a metabolic problem where a person progressively loses muscle mass, usually due to a serious illness. This is commonly associated with conditions such as cancer and COPD and leads to a person becoming progressively frail. This type of frailty does not typically respond to conventional nutritional support such as increasing caloric and nutritional intake.

9. Mrs A remained in hospital and, on 5 December, further tests showed part of her left lung had collapsed and she had a pleural effusion. A pleural effusion is a collection of fluid between the lungs and the chest wall. She also developed a mucus plug in her lungs, which further obstructed her breathing, and was confirmed to have cancer in her right lung on 22 December.

10. On 15 January 2024, Mrs A’s condition deteriorated suddenly and she tested positive for COVID-19 the following day. She continued to deteriorate despite active treatment. On 19 January the Trust decided to withdraw active treatment and focus on making Mrs A comfortable. The Trust documented this was discussed with her family and they understood her deterioration could not be reversed. Mrs A, sadly, died on 20 January.

COVID-19 14. COVID-19 is now endemic within the UK and is as common as other upper respiratory tract infections such as the common cold. Many hospitals no longer routinely test patients for COVID-19 and only test patients when there is a clinical reason to do so. This is accepted practice within the NHS. It is also accepted that it is very difficult to prevent COVID-19 infections in hospitals because it is so common amongst the general population. Upper respiratory tract infections are commonly contracted in hospitals, including COVID-19, and this is not an indication the service has failed to safeguard patients.

15. During Mrs A’s admission, the Trust regularly completed a screening tool decide whether she required testing for COVID-19. The screening tool covered the main symptoms of COVID-19 and Mrs A did not meet the criteria for testing until her condition deteriorated on 15 January 2024. This appears to have been an appropriate and proportionate approach to deciding whether or not to test her for COVID-19 and there is no indication of a delay in doing this.

16. We have seen no indication the Trust should have tested Mrs A for COVID-19 sooner. We understand that COVID-19 infection still causes significant concern for the general public and, whilst it is not proportionate for hospitals to routinely test patients for COVID-19, we recognise this can cause worry for patients and their families.

17. We note Miss O reports another patient had tested positive for COVID-19 in the days prior to Mrs A developing the illness. We cannot verify this account as we cannot access the medical records of other patients. That said, this would not have meant the Trust needed to depart from its COVID-19 testing protocol. In addition, the steps taken to isolate patients with COVID-19 are dependent on the resources available. If there are no side rooms available, for example, the Trust has no option other than the care for a patient on a ward.

18. With regards to responding to the call bell when Mrs A was being nursed in a side room due to her COVID-19 infection, we understand this would have been concerning for her family. Delays in responding to a call bell can be unavoidable at times on a busy ward and we can see the Trust has already apologised for this. There is nothing further we could reasonably achieve for Mrs A’s family because the Trust has already done what we would likely recommend.

Nutrition 19. NICE guideline CG32 (nutrition support for adults) recommends all hospital inpatients be screened for their risk of malnutrition on admission to hospital. The guidelines say nutrition support should be considered for patients who have:

• a body mass index (BMI) of less than 18.5kg/m² • unintentional weight loss of more than 10% within the last 3-6 months • eaten little or nothing for more than 5 days, or are likely to do so for the next 5 days or longer • an impairment in their ability to absorb nutrition.

20. These guidelines state this screening should be repeated weekly for hospital inpatients.

21. Mrs A was taken to hospital in the afternoon of 19 November 2023. The Trust decided to admit Mrs A to a ward for further care on 21 November, and the nursing staff completed the Malnutrition Universal Screening Tool (MUST). This is a clinically validated tool used to assess the parameters recommended by NICE guideline CG32.

22. When the staff undertook the initial screening, Mrs A was too unwell to be moved and weighed. Her daughter provided an estimated weight and the outcome of this screening scored Mrs A as being at low risk of malnutrition. This was not consistent with the clinical information recorded by the ED physician at that time, who noted Mrs A appeared ‘very fragile and cachectic’. The physician also documented Mrs A appeared dehydrated and malnourished, which was also not incorporated into the malnutrition screen.

23. It is difficult to reconcile this screening outcome with the documented clinical account of Mrs A’s frailty. When weighed in hospital she weighed just 34 kilograms and had a BMI of 13. She had also been documented as being frail and appearing malnourished from admission. This appears to fall short of the standard set out in NICE guideline CG32 and not taking account of this information may have caused her risk of malnutrition to be miscalculated. Our nurse adviser explained that had the correct clinical information been incorporated into this screen, Mrs A would likely have scored as a high risk of malnutrition.

24. The MUST screen was repeated on 28 November, in line with NICE guideline CG32. At this point the Trust correctly identified Mrs A was at a higher risk of malnutrition and implemented a nutritional care plan. The Trust also referred Mrs A for support from dieticians. This referral was initially rejected by the dietetics team due to a lack of information, and the nursing team resubmitted the referral promptly.

25. Mrs A was reviewed by a dietician on 4 December who documented that she had a poor oral intake of food due to her COPD. They also noted Mrs A was not finishing her meals whilst in hospital. The dietician prescribed additional oral supplements to increase Mrs A’s nutritional intake. They noted that, sadly, due to how unwell Mrs A was it was unlikely her nutritional needs could be met even with enhanced nutritional support.

26. Mrs A was reviewed regularly by the dietetics team during her admission and the staff attempted different strategies for supplementing Mrs A’s nutritional intake via different supplements.

27. It is common for patients with COPD to struggle to maintain an adequate nutritional intake. This was identified as a problem for Mrs A following the first assessment by the dietician. Additional reviews by the dietetics team noted a poor oral intake of food but that Mrs A was managing to take her prescribed oral supplements. There was little more the Trust could do to support Mrs A’s nutritional intake other than to encourage her to eat and ensure she was given her prescribed nutritional supplements. The evidence indicates this happened.

28. Mrs A’s condition deteriorated suddenly from 15 January. She became more reliant on her supplemental oxygen and her oral intake of nutritional supplements reduced. Staff trialled inserting a nasogastric tube on 17 January to attempt to support her intake of nutrition when she was refusing the supplements. Unfortunately, Mrs A was unable to tolerate this.

29. The evidence indicates there may have been an oversight when completing the initial malnutrition screen, which could have delayed a referral to the dietetics service by one week. That said, based on the dietician’s assessment on 4 December, it was unlikely Mrs A’s nutritional needs could be fully met whilst she was in hospital and during the period of delay she was given the nutritional supplements that had been prescribed in the community.

30. We understand Miss O is also dissatisfied that on one occasion the staff may have forgotten to give Mrs A her lunch. The Trust’s account is that Mrs A had declined her lunch. There is insufficient evidence to take a view on which account is more likely than not accurate.

31. We have seen no indication the Trust failed to meet Mrs A’s nutritional needs. Although it appears to have initially miscalculated her risk of malnutrition, this was addressed the following week and a nutritional care plan was implemented from 28 November 2023. Due to how unwell Mrs A was, there was little more the Trust could do to support her nutritional intake aside from administering the prescribed supplements and encouraging her oral intake of food. We recognise, however, that witnessing Mrs A’s deteriorating condition and decreased oral intake of food would have been distressing for her family.

End of life care and communication

32. The terms end-of-life (EOL) and palliative care do not have specific definitions and the interpretation of these terms depends on the context within which they are used. Clinicians can use these terms interchangeably and, in general, these terms refer to a patient who may be approaching the end of their life. We have used both terms in our consideration because both terms were used by the Trust when describing Mrs A’s care.

33. The GMC’s guidance on care and treatment at the end of life defines patients as approaching the end of their life when they are likely to die within the next 12 months. This includes a broad range of scenarios, including patients:

• whose death is imminent – expected within the next few hours or days • with an advanced, progressive and incurable condition (e.g. terminal cancer) • experiencing general frailty and health conditions that mean they will likely die within 12 months • who are at risk of dying from a sudden acute illness • who have a life-threatening acute condition caused by a sudden catastrophic event (e.g. a cardiac arrest).

34. This guidance also states that it is important to respect the support needs of those close to the patient. Doctors can share information about the patient’s diagnosis and prognosis with consent from the patient. If a patient cannot consent, it is reasonable to assume they would want those closest to them to be kept informed about their condition and prognosis, unless they have previously indicated otherwise.

35. The provision of EOL care requires a consideration of the benefits and risks of any care or treatment provided. This consideration is often clinically complex and it is not always clear when a physician should consider withdrawing active treatment and focus on comfort instead. The GMC recognises this is the most challenging decision for a doctor to make.

36. Furthermore, the risks and benefits of active treatment vs comfort care is not always clear cut, and there can be uncertainty about the best course of action. Patients can also deteriorate unexpectedly and die sooner than could have been anticipated. Even in specialist services, such as hospices, up to 10% of patients can die much sooner than expected.

37. From the point Mrs A was admitted to hospital she was significantly unwell with severe frailty and an infective exacerbation of her COPD. Further tests revealed a collapsed lung, a pleural effusion, mucus plug, and cancer. Based on the GMC’s criteria, it appears Mrs A was likely approaching the end of her life at the point of admission due to her progressive and incurable health conditions. This did not mean she was at imminent risk of death, but that she was likely to die within the next 12 months.

38. Despite likely being in the final 12 months of her life, for much of Mrs A’s admission she remained clinically stable. This clinical picture changed when she suddenly deteriorated on 15 January 2024 and continued to deteriorate despite active treatment. Prior to this deterioration the Trust was planning to discharge Mrs A to receive palliative care in the community.

39. The records indicate the Trust was aware that Mrs A may be in the final 12 months of her life from early in her admission. On 6 December, a respiratory consultant noted there should be a ‘low threshold’ for implementing palliative care planning. A doctor documented they discussed this with Mrs A’s daughter that day and explained that despite all active treatment, the Trust may need to consider palliative care. They documented Mrs A’s daughter understood this and agreed to this plan.

40. The Trust continued to provide active treatment to Mrs A, and she appeared clinically stable despite the progression of her respiratory disease. On 22 December the Trust documented that a multidisciplinary meeting had identified cancer on her right lung and that there were very limited treatment options available due to Mrs A’s frailty. A doctor documented they contacted Mrs A’s daughter via telephone and advised of the new diagnosis and limited options for treatment. The plan remained for Mrs A to be discharged home for palliative care in the community.

41. On 8 January the Trust documented a discussion with Mrs A’s daughter about the need for palliative care and the potential need for a transfer to a hospice environment. The Trust continued to monitor and plan for Mrs A’s discharge from hospital to receive this palliative care.

42. Following Mrs A’s acute deterioration on 15 December, the Trust recognised she may be in the final days of her life if she did not respond to treatment. Mrs A continued to deteriorate and on 16 December the Trust sought advice from the palliative care team and documented it had informed Mrs A’s daughter of the plan to provide EOL care. The Trust obtained advice on anticipatory medications from the palliative care team and a local hospice.

43. On 19 December the consultant caring for Mrs A documented a long discussion with her family where they advised her continued deterioration meant she was likely in the final phase of her life. They explained that further medical interventions would be unlikely to have any benefit and would likely prolong her suffering. The plan was was to make Mrs A comfortable. The consultant documented her family agreed with this plan and comfort medications were prescribed. Mrs A died the following day.

44. Whilst it appears Mrs A was likely in the final 12 months of her life from admission, the active treatment provided appeared to be keeping her clinical condition stable. It was initially anticipated she would likely continue to decline, but that this would be gradual and likely take place over a period of several months or longer. She was still at risk of deteriorating rapidly, however, if she were to contract an illness because her frailty meant she would be unlikely to have the capacity to recover. This meant a plan to discharge Mrs A for palliative care in the community appears to have been appropriate up until the point she deteriorated. We can see this was communicated to Mrs A’s daughters.

45. It can be very challenging to predict exactly when a patient will enter the final hours or days of their life. There is a difficult balance to be struck between providing and withdrawing active treatment, and pros and cons of these options. Once the Trust identified that further treatment was unlikely to prolong Mrs A’s life, it sought advice and provided care to make her final hours/days as comfortable as possible.

46. The evidence indicates the Trust did not fail to provide appropriate EOL care. It was aware Mrs A was likely in the final 12 months of her life and was taking steps to arrange palliative care upon discharge. Once it became clear Mrs A deteriorated and was not responding to active treatment the Trust appropriately implemented EOL care that aligned with the advice from specialist practitioners.

47. The Trust documented consistent communication with Mrs A’s family during her admission and there were no documented concerns from the family about a lack of communication overall. Similarly, the complaint Miss O submitted to the Trust, which she provided a copy of, did not raise a complaint about the overall communication and the Trust’s response to this complaint also did not cover this issue.

48. The Trust also communicated its view on Mrs A’s need for palliative care on several occasions in December 2023 and January 2024. Both our nurse and physician adviser agree the documented communication with Mrs A’s family appears to have been adequate.

49. We note that in the Trust’s complaint response the consultant caring for Miss A reflected on whether they should have communicated the involvement of the EOL team sooner when they recognised Mrs A was actively dying. We can see the consultant felt, at the time, that this may cause Mrs A’s family distress because the consultant felt they were not ready to accept Mrs A was dying. The consultant reflected that they did not communicate this as quickly as they could have and that they regretted this decision. The consultant apologised for any additional distress this decision caused.

50. We have not seen indications of service failure regarding the EOL care provided or the Trust’s communication about this with Mrs A’s family. We consider the Trust took the family’s complaint about this seriously and it reflected on how it could improve communication at the very end stage of a person’s life. There is nothing further we would likely recommend as an outcome for any potential breakdown in communication. Delay in inserting cannula and providing antibiotics 51. The NMC Code states that nurses should ensure treatment is delivered without undue delay and make a timely referral to another practitioner when any action, care or treatment is needed.

52. On 15 January Mrs A’s National Early Warning Score (NEWS) increased significantly. The NEWS is a nationally recognised system of recognising acute patient deterioration that aggregates a score based on a patient’s physical observations such as temperature, blood pressure, and respiration rate. A score of over seven requires an urgent response, and Mrs A’s score escalated above seven that afternoon. This was a significant deterioration when compared to her NEWS score that morning, which was three. A nurse immediately escalated her care to a doctor for a review.

53. On review, the doctor felt Mrs A’s deterioration was likely due to a mucus plug in her lungs but was cautious that she may have hospital acquired pneumonia. The doctor prescribed IV antibiotics and requested a COVID-19 test. The nursing team documented they had been unable to insert a cannula to administer the antibiotics and escalated this to the on-call doctor. The on-call doctored attempted to place the cannula with the assistance of an ultrasound machine but was also unable to place the cannula.

54. The following morning, a doctor reviewed the need for a cannula again and noted a specialist team may need to do this. It is unclear what further attempts were made to cannulate Mrs A in order to administer the antibiotics.

55. Mrs A tested positive for COVID-19 on 16 January. When reviewing her care, the consultant documented her deterioration was unlikely to be due to bacterial infection; rather, it was more likely due to the ongoing collapse of her left lung, the mucus plug, and severe COPD. Antibiotics would also not have been an effective treatment for COVID-19 unless there was a suspected secondary bacterial infection.

56. Our physician adviser reviewed Mrs A’s records and noted it appears unlikely her deterioration was as a result of a bacterial infection. The antibiotics prescribed appear to have been prophylactic (preventative) and aimed to cover the potential for a bacterial lung infection, not treat an established infection. In vulnerable patients it is common to prescribe antibiotics in advance when there is a chance there is an infection present and stop these if a bacterial infection is ruled out. Because the clinical evidence indicates it is unlikely her deterioration was due to a bacterial infection, any delay in administering the antibiotics more likely than not had no clinical impact on her deterioration.

57. It appears the delay in inserting the cannula was not due to the Trust failing to act on the recommendation to do this. Instead, it was due to significant difficulty in inserting the cannula. The nursing team attempted to insert the cannula but was unable to. They promptly escalated this to a doctor, who used assistive technology to attempt to place the cannula, but this was also unsuccessful. The nurses continued to request assistance in placing the cannula throughout the night, though it is unclear what further action was taken following this. Difficulties in inserting cannulas are not uncommon, and being unable to place a cannula does not indicate service failure in and of itself. This can happen for clinical reasons which are beyond the control of clinicians.

58. The Trust undertook an internal review of the delay in placing the cannula. It noted the matter was escalated appropriately and several different clinicians attempted, and failed, to cannulate Mrs A. The review identified that the anaesthetic team may have been helpful in assisting the doctors and nurses who had not been able to insert the cannula. It shared learning across the hospital to advise clinicians to request support from the anaesthetic team when the ward team has been unable to cannulate a patient.

59. Given it was unlikely Mrs A had a bacterial infection that required active treatment with antibiotics and the delay was due to being unable to place to cannula, not overlooking the need to insert it, there is no indication of service failure. Furthermore, the Trust reviewed this incident and took action to improve the steps it will take in these circumstances in the future. There is nothing further we would likely recommend the Trust do regarding this matter.

60. In summary, we have reviewed the concerns raised by Miss O and we have seen no indication Mrs A’s care fell below an acceptable standard. We recognise that witnessing a loved one’s final months of life can be very distressing and it is natural for a family to have questions when their loved one dies sooner than expected. We hope this review reassures Miss O and her family that the care Mrs A received does not appear to have fallen below and adequate standard or contributed to her death.

1. We have carefully considered Miss O’s complaint about the care Medway NHS Foundation Trust (the Trust) provided to her mother, Mrs A, between November 2023 and January 2024. We have seen no indication her care fell so far below the relevant standards that it could amount to service failure. We have also seen that the Trust reviewed the care it provided and took learning from instances where it felt its service could be improved.

2. Mrs A was very unwell on admission to hospital and it appears she was more likely than not in the final 12 months of her life from the point of admission. We recognise that witnessing Mrs A’s significant frailty, deterioration, and her death was very distressing for her family and our decision does not detract from this experience. We hope Miss O is reassured that there is no indication the care her mother received led to her death.