Chesterfield Royal Hospital NHS Foundation Trust

3. Mrs E complains about aspects of the care and treatment clinicians at the Hospital gave to her husband on 18 and 19 February 2023. She specifically complains about:

• Treatment of heart failure • Blood sugar monitoring • The decision to discharge her husband from hospital and follow up arrangements.

4. Mrs E believes her husband’s death could have been avoided. She says she also experienced distress relating to these issues. She seeks a financial remedy.

5. On 18 February 2023 Mr E attended the Hospital’s emergency department. He had been having breathing difficulties for around two weeks. Doctors admitted him to the emergency management unit (EMU) with suspected congestive heart failure (where the heart muscle cannot pump blood efficiently).

6. In EMU a doctor diagnosed congestive heart failure and increased his furosemide (medication for heart failure). Doctors discharged him the next day. Sadly, Mr E died on 22 February 2023 from ischaemic heart disease (where arteries become too narrow leading to reduced blood flow to the heart).

7. Mrs E first complained to the Trust in July 2023. Over the following years the Trust sent two written replies and arranged a meeting for Mrs E to meet clinicians. Mrs E remained dissatisfied, so she complained to us.

Treatment of heart failure

10. Mrs E complains about how clinicians treated her husband’s heart failure during his attendance at the Hospital on 18 and 19 February 2023.

11. The Heart Failure Guideline says the first line treatments for stable heart failure are ACE inhibitors (medication to lower blood pressure by stopping an enzyme that causes narrowing of blood vessels) and beta blockers (medication to treat a range of heart conditions). For people with congestive (fluid retention) symptoms, such as swollen legs or difficulty breathing due to fluid on the lungs, diuretics should be used.

12. Mr E attended the Hospital’s emergency department with increased breathlessness and orthopnoea (shortness of breath when lying flat which is a common symptom of congestive heart failure) for two weeks. He reported that he had felt better after increasing his furosemide. He had also lost weight.

13. Mr E’s observations were all normal. A doctor examined his chest and found crackles at the base of his lungs. The Medical Adviser told us this is a common finding for people who have an exacerbation of heart failure. He also had a chest X-ray which suggested congestive heart failure.

14. Mr E was already taking bisoprolol (a beta blocker) and ramipril (an ACE inhibitor) when he arrived at the Hospital. Furosemide is a diuretic. Mr E was taking 120mg each day before his arrival and doctors increased this to 160mg daily. The Medical Adviser told us this was the principal treatment for heart failure.

15. We find the doctors treated Mr E in line with the Heart Failure Guideline. We have seen no evidence of any failings relating to the management of Mr E’s heart failure.

Blood sugar monitoring

16. Mrs E complains that her husband’s blood sugar level was very high when doctors discharged him from the Hospital. She says there was no follow-up other than a blood test in one week.

17. The NMC Code contains the professional standards that nurses must uphold. It says they should work with colleagues to preserve the safety of those receiving care. Nurses should share information to identify and reduce risk. The NMC Code says nurses must keep clear and accurate records which should be completed as soon after the event as possible. Nurses should ensure it is clear who is making the record and when.

18. The Trust Policy says that if a patient’s blood sugar level is greater than 11mmol/L a clinician should review the patient, increase monitoring and look for the cause. If the blood sugar level remains above 18mmol/L and the patient has symptoms clinicians should give a dose of the patient’s usual insulin and check blood sugar levels every two to four hours.

19. Mr E had type 2 insulin-controlled diabetes. He took long-acting insulin (Tresubin) once a day and a fast-acting insulin (Novorapid) ten to fifteen minutes before meals. Our clinical advisers told us it was clear Mr E’s blood sugars were elevated throughout his stay at the Hospital (he had hyperglycaemia). Charts show his blood sugar level was shortly after his arrival and was at 8.30am on 19 February 2023.

20. The Nursing Adviser told us the nursing records were poorly completed. This includes the handover record (Accountability Handover Record) between the emergency department and EMU. This was largely blank and should have included details of Mr E’s insulin needs or frequency of blood sugar monitoring. It was unsigned by both the nurse handing over and the nurse accepting care. This was not in line with the NMC Code.

21. Mr E’s blood sugar levels were measured on three occasions. With all the readings it is unclear whether these were before or after food. The first measurement was at 4.05pm on 18 February 2023 when it was 21.1mmol/L. It is documented that he had Novorapid afterwards. But the effect of this is unclear. This is because the measurement was not repeated within four hours. This was not in line with the Trust Policy.

22. At 9.15pm Mr E’s blood sugar level had reduced but was still high at 15.8mmol/L. The third measurement was taken at 8.30am on 19 February 2023. Mr E’s blood sugar level had increased to 18.6mmol/L. again, nurses gave him Novorapid and again the effect of this is unknown because the measurement was not checked again before his discharge from the Hospital around 12pm.

23. The Nursing Adviser said given that all Mr E’s blood sugar measurements were high nurses should, as a minimum, have noted if he had any symptoms and had been eating or drinking inappropriate foods and drinks. They should also have documented his response to Novorapid.

24. The Medical Adviser explained that clinicians should have excluded two life-threatening conditions when considering Mr E’s blood sugars. Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that occurs when a severe lack of insulin results in the break down fat, producing toxic acids called ketones, causing the blood to become dangerously acidic. DKA is excluded by performing a blood ketone level test. Mr E had this test on 18 February 2023 and the result was normal.

25. The second consideration was hyperosmolar hyperglycaemic state (HHS). This is a life-threatening medical emergency primarily affecting older adults with type 2 diabetes and characterized by extremely high blood glucose levels (usually above 30mmol/L) with severe dehydration, but without significant ketones or acidosis (too much acid in the body). Blood tests from 18 February 2023 again showed Mr E did not have HHS.

26. The Medical Adviser said once doctors had excluded DKA and HHS there was less urgency to treat Mr E’s hyperglycaemia. The evidence suggests Mr E was clinically well and had no obvious symptoms of hyperglycaemia.

27. The Medical Adviser said it is extremely unlikely that hyperglycaemia played any role in Mr E’s death. This was because there is no evidence he had a serious illness due to hyperglycaemia, such as DKA or HHS.

28. We find clinicians at the Trust did not follow the Trust Policy and the NMC Code when monitoring Mr E’s blood sugar level. We cannot say this had any significant impact on Mr E’s health or that it contributed to his death a few days later. Clearly, this failing has led to avoidable distress for Mrs E.

29. The Trust has accepted that there was ‘a lapse’ in Mr E’s care when staff omitted to check his blood sugar level before discharging him. It also accepted that nurses should have contacted doctors about Mr E’s hyperglycaemia and did not do so. The Trust apologised to Mrs E. It also explained how there would be learning from her complaint. The Trust had shared the details of the complaint with the clinicians involved and introduced further point of care training from the diabetes team and the ward educator.

30. We are satisfied the Trust has already taken appropriate action in response to this part of Mrs E’s complaint. It has apologised and shown how there has been learning to try and improve services. We do not consider a financial remedy is appropriate in this case. We are not asking the Trust to take any further action.

Discharge from hospital

31. Mrs E complains about the decision to discharge her husband from the Hospital. She believes he should have been monitored or admitted to a cardiology ward. She also complains that doctors did not arrange follow up investigations other than a blood test for the following week.

32. The Discharge Guidance says people do not have a right to remain in hospital if not clinically indicated. It contains a list of criteria in one of its annexes of reasons why people should remain in hospital. It is widely accepted that people should not remain in hospital when they do not need to be there. There are inherent risks to remaining and it is logical to minimise hospital stays.

33. The Medical Adviser told us it was clear Mr E fulfilled the criteria for discharge. During the admission he had a relatively mild exacerbation of heart failure. Follow up arrangements would not be expected. It was right to arrange follow up blood tests because he was taking furosemide, which can cause changes in blood electrolyte levels.

34. We find that clinicians followed the Discharge Guidance. There is no evidence Mr E required continuing hospital treatment or that specific follow up investigations should have been arranged.

Conclusion

35. Clearly Mr E’s illness was incredibly distressing for his wife. We find there was a failing in care relating to blood sugar monitoring, which led to avoidable distress. But we are satisfied the Trust has already taken appropriate action relating to that issue. We have not seen any evidence of failings that could have had a significant impact on Mr E’s health. We hope our investigation provides Mrs E with reassurance there were no serious failings in her husband’s care.

36. We do not uphold Mrs E’s complaint.