University of Leeds HECS3295 Adult Nursing: Providing Complex Care, Case Study of Complex Care and Deterioration

Write a 3,000-word case study analysing one adult patient with complex needs whom you nursed during your fourth assessed placement. Leeds School of Healthcare sets HECS3295 Adult Nursing: Providing Complex Care as a 40-credit level 6 module in Semester 1, assessed by a single 3,000-word case study worth 100 per cent of the module mark, with no compensation between the theoretical and practice components.

Assessment Context

University of Leeds runs HECS3295 Adult Nursing: Providing Complex Care across the third year of BSc Nursing (Adult) with Registration, and the module manager is Fiona Meth in the School of Healthcare. The assessment is coursework, submitted as one 3,000-word case study, and it carries the whole of the formal module mark. A practice assessment document recorded in the MYEPAD runs alongside it as a pass or fail component rather than a graded one. Coursework weight sits in the theory half of a 40-credit module built on a 50:50 theory and practice split. The module catalogue publishes the assessment type, the credit value, the learning outcomes and the syllabus, while the detailed marking criteria sit in Minerva. Marking criteria below derive from the four stated learning outcomes and from the University’s level 6 descriptor band, so check the Minerva assessment brief before submission and treat the version posted there as authoritative.

Two patterns recur in feedback on this assignment. Students narrate an entire admission in chronological order and run out of words before the analysis begins. Students also describe what the team did without ever committing to what they would have done differently, which leaves the leadership criterion unsupported.

Module Position and Study Sequence

• Professional practice: NMC Code obligations, accountability in decision making, leadership models, resilience under increasing responsibility.
• Applied practice: structured assessment of the acutely ill adult, deterioration, referral, coordination and delegation of care, pharmacology.
• Bio-psycho-social-spiritual model: pathophysiology, coping with uncertainty and existential distress, cultural and spiritual need, sudden death.
• Evidence-based practice: standardised measures, decision support tools, clinical guidelines, barriers and facilitators to implementation.

HECS3295 runs in Semester 1 of year three, sits alongside the dissertation module HECS3294, and precedes Nursing Leadership and Role Transition in the final teaching block. Choose your patient early in the placement, secure consent for use of anonymised case material in line with local trust policy, and begin the evidence search while the clinical detail is still fresh.

Learning Outcomes Assessed

1. Practise in accordance with recognised professional, ethical and legal frameworks guiding adult nursing, and discuss your own limitations.
2. Critically evaluate the care requirements of adults and older adults with complex needs to facilitate optimal recovery or end of life care.
3. Recognise and respond to mental and physical deterioration in adults and older persons, demonstrating evidence-based decisions.
4. Critically evaluate the impact of interventions for adults and older persons and their families.

Task Instructions

1. Select one adult or older adult from your fourth assessed placement whose needs meet the module’s definition of complexity. Complexity means more than one long-term condition, or an acute event superimposed on frailty, cognitive change, learning disability or serious mental illness.
2. Anonymise every identifier. Use a pseudonym, omit the ward name, the trust name, exact dates and any detail that could identify the patient or a colleague. Breach of confidentiality fails the assignment outright under NMC Code standards.
3. Open with a short introduction of no more than 250 words that states the patient’s presenting problem, the complexity you are analysing and the order of the argument. Do not summarise the admission.
4. Present the case in a concise narrative section of 400 to 600 words. Include only material the analysis later uses. Cut family detail, ward geography and staffing trivia that carries no analytical weight.
5. Analyse the pathophysiological basis of the patient’s condition and the assessment findings that mattered. Link each finding to the underlying mechanism rather than listing observations.
6. Analyse one episode of actual or imminent deterioration. Show the recognition, using the assessment framework applied in practice, and show the response, including the escalation route, the timing and the outcome.
7. Interrogate the decisions taken. Where a decision departed from a guideline or from the early warning score pathway, state the clinical reasoning offered at the time and evaluate it against the evidence.
8. Examine one element of your own leadership, delegation or coordination of care. Name what you delegated, to whom, on what basis, and what accountability you retained as the registered nurse responsible.
9. Address the ethical and legal dimension of the case. Draw on the Mental Capacity Act 2005, best interests decision making, deprivation of liberty safeguards, or a DNACPR discussion as the case allows, and show how the team reasoned through it.
10. Evaluate the impact of the care on the patient and on the family or carers. Draw on evidence about what patients and families report, not on your own impression alone.
11. State what you would do differently and why. Ground the alternative in a cited source rather than in preference.
12. Close with a conclusion of no more than 200 words that answers the question you set in the introduction. Introduce no new material.
13. Attach a reference list in Leeds Harvard style and state the word count on the title page. Submit through Minerva before the published deadline.

Structure and Weighting

Section	Words	Function within the argument
Introduction	up to 250	Frames the patient, the complexity and the analytical order. No history taking.
Case presentation	400 to 600	Selection of clinically relevant detail only, written in past tense and anonymised.
Pathophysiology and assessment	500 to 600	Mechanism linked to findings, with normal and abnormal ranges defined for the reader.
Deterioration, recognition and escalation	600 to 700	The analytical core. Evidence-based decisions examined, including any deviation from protocol.
Leadership, delegation and accountability	400 to 500	Your own decisions and the accountability attached to them, not a description of the team.
Ethics, law and end of life	400 to 450	One framework applied properly rather than several named in passing.
Patient and family impact, plus what you would change	250 to 300	Evidence on patient and carer experience, then a defensible alternative course of action.
Conclusion and reference list	up to 200	Direct answer to the framing question. References excluded from the count.

Word Limit and Submission Requirements

• Target 3,000 words in the body text. A tolerance of ten per cent either way applies, so 2,700 to 3,300 words is acceptable and anything beyond it attracts a penalty.
• Exclude the title page, reference list and any appendices from the count. Include headings and in-text citations.
• Use Leeds Harvard referencing. Cite an author, year and, where you paraphrase a specific claim, a page number.
• Write in the third person for the case narrative and the first person for your own decisions. Mixing the two inside one sentence confuses who acted.
• Name the guidelines you apply. A statement that the early warning score pathway was followed carries no weight unless you name the tool, the score and the trigger threshold.
• Keep the evidence base current. Sources from the last eight years carry the argument, and national guidance in its current edition supersedes any earlier version you find referenced in older literature.
• Submit as a single document through Minerva. A late submission falls under the University’s penalties for assessed coursework.

Marking Criteria

Criterion	Weight	First class, 70 and above	Lower second and below, under 60
Knowledge of complex care and applied pathophysiology	25%	Explains the mechanism behind each significant finding and evaluates competing explanations. Defines clinical terms so a non-specialist examiner can follow. Distinguishes what the evidence establishes from what remains uncertain.	Describes the condition and lists observations without linking finding to mechanism. Uses technical vocabulary without definition. Accepts the first explanation offered.
Recognition, response and escalation	20%	Reconstructs the deterioration episode precisely, evaluates the timeliness of the response against current guidance, and examines any justified departure from the escalation protocol.	Narrates that the patient deteriorated and that staff were informed. Treats escalation as a single act rather than a sequence with decision points.
Leadership, delegation and accountability	20%	Analyses your own decisions as a leader of care. Justifies delegation by competence and supervision, and identifies the accountability you could not delegate. Evaluates what the episode revealed about your readiness for registration.	Describes the ward team in general terms. Reports delegation without justification, or claims leadership without evidence of a decision you made.
Ethical and legal reasoning, including end of life	20%	Applies one statutory or ethical framework to the facts and reasons through the tension in it. Shows how capacity, best interests or palliative need were assessed, and critiques the reasoning where it was thin.	Names the Mental Capacity Act or the NMC Code without applying it. Treats end of life care as a separate topic rather than part of the care decision.
Use of the evidence base	10%	Integrates peer-reviewed and guideline sources into the argument, appraises at least one source for strength and limitation, and uses evidence to justify the alternative course of action.	Cites sources to support description. Reports a study finding without appraisal, or cites guidance that has been superseded.
Structure, presentation and referencing	5%	Sections build an argument in the order promised in the introduction. Prose is direct, Leeds Harvard is accurate, and confidentiality is protected throughout.	Chronological narrative replaces argument. Referencing is inconsistent or incomplete, or identifying detail survives anonymisation.

Example Student Case Study Answer

Recognition of deterioration on a general ward depends less on the score than on what the nurse notices before the score changes. Ede and colleagues synthesised twenty-four studies of ward escalation and found that soft signals, including skin colour and temperature, respiratory pattern, personality change and patient complaint, drove escalation more often than the early warning score itself (Ede et al., 2021). Their evidence on human factors in escalating acute ward care matters for this case because Mr B’s score stayed at four for two hours while his breathing pattern and colour changed. Recording the score satisfied the documentation requirement and left the clinical concern unrecorded. Reframing the observation as a respiratory pattern change would have triggered an earlier review. That reframing is a nursing decision rather than a clerical one, and it sits squarely within the accountability the NMC Code places on the registered nurse.

Escalation works as a sequence of decisions, and each link in the sequence can fail independently. Mr B was assessed, the concern was voiced to a colleague, the colleague agreed, and the medical review was requested and arrived. Written down in that order, the episode looks unremarkable. Written down with the times attached, a different picture emerges, because forty minutes passed between the first concern and the first escalation. Anonymised timings are the single most useful analytical device in a case study of this kind. They convert a narrative into evidence about a system. The human factors evidence explains why the delay was predictable rather than inexplicable, since high workload and low staffing reduce the capacity to detect and escalate deterioration (Ede et al., 2021). Judgement about the individual nurse is therefore the weaker analysis, and judgement about the conditions that shaped her decision is the stronger one.

Soft Signals and the Score

Early warning score systems carry a documented weakness that students often miss when they write about escalation. Langkjaer and colleagues observed thirty-two nurses across fifteen wards and found that the score supported risk assessment but could not replace clinical judgement, because a standardised instrument does not differentiate between conditions or account for the individual patient (Langkjaer et al., 2023). Their fieldwork also recorded a finding that matters for the leadership criterion, since risk assessment was sometimes delegated to nursing students and healthcare assistants. Delegation of a scored observation is defensible. Delegation of the interpretive judgement that follows the score requires supervision, and a case study that blurs the two misses the accountability question the module asks.

• Name the instrument: early warning score version, aggregate value, and the trigger threshold that applied on your ward.
• Separate detection from escalation. Detection rests on assessment, escalation rests on communication and on the response of the receiving clinician.
• Record the interval between concern and review. A time interval is analysable and an impression is not.
• Check whether the score was calculated by the most junior person on shift, and say so if it was.

Failure to Escalate: Common Misreadings

Students searching for guidance on this assignment usually want to know why a detailed case study returns a lower second when the placement evidence was strong.

Three misreadings account for most of the shortfall. Replacing the case narrative with a reflective diary loses the analytical structure the rubric rewards, because reflection without evidence reads as feeling. Naming several ethical frameworks in a paragraph and applying none of them fails the ethics criterion, since the marker looks for one framework carried through the facts. Citing the NMC Code as a substitute for an argument about accountability produces a claim the marker cannot test, because every registrant is bound by the Code and the Code therefore distinguishes nothing. A fourth misreading concerns end of life care, treated by many students as a separate section bolted onto the end. The module frames optimal recovery and end of life care as two ends of one decision (Nursing and Midwifery Council, 2018), so the choice between them belongs in the deterioration analysis. Writing it there also solves a structural problem, because it forces the student to say when active treatment stopped being in the patient’s interests and who made that judgement.

What Families Report

Patient and family experience carries twenty per cent of nothing visible in most student drafts, and the evidence on it is straightforward to use. Reid and colleagues surveyed frontline nurses on acute medical wards and found that nurses identified communication with families, symptom management and confidence in recognising dying as their principal learning needs (Reid et al., 2023). Their findings imply that the quality of a family’s experience turns on whether someone with the confidence to name dying was present, rather than on the availability of a specialist palliative team. Apply that to a case where the family asked repeatedly whether the patient was dying. The analysis then examines who answered, what they said, and whether the answer matched the clinical reality. Sepsis guidance reinforces the point from another direction, since recovery depends on time to recognition and on the appropriate use of escalation, and both belong to the ward nurse before any specialist arrives (Evans et al., 2021).

Closing Judgement on the Assignment

HECS3295 rewards a student who chooses a narrow episode and analyses it hard rather than one who covers an admission. Pick a deterioration you witnessed, not the most dramatic event on the ward, since your own decisions must be visible in the account. Fix the timings, name the tool, and write the case presentation last so that only the details the argument needs survive into the final draft. Apply one legal framework properly and let the alternative course of action follow from the evidence rather than from regret. Anonymise ruthlessly, because a single identifying detail ends the submission regardless of its quality. A marker reading the finished case study should be able to say what you noticed, what you did, what you would change, and which source justifies the change.

References

Ede, J., Petrinic, T., Westgate, V., Darbyshire, J., Endacott, R. and Watkinson, P. (2021) ‘Human factors in escalating acute ward care: a qualitative evidence synthesis’, BMJ Open Quality, 10(1), e001145. doi: 10.1136/bmjoq-2020-001145.

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C.M., French, C., Machado, F.R., Mcintyre, L., Ostermann, M., Prescott, H.C., Schorr, C., Simpson, S., Wiersinga, W.J., Alshamsi, F., Angus, D.C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., Burry, L., Cecconi, M., Centofanti, J., Coz Yataco, A., De Waele, J., Dellinger, R.P., Doi, K., Du, B., Estenssoro, E., Ferrer, R., Gomersall, C., Grady, C., Gunn, C., Hammond, N., Han, Y., Hayashi, Y., Hirasawa, K., Iwashyna, T., Jacob, S., Kleinpell, R., Klompas, M., Koh, Y., Kumar, A., Kwizera, A., Lathyris, D., Lee, F., Levy, M., Lopes, R., Machado, F., Malbrain, M., Marshall, J., McCartney, C., McGloughlin, S., Mehta, S., Mer, M., Myatra, S., Nadkarni, V., Nainan, M., Nand, K., Nanjayya, V., Nunnally, M., Neto, A., Nunes, P., O’Kane, C., Olive, D., Paternoster, G., Paterson, D., Peake, S., Pelosi, P., Pereira, J., Periyasamy, R., Perner, A., Pfenninger, L., Phua, J., Piquilloud, L., Qiu, H., Ramakrishnan, N., Ray, S., Roberts, J., Rowan, K., Rudd, K., Runnels, J., Sakr, Y., Sanchez, M., Sathian, B., Schorr, C., Seppelt, I., Seymour, C., Shankar-Hari, M., Singer, M., Singh, S., Sorbello, A., Taylor, C., Teixeira, C., Thomas-Rueddel, D., Townsend, S., Udy, A., Venkatesh, B., Vieillard-Baron, A., Webb, S., Weyland, A., Wilson, J., Wise, R., Yaguchi, A., Yu, A. and Zampieri, F.G. (2021) ‘Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021’, Intensive Care Medicine, 47(11), pp. 1181–1247. doi: 10.1007/s00134-021-06506-y.

Langkjaer, C.S., Bundgaard, K., Bunkenborg, G., Nielsen, P.B., Iversen, K.K., Bestle, M.H. and Bove, D.G. (2023) ‘How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: a fieldwork study’, Journal of Advanced Nursing, 79(2), pp. 789–797. doi: 10.1111/jan.15547.

Nursing and Midwifery Council (2018) Future nurse: standards of proficiency for registered nurses. London: NMC.

Patient Profile

• Pseudonym: Mrs A.
• Age and sex: 82, female.
• Social situation: widowed, lives alone in a two-storey house with a daily carer for medication and shopping. Mobile indoors with a stick before admission.
• Cognitive baseline: mild cognitive impairment. Orientated to person, place and time; managed her own tablets with carer prompts; no prior delirium.

Presenting Condition and Admission

Unwitnessed fall at home with a left neck of femur fracture. Admitted through the emergency department and taken to theatre on day one for a left hemiarthroplasty under spinal anaesthetic. Weight-bearing as tolerated from day one, catheter removed on day two under the ward’s removal protocol.

Relevant Medical History

• Type 2 diabetes on metformin and gliclazide, latest HbA1c 62 mmol/mol.
• Chronic obstructive pulmonary disease, GOLD 2, FEV1 54 per cent predicted, one exacerbation in the previous year, no long-term oxygen.
• Chronic kidney disease stage 3a, baseline creatinine 118 micromol/L, baseline eGFR 48.
• Hypertension on amlodipine. Osteoporosis. Vitamin D deficiency.
• Post-operative analgesia: regular paracetamol, codeine 30 mg four times daily, oromorph 2.5 to 5 mg as required. Enoxaparin for venous thromboembolism prophylaxis.
• No penicillin allergy recorded. No existing treatment escalation plan and no DNACPR on admission.

Deterioration, With Timings

Day two, catheter removed at 06:00. Urine output reached only 150 mL by 22:00, bladder scan showed 480 mL residual, and intermittent catheterisation drained 550 mL. Fluid balance was negative by 700 mL for the day.

1. Day three, 06:00. Observations stable, NEWS2 of 1. Patient alert, took toast and tea, sat out for the physiotherapist.
2. Day three, 09:40. Delivered urine in the catheter bag described as cloudy with an offensive smell. Patient declined a wash, ate nothing at breakfast and dozed during the physiotherapy session.
3. Day three, 10:00. Observations recorded by the student nurse: respiratory rate 21, oxygen saturation 94 per cent on air, systolic blood pressure 112, pulse 98, alert, temperature 37.9. NEWS2 of 4.
4. Day three, 10:15 to 10:30. Concern raised verbally with the nurse in charge and entered in the notes as “drowsy, reduced oral intake, urine offensive”. Concern attributed to post-operative fatigue and codeine. Codeine withheld at 10:30. No medical review requested.
5. Day three, 13:50. Patient found by the student nurse to be confused about where she had been admitted and pulling at the catheter. Repeat observations: respiratory rate 24, oxygen saturation 93 per cent on air, systolic blood pressure 96, pulse 118, new confusion, temperature 38.4. NEWS2 of 12, confirmed on a second set five minutes later.
6. Day three, 14:10. Escalated by telephone using SBAR to the on-call foundation doctor.
7. Day three, 14:35. Doctor attended. Capillary glucose 14.8 mmol/L, point-of-care lactate 3.1 mmol/L, chest clear on auscultation, abdomen soft, surgical wound clean and dry, catheter draining dark concentrated urine.
8. Day three, 14:40 to 14:55. Two sets of blood cultures and a catheter specimen of urine taken, blood gas sent, intravenous access secured. Ceftriaxone 2 g given at 14:55, forty-five minutes after recognition of NEWS2 of 12, in line with the local antimicrobial guideline.
9. Day three, 15:00 to 16:00. Two 500 mL crystalloid boluses with reassessment between them. Urine output for the preceding three hours recorded at 15 mL per hour. Catheter re-sited at 16:00 because it had blocked, draining 400 mL.
10. Day three, 15:20. Critical care outreach review. Agreed ward-based care with hourly observations, outreach review at 18:00 and a ceiling of treatment discussion with the family before the evening.
11. Day three, 18:00. Observations: respiratory rate 22, oxygen saturation 94 per cent on 2 litres of nasal oxygen, systolic blood pressure 108, pulse 104, alert, temperature 38.1. NEWS2 of 8.

NEWS2 Working Table

Parameter	06:00 (score 1)	10:00 (score 4)	13:50 (score 12)	18:00 (score 8)
Respiratory rate	18 (0)	21 (2)	24 (2)	22 (2)
Oxygen saturation, Scale 1	95% (1)	94% (1)	93% (2)	94% (1)
Air or oxygen	Air (0)	Air (0)	Air (0)	2 L oxygen (2)
Systolic blood pressure	126 (0)	112 (0)	96 (2)	108 (1)
Pulse	88 (0)	98 (1)	118 (2)	104 (1)
Consciousness, ACVPU	Alert (0)	Alert (0)	New confusion (3)	Alert (0)
Temperature	37.2 (0)	37.9 (0)	38.4 (1)	38.1 (1)
Aggregate	1	4	12	8

Scale 1 applies here because no target range of 88 to 92 per cent had been prescribed. Where a target range is prescribed for a patient with hypercapnic respiratory failure, score on Scale 2 and state that choice in the text, since the marker will check which scale you used.

Your Involvement in the Constructed Case

• Performed and documented the 10:00 observations and the clinical description of the urine, then raised the concern with the nurse in charge at 10:15.
• Recognised new confusion during hourly rounding at 13:50, repeated the observations, calculated the aggregate score by hand rather than accepting the electronic total, and escalated using SBAR at 14:10.
• Remained with the patient, allocated a healthcare assistant to continuous observation, and delegated the second set of observations to a first-year student under direct supervision while retaining responsibility for interpretation.
• Collected the urine specimen, recorded fluid balance hourly, and accompanied the patient to the catheter change.
• Attended the family conversation on the evening of day three with the ward doctor and the nurse in charge.
• Named limitation for the reflection: documented the concern at 10:15 but did not request a medical review, and accepted the fatigue explanation without testing it against the rising respiratory rate.

Ethical and Legal Thread

• Capacity at 13:50 was absent for treatment decisions because of delirium secondary to sepsis. Assessed under sections 1 to 3 of the Mental Capacity Act 2005, and the assessment recorded rather than asserted.
• Best interests decision made under section 4, with the daughter consulted by telephone and the son present. Neither held lasting power of attorney for health and welfare, so both were consultees and not decision makers.
• Ceiling of treatment agreed at 19:00 on day three: DNACPR, ward-based escalation with fluids, antibiotics and oxygen, and no transfer to intensive care. Recorded on the treatment escalation plan and communicated to the outreach team.
• Continuous observation and bed rails reviewed each shift as the least restrictive option for her immediate safety, with the reasoning documented rather than assumed.
• Capacity returned on day seven. The DNACPR decision was revisited with her, the meaning of “not for intensive care” was explained, and her view was recorded in the notes.
• Consent to use anonymised case material for academic work requested on day twelve through the ward manager, following local policy on student use of patient information.

Outcome

Blood cultures and urine culture both grew Escherichia coli sensitive to ceftriaxone. Antibiotics narrowed to oral on day six and completed a seven-day course. Lactate fell to 1.8 mmol/L by day four. Confusion resolved by day six and orientation returned fully by day seven. Successful trial without catheter on day twelve. Discharged on day fourteen to an interim reablement bed with physiotherapy and a reviewed treatment escalation plan. No intensive care admission.

Mapping the Case to the Marking Criteria

Criterion	What to write from this case
Knowledge of complex care and pathophysiology	Explain why a fractured neck of femur plus diabetes, COPD and chronic kidney disease narrows physiological reserve. Link the cloudy offensive urine, the raised respiratory rate and the lactate of 3.1 mmol/L to the mechanism of obstructive urosepsis rather than listing them.
Recognition, response and escalation	Use the 10:00 to 13:50 window as the analytical core. Show the score rising from 4 to 12 across four hours, show what the concern was attributed to, and evaluate the forty-five minute interval from recognition to antibiotic against current sepsis guidance.
Leadership, delegation and accountability	State what you delegated at 13:50 (the repeat observations, to a first-year student under supervision), why competence rather than convenience justified it, and which judgement you kept.
Ethical and legal reasoning and end of life	Carry the Mental Capacity Act 2005 through the facts: absent capacity, best interests, consultees rather than attorneys, DNACPR recorded in incapacity, decision revisited on day seven when capacity returned.
Use of the evidence base	Appraise one source for strength and limitation. The Ede synthesis of twenty-four escalation studies is moderate to high confidence but draws on qualitative designs, which limits any claim about effect size.
Structure, presentation and referencing	Fix the timeline first, write the analysis second, and write the case presentation last so only the details the argument uses remain.

Writing the Four-Hour Window

Chart the four hours from 10:00 to 13:50 and the case study writes itself, because the interval carries the argument. At 10:00 the aggregate score sat at four while the nurse recorded reduced oral intake, a rising respiratory rate and cloudy urine. Escalation reached the nurse in charge rather than a doctor, and the concern was folded into a fatigue narrative. Ede and colleagues found soft signals of exactly that kind driving escalation in practice, and they also found that scores below the trigger threshold can inhibit the very action the concern demands (Ede et al., 2021). Reading the human factors evidence on escalating acute ward care beside the observation chart turns one bad afternoon into a system finding. Four hours and eight NEWS2 points later, the patient met the criteria for emergency assessment by a team with critical care competencies (Royal College of Physicians, 2017). Accountability belongs to whoever held the concern at 10:00, and at 10:00 that person was the student who noticed.

Case B: Ceiling of Treatment With Capacity Intact

Use this variant when your placement produced a treatment escalation decision rather than a sepsis event, or when you want a sharper ethics section. Keep the same headings and the same timings discipline.

• Patient. Mr C, 74, male, lives with his wife, independent, retired joiner. Severe COPD, FEV1 38 per cent predicted, two admissions in twelve months, on long-term oxygen assessment waiting list. Ischaemic heart disease, atrial fibrillation on apixaban.
• Admission. Community-acquired pneumonia, day two of intravenous antibiotics on a respiratory ward.
• Deterioration. 09:00 observations: respiratory rate 26 (score 3), oxygen saturation 88 per cent on 2 litres of oxygen (score 3 plus 2 for oxygen), systolic blood pressure 118 (0), pulse 112 (2), alert (0), temperature 37.8 (0). NEWS2 of 10. Arterial blood gas shows pH 7.28, carbon dioxide 8.9 kPa, oxygen 7.8 kPa, bicarbonate 30 mmol/L, an acute on chronic type 2 respiratory failure.
• Interventions. Venturi mask titrated to a target range of 88 to 92 per cent, respiratory team review at 09:40, trial of non-invasive ventilation commenced at 10:30 and tolerated.
• Your involvement. Recorded the observations, calculated the score on Scale 2 because a target range was prescribed, escalated within ten minutes, sat with the patient during the first hour of ventilation and coached his breathing, and documented his stated wishes in his own words.
• Ethics. Mr C held capacity throughout. Non-invasive ventilation was explained and accepted. Intubation and cardiopulmonary resuscitation were declined, and the refusal was documented in his words, witnessed, and added to the treatment escalation plan. Best interests decision making under the Mental Capacity Act 2005 did not apply at any point, and saying so is worth a sentence, because a marker looks for the difference between a capacitous refusal and a best interests judgement.
• Outcome. Ventilation weaned on day four, discharged on day nine with a follow-up respiratory review and a plan for a future admission discussion.
• Analytical use. Weigh the evidence on non-invasive ventilation in acute hypercapnic exacerbation against the patient’s stated priorities, and evaluate whether the conversation happened early enough to shape care rather than ratify it.

Details to Replace Before Submission

• All scores, timings, drug names, doses, staff grades and outcomes, replaced with your own documented record.
• The patient pseudonym and every social detail, since a widow living alone in a two-storey house can identify a person on a small ward.
• The reflection bullet, which must describe a limitation you actually encountered rather than one invented here.
• Any guideline that has since been superseded. Sepsis guidance for adults in England is now NICE NG253, which partially replaces NG51, and citing the older guideline in a 2026 submission signals an undeclared source.

References

Department for Constitutional Affairs (2005) Mental Capacity Act 2005. London: The Stationery Office. Available at: legislation.gov.uk/ukpga/2005/9/contents.

Ede, J., Petrinic, T., Westgate, V., Darbyshire, J., Endacott, R. and Watkinson, P. (2021) ‘Human factors in escalating acute ward care: a qualitative evidence synthesis’, BMJ Open Quality, 10(1), e001145. doi: 10.1136/bmjoq-2020-001145.

Evans, L. et al. (2021) ‘Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021’, Intensive Care Medicine, 47(11), pp. 1181–1247. doi: 10.1007/s00134-021-06506-y.

Langkjaer, C.S., Bundgaard, K., Bunkenborg, G., Nielsen, P.B., Iversen, K.K., Bestle, M.H. and Bove, D.G. (2023) ‘How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: a fieldwork study’, Journal of Advanced Nursing, 79(2), pp. 789–797. doi: 10.1111/jan.15547.

National Institute for Health and Care Excellence (2025) Suspected sepsis in people aged 16 or over: recognition, diagnosis and early management. NICE guideline NG253. London: NICE. Available at: nice.org.uk/guidance/ng253.

Nursing and Midwifery Council (2018) Future nurse: standards of proficiency for registered nurses. London: NMC. Available at: nmc.org.uk standards of proficiency.

Reid, J.C. et al. (2023) ‘Learning needs and perceived barriers and facilitators to end-of-life care: a survey of front-line nurses on acute medical wards’, BMJ Open Quality, 12(2), e002219. doi: 10.1136/bmjoq-2022-002219.

Royal College of Physicians (2017) National Early Warning Score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. London: RCP. Available at: rcp.ac.uk NEWS2 final report.

Reid, J.C., Hoad, N., Willison, K., Hanmiah, R., Brandt Vegas, D., Mitri, M., Boyle, A., Weatherston, A., Lohin, S., McInnes, D., Rudkowski, J.C., Joyner, M. and Cook, D.J. (2023) ‘Learning needs and perceived barriers and facilitators to end-of-life care: a survey of front-line nurses on acute medical wards’, BMJ Open Quality, 12(2), e002219. doi: 10.1136/bmjoq-2022-002219.

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Recognition and Management of Post-operative Deterioration in an Older Adult: A Critical Case Study of Complex Nursing Care

Module: HECS3295 Adult Nursing: Providing Complex Care
Institution: University of Leeds, School of Healthcare
Academic level: Level 6
Assessment: Case Study of Complex Care and Deterioration
Patient pseudonym: Mrs A
Word count: Approximately 3,000 words, excluding references

Introduction

The management of complex nursing needs in older adults requires nurses to recognise subtle clinical changes, respond to deterioration and coordinate care across different healthcare professionals. These responsibilities become more demanding when an acute illness develops alongside several long-term conditions. This case study examines the deterioration of Mrs A, an 82-year-old woman who developed urinary-source sepsis following surgery for a fractured neck of femur. Her medical history included type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), stage 3a chronic kidney disease (CKD) and mild cognitive impairment. These conditions reduced her physiological reserve and increased the demands of post-operative care.

The central argument is that earlier recognition and escalation of Mrs A’s deterioration could have reduced the period during which her condition progressed without medical assessment. Although the student nurse identified concerning signs and reported them, the decision to attribute these changes to post-operative fatigue and analgesia delayed further review. The discussion critically examines the underlying pathophysiology, clinical assessment, deterioration management, leadership, delegation and legal responsibilities. It also evaluates the impact of treatment and identifies improvements that could strengthen future nursing practice.

Case Presentation

Mrs A was admitted to hospital following an unwitnessed fall that resulted in a left fractured neck of femur. She underwent a left hemiarthroplasty under spinal anaesthesia on the first day of admission. Her post-operative plan allowed weight-bearing as tolerated, and clinicians removed her urinary catheter on the second day in accordance with the ward protocol. Before admission, she had mild cognitive impairment but remained orientated and managed her medication with support from a daily carer.

Her medical history included type 2 diabetes treated with metformin and gliclazide, COPD with an FEV1 of 54% predicted, stage 3a CKD and hypertension. Her baseline creatinine was 118 micromol/L, with an estimated glomerular filtration rate (eGFR) of 48 mL/min/1.73 m². Her post-operative analgesia included regular paracetamol, codeine and as-required oral morphine. She also received enoxaparin for venous thromboembolism prevention. These conditions and treatments required careful monitoring because infection, dehydration, reduced mobility and medication effects could complicate her recovery.

Following catheter removal, Mrs A developed urinary retention. A bladder scan showed a residual volume of 480 mL, and intermittent catheterisation drained 550 mL. Her recorded fluid balance was negative by 700 mL. At 06:00 on the third day, her observations remained relatively stable, with a National Early Warning Score 2 (NEWS2) of one. However, by 09:40, nursing staff had noticed cloudy, offensive-smelling urine, reduced appetite and increased drowsiness. She also declined personal hygiene assistance and struggled to remain awake during physiotherapy.

At 10:00, her respiratory rate was 21 breaths per minute, oxygen saturation was 94% on room air, pulse was 98 beats per minute, systolic blood pressure was 112 mmHg and temperature was 37.9°C. Her NEWS2 score had increased to four. The student nurse documented these findings and reported the concerns to the nurse in charge. The team attributed her presentation to post-operative fatigue and codeine. Staff withheld codeine, but no medical review followed.

The patient’s condition deteriorated further. At 13:50, the student nurse found her confused about her location and pulling at her catheter. Her respiratory rate had increased to 24, oxygen saturation had fallen to 93%, systolic blood pressure had decreased to 96 mmHg and pulse had risen to 118 beats per minute. Her temperature was 38.4°C, and her NEWS2 score had reached 12. The student repeated the observations, confirmed the score and escalated the situation through an SBAR telephone referral at 14:10.

The foundation doctor attended at 14:35. Investigations identified a capillary blood glucose of 14.8 mmol/L and a lactate concentration of 3.1 mmol/L. Blood and urine cultures were collected, intravenous access was secured and ceftriaxone was administered at 14:55. The patient received two 500 mL crystalloid boluses, with reassessment between them. Critical care outreach reviewed her at 15:20 and recommended ward-based management with increased observation and a treatment ceiling discussion.

By 18:00, her NEWS2 score had reduced to eight, although she remained clinically unwell. Both blood and urine cultures subsequently grew Escherichia coli sensitive to ceftriaxone. Antibiotic treatment was narrowed to oral medication on day six, and her confusion resolved. She regained full orientation by day seven and passed a trial without catheter on day twelve. She left hospital on day fourteen for an interim reablement placement with ongoing physiotherapy.

Pathophysiology and Clinical Assessment

Mrs A’s deterioration reflected the interaction between infection, reduced physiological reserve and post-operative complications. Sepsis develops when the body’s response to infection causes organ dysfunction. The inflammatory response can produce widespread vasodilation, increased vascular permeability and disturbances in tissue perfusion. These changes can reduce circulating blood volume and impair the delivery of oxygen to organs. In Mrs A’s case, the urinary findings, fever, tachycardia, hypotension, confusion and raised lactate were consistent with a systemic response to urinary infection.

The urinary retention that followed catheter removal provides an important explanation for the possible development of infection. Urinary stasis can encourage bacterial growth because incomplete bladder emptying reduces the normal mechanical clearance of microorganisms. Catheter blockage may also interfere with drainage and increase the risk of complications associated with catheter use. However, cloudy or offensive-smelling urine alone cannot establish a urinary tract infection. Nurses must consider these findings alongside systemic symptoms, examination results and microbiological evidence. The subsequent identification of E. coli in both blood and urine cultures supported a urinary source of the bloodstream infection.

Diabetes added further complexity. Hyperglycaemia can impair immune function and increase susceptibility to infection. During acute illness, stress hormones also stimulate glucose production and reduce insulin sensitivity. Mrs A’s glucose concentration of 14.8 mmol/L may therefore have reflected both her underlying diabetes and the physiological stress associated with sepsis. Poor glucose control can interfere with recovery, particularly after major orthopaedic surgery, when effective tissue repair and infection control are important. Her HbA1c of 62 mmol/mol also indicated that glycaemic management required attention beyond the immediate episode.

Her CKD further reduced her ability to tolerate acute physiological stress. The kidneys regulate fluid balance, electrolytes and the removal of metabolic waste products. Infection, hypotension and dehydration can reduce renal perfusion, increasing the risk of acute kidney injury. Mrs A’s negative fluid balance and low urine output therefore raised concern about inadequate renal circulation. Her urine output of approximately 15 mL per hour over the preceding three hours was particularly concerning. However, the absence of a contemporaneous creatinine result and body weight means that the available evidence cannot establish whether she met the formal criteria for acute kidney injury.

COPD also reduced her physiological reserve. Her raised respiratory rate may have reflected a compensatory response to infection and metabolic stress. Tachypnoea can help the body remove carbon dioxide and compensate for metabolic acidosis. Her lactate concentration of 3.1 mmol/L suggested impaired tissue perfusion or altered cellular metabolism, although lactate is not specific to sepsis. A blood gas examination would have helped assess acid-base balance and respiratory function. The supplied case does not provide the results, which limits further interpretation.

The patient’s cognitive changes also carried clinical significance. Although mild cognitive impairment formed part of her baseline history, she had remained orientated before the acute event. Her new confusion, reduced attention and agitation therefore suggested an acute change rather than a continuation of her usual cognitive condition. Infection, dehydration, pain, medication effects and metabolic disturbances can contribute to delirium in older adults. Codeine may have contributed to drowsiness, but it could not adequately explain the full pattern of physiological deterioration.

The combination of physical and cognitive findings demonstrates why nurses should assess older adults through a bio-psycho-social perspective. A fractured hip, diabetes, COPD, CKD and cognitive impairment interact to complicate treatment and rehabilitation. Mrs A’s clinical presentation required assessment of infection, circulation, breathing, renal function, medication effects and mental status rather than an isolated focus on post-operative recovery.

Recognition, Deterioration and Clinical Escalation

The most significant nursing issue in this case was the delay between the first concerning observations and the medical assessment. The increase in NEWS2 from four at 10:00 to 12 at 13:50 demonstrated substantial deterioration over less than four hours. Although the initial score did not independently indicate the same emergency response as the later score, the accompanying clinical changes required attention. The student nurse recorded a rising respiratory rate, reduced oral intake, drowsiness and abnormal urine appearance. Taken together, these findings should have prompted further assessment rather than an assumption of routine post-operative fatigue.

NEWS2 provides a standardised approach to identifying physiological deterioration. It considers respiratory rate, oxygen saturation, supplemental oxygen use, systolic blood pressure, pulse, consciousness and temperature. The Royal College of Physicians (2017) identifies an aggregate score of seven or above as requiring an urgent or emergency response involving clinicians with appropriate acute and critical care competencies. Mrs A’s score of 12 therefore required urgent medical assessment and escalation.

NICE guideline NG253 also identifies a NEWS2 score of seven or above in a person with suspected or confirmed infection as indicating a high risk of severe illness or death. The guideline stresses that clinicians must interpret the score alongside clinical findings, previous observations and underlying health conditions. It also advises reassessment when a patient’s condition deteriorates or an unexpected change occurs (National Institute for Health and Care Excellence, 2025). <Cite refs={[“turn569988search3″,”turn569988search0”]}/>

At 10:00, Mrs A’s NEWS2 score of four placed her within the low-risk category for suspected sepsis under the current NICE classification. Nevertheless, the score did not eliminate the need for clinical judgement. Her respiratory rate of 21 contributed two points, oxygen saturation of 94% contributed one point and pulse of 98 contributed another. The observations indicated emerging physiological stress. Her reduced appetite, drowsiness and unusual urine findings added further reasons for concern. The student’s decision to report these signs demonstrated appropriate initial awareness, but the absence of a medical review represented a weakness in the subsequent response.

The explanation that codeine caused the drowsiness had some clinical plausibility. Opioid analgesics can produce sedation, particularly in older adults and patients with impaired renal function. However, this explanation did not account for the rising respiratory rate, declining blood pressure, tachycardia, fever and urinary changes. Withholding codeine addressed one possible contributor without investigating the broader deterioration. The nurse in charge should have considered medication effects alongside infection and dehydration, rather than treating analgesia as the most likely explanation.

Research by Ede et al. (2021) supports the importance of recognising clinical changes that may not initially produce a high early warning score. Their qualitative evidence synthesis included 24 studies and found that soft signs, such as altered breathing patterns, changes in personality, fatigue and patient complaints, often helped nurses identify deterioration. The authors also reported that workload and staffing pressures could reduce opportunities to recognise and escalate patient concerns. Their synthesis provides useful evidence for the present case because Mrs A showed several warning signs before her score reached the emergency threshold. However, the qualitative design explains clinical experiences and processes rather than proving that a particular escalation strategy reduces mortality. <Cite refs={[“turn569988search4”]}/>

The deterioration became unmistakable at 13:50. Mrs A’s new confusion, respiratory rate of 24, pulse of 118, systolic blood pressure of 96 mmHg and temperature of 38.4°C accompanied a NEWS2 score of 12. The student nurse appropriately repeated the observations and manually checked the aggregate score rather than relying entirely on the electronic calculation. This action was important because accurate scoring supported the urgency of the referral. The subsequent SBAR communication at 14:10 also helped organise the information for the receiving doctor.

The doctor’s assessment identified additional evidence of systemic illness. A lactate concentration of 3.1 mmol/L raised concern about tissue hypoperfusion, while concentrated urine and low output suggested inadequate renal perfusion or impaired drainage. The clear chest examination and clean surgical wound made a respiratory or wound source less apparent, although they did not exclude other causes. Collecting blood and urine cultures before antibiotics supported microbiological investigation, provided sampling did not create unnecessary treatment delays.

NICE NG253 recommends urgent assessment by a clinician competent in managing acute illness for patients at high risk. It also recommends intravenous broad-spectrum antibiotics within one hour of calculating the NEWS2 score on ward deterioration (National Institute for Health and Care Excellence, 2025). In this case, the score reached 12 at 13:50, so the one-hour target ended at 14:50. Ceftriaxone was administered at 14:55, five minutes beyond that target. The treatment was therefore close to the recommended interval but did not meet it on the recorded timings. This distinction matters because accurate assessment of treatment performance requires attention to the time of the original deterioration, not merely the time the doctor received the telephone referral. <Cite refs={[“turn158339search0″,”turn158339search4”]}/>

The intravenous fluid treatment also warrants critical consideration. Mrs A received two 500 mL crystalloid boluses, with reassessment between them. Although restoring circulating volume was clinically appropriate given her hypotension, low urine output and raised lactate, her age and CKD increased the importance of cautious fluid administration. Current NICE guidance recommends an initial 250 mL crystalloid bolus, followed by reassessment and further 250 mL boluses when required, up to a total of 1,000 mL before senior advice if improvement remains inadequate. The 500 mL increments in this case therefore differed from the current recommended approach. The record does not document whether clinicians considered fluid overload risk or why they selected larger increments. No pulmonary complication is reported, but the absence of documented harm does not establish that the approach carried no avoidable risk. <Cite refs={[“turn569988search0”]}/>

A further issue concerns monitoring after the initial treatment. Mrs A’s NEWS2 score remained eight at 18:00, indicating that she continued to meet the high-risk threshold. NICE recommends recalculating NEWS2 every 30 minutes in patients at high risk of severe illness or death from sepsis. The case describes hourly observations, which would not meet that current recommendation unless additional monitoring occurred but was omitted from the record. The critical care outreach review and ward-based management decision were appropriate components of ongoing care, but they did not remove the need for close monitoring and repeated clinical assessment. <Cite refs={[“turn569988search3″,”turn569988search0”]}/>

The response eventually controlled the infection, but the earlier delay remains the most important learning point. The student nurse raised a concern at 10:15, yet did not request a medical review or challenge the explanation offered. A more effective response would have included repeat observations, documented clinical concern and further escalation if the nurse in charge did not arrange an appropriate review. Early warning scores should support clinical judgement, not restrict it.

Leadership, Delegation and Professional Accountability

The episode illustrates that leadership in nursing involves taking responsibility for the organisation and safety of care, even when the individual is not yet a registered nurse. At 13:50, the student nurse recognised that Mrs A required urgent attention and responded by repeating the observations, checking the NEWS2 score and contacting the on-call doctor using SBAR. Remaining with the patient also helped maintain direct observation while medical assistance was arranged. These actions demonstrated initiative and an understanding of the need to prioritise an acutely deteriorating patient.

The student also delegated continuous observation to a healthcare assistant and asked a first-year nursing student to obtain the second set of observations under direct supervision. The allocation reflected the need to maintain close observation while facilitating further clinical assessment. However, effective delegation requires consideration of the individual’s competence, the complexity of the task and the level of supervision available. The healthcare assistant could assist with observation and promptly report changes, but could not independently undertake clinical interpretation or decide whether escalation was required.

Research by Langkjaer et al. (2023) examined how nurses use early warning scores in clinical practice. Their fieldwork included observations of 32 nurses across 15 hospital wards and found that early warning scores supported patient assessment and clinical decision-making. However, the researchers also identified risks when less experienced staff undertook risk assessment without appropriate oversight. This finding supports the importance of maintaining clear distinctions between collecting observations and interpreting their clinical significance. The student nurse therefore acted appropriately by retaining responsibility for checking the score, interpreting the findings and communicating deterioration to the medical team. <Cite refs={[“turn293719search5″,”turn293719search3”]}/>

The distinction between student and registered-nurse accountability also requires attention. As a student, I remained accountable for working within my competence, reporting accurate findings and seeking supervision when necessary. The registered nurse supervising the patient’s care retained responsibility for appropriate oversight and decisions concerning delegation. I could not transfer my own responsibility for accurate documentation or timely escalation to another team member. Equally, I could not assume the full accountability of the registered nurse responsible for the shift.

The NMC Code requires nurses to recognise deterioration, make timely referrals, work within their competence and raise concerns when patient safety becomes threatened. It also requires practitioners to take action when the quality of care presents a risk to patients (Nursing and Midwifery Council, 2018). These standards apply to student learning through the responsibility to develop safe practice under supervision. In this case, I met some of these responsibilities by documenting the 10:00 findings and escalating the later deterioration. However, I did not respond sufficiently to the earlier clinical concern because I accepted the fatigue explanation without testing it against the patient’s changing observations.

My main leadership limitation was therefore not a failure to notice deterioration, but a failure to sustain escalation when the first concern did not produce an adequate response. A more assertive approach would have involved requesting a medical assessment at 10:15, explaining the combination of abnormal observations and soft signs, and seeking help from a more senior practitioner if the concern remained unresolved. The incident demonstrates that effective leadership requires communication, prioritisation and professional courage. It also shows that delegation is safe only when the person allocating the task retains appropriate oversight and ensures that concerns reach the correct decision-maker.

Ethical and Legal Considerations

The Mental Capacity Act 2005 provided the main legal framework for decisions concerning Mrs A during her episode of delirium. The Act requires practitioners to presume that adults have capacity unless evidence establishes otherwise. It also makes clear that capacity is decision-specific and may fluctuate over time. A patient cannot be regarded as lacking capacity simply because they have a diagnosis, cognitive impairment or make a decision that others consider unwise (Mental Capacity Act 2005, s. 1). <Cite refs={[“turn293719search1”]}/>

At 13:50, Mrs A showed new confusion and was unable to make the relevant treatment decisions because of delirium associated with her acute illness. Her baseline mild cognitive impairment did not automatically remove her legal right to make decisions. The team therefore needed to assess her ability to understand, retain, use or weigh relevant information and communicate a decision. The case records that a capacity assessment took place, although it does not provide the detailed findings for each element of the statutory test. Such details would strengthen the documentation and demonstrate that the assessment followed the legal requirements rather than relying on the observation of confusion alone.

Once the team established that Mrs A lacked capacity for the relevant decisions, treatment had to follow the best-interests principle. Section 4 of the Act requires decision-makers to consider the patient’s past and present wishes, beliefs, values and relevant circumstances. It also requires them to involve the person as fully as possible and consult appropriate individuals when determining best interests. The team contacted Mrs A’s daughter and involved her son in discussions about the treatment ceiling. Neither relative held lasting power of attorney for health and welfare. They therefore acted as consultees who could provide information about Mrs A’s wishes, rather than making the decisions on her behalf. <Cite refs={[“turn293719search2″,”turn293719search7”]}/>

At 19:00, the team documented a decision for ward-based treatment, including antibiotics, fluids and oxygen, alongside a do-not-attempt-cardiopulmonary-resuscitation decision and no transfer to intensive care. The decision required careful reasoning because a DNACPR instruction concerns cardiopulmonary resuscitation, not the withdrawal of other appropriate treatment. Mrs A continued to receive active treatment for sepsis, and the treatment escalation plan distinguished resuscitation decisions from other interventions.

Nevertheless, the case provides limited information about the clinical reasoning supporting the decision not to transfer Mrs A to intensive care. A treatment ceiling should consider the likely benefits and burdens of intensive care, the patient’s clinical condition and, where possible, the person’s known preferences. Family involvement can help establish these values, but relatives do not automatically possess decision-making authority. The team should document the reasons for the decision and explain the distinction between DNACPR and the continuation of other treatment.

The use of continuous observation and bed rails also required an assessment of necessity and proportionality. These measures may reduce immediate risks associated with confusion and falls, but they can restrict movement and autonomy. The Mental Capacity Act requires decision-makers to consider less restrictive alternatives. Regular review was therefore necessary to establish whether these measures remained appropriate as Mrs A’s delirium improved.

An important positive feature was the review of the treatment escalation plan when Mrs A regained capacity on day seven. The team explained the DNACPR decision and the meaning of the intensive care treatment ceiling, then recorded her views. This step recognised that a decision made during temporary incapacity should not continue without review once the person’s decision-making ability returns. The case demonstrates that legal and ethical nursing practice requires respect for autonomy even during periods of acute illness.

Patient and Family Impact and Areas for Improvement

Mrs A’s clinical outcome was positive. Her lactate decreased from 3.1 to 1.8 mmol/L by day four, blood and urine cultures confirmed an organism sensitive to the prescribed antibiotic, and treatment was successfully narrowed. Her confusion resolved by day six, and she regained full orientation by day seven. She passed a trial without catheter and transferred to an interim reablement placement for further rehabilitation. These outcomes suggest that treatment controlled the infection and supported her recovery, although the case does not establish that any single intervention caused the improvement.

The admission also affected her independence. Before hospitalisation, Mrs A mobilised indoors with a stick and lived in her own home with limited daily support. Following major surgery and sepsis, she required further rehabilitation before returning to her previous living arrangements could be considered. The available case material does not document her or her relatives’ satisfaction with communication, so their experience should not be assumed to have been positive. Reid et al. (2023) surveyed 144 nurses working across four acute medical wards and identified communication with families, conflicts about goals of care and staffing challenges as barriers to effective end-of-life care. Although their study examined nurses’ reported learning needs rather than patient experiences, it highlights the importance of clear communication during difficult treatment discussions. <Cite refs={[“turn478202view0”]}/>

Future practice should address three areas. First, I would request medical review when early warning signs develop alongside new confusion, reduced intake or other clinical concerns, rather than relying solely on the aggregate score. Second, I would use a more structured escalation approach, documenting the time of the concern, the person contacted, the response and any further action required. Third, I would monitor fluid administration and reassess the patient after each smaller bolus in accordance with current NICE guidance. I would also ensure that high-risk patients receive NEWS2 reassessment at the recommended frequency and that their capacity and treatment preferences remain under review.

Conclusion

Mrs A’s deterioration demonstrates the importance of early clinical recognition, evidence-based escalation and accountable nursing leadership in complex adult care. Her diabetes, COPD, CKD, recent surgery and cognitive vulnerability increased her susceptibility to complications and reduced her capacity to tolerate sepsis. Although the student nurse identified concerning changes and later escalated the emergency appropriately, the failure to obtain medical review at 10:00 allowed deterioration to progress. The case demonstrates that NEWS2 must inform, rather than replace, clinical judgement. It also highlights the importance of safe delegation, accurate documentation and decision-specific capacity assessments. Earlier escalation, closer observation and more cautious fluid administration could have improved the safety of her care. Effective adult nursing therefore requires practitioners to recognise changes early, challenge inadequate explanations and coordinate interventions while respecting the patient’s legal rights and individual preferences.

References

Department of Health and Social Care (2005) Mental Capacity Act 2005. London: The Stationery Office. Available at: https://www.legislation.gov.uk/ukpga/2005/9/contents (Accessed: 10 November 2026).

Ede, J., Petrinic, T., Westgate, V., Darbyshire, J., Endacott, R. and Watkinson, P. (2021) ‘Human factors in escalating acute ward care: a qualitative evidence synthesis’, BMJ Open Quality, 10(1), e001145. Available at: https://doi.org/10.1136/bmjoq-2020-001145.

Langkjaer, C.S., Bundgaard, K., Bunkenborg, G., Nielsen, P.B., Iversen, K.K., Bestle, M.H. and Bove, D.G. (2023) ‘How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: a fieldwork study’, Journal of Advanced Nursing, 79(2), pp. 789–797. Available at: https://doi.org/10.1111/jan.15547.

National Institute for Health and Care Excellence (2025) Suspected sepsis in people aged 16 or over: recognition, diagnosis and early management. NICE guideline NG253. Published 19 November 2025; updated 23 September 2026. London: NICE. Available at: https://www.nice.org.uk/guidance/ng253 (Accessed: 10 November 2026).

Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 10 November 2026).

Reid, J.C., Hoad, N., Willison, K., Hanmiah, R., Brandt Vegas, D., Mitri, M., Boyle, A., Weatherston, A., Lohin, S., McInnes, D., Rudkowski, J.C., Joyner, M. and Cook, D.J. (2023) ‘Learning needs and perceived barriers and facilitators to end-of-life care: a survey of front-line nurses on acute medical wards’, BMJ Open Quality, 12(2), e002219. Available at: https://doi.org/10.1136/bmjoq-2022-002219.

Royal College of Physicians (2017) National Early Warning Score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. London: RCP. Available at: https://www.rcp.ac.uk/improving-care/resources/national-early-warning-score-news-2/ (Accessed: 10 November 2026).