Complaint about the swallowing assessments
15. Mr T says his brother was choking on food and drink and this meant he developed a chest infection. He says the Trust should have considered other methods for feeding his brother, such as tube feeding.
16. In its response to the complaint the Trust said Mr O had ‘timely specialist swallowing assessments’ that were repeated during his admission. It disagreed that Mr O developed a chest infection whilst in hospital. It said his chest was ‘clear and symptom free’ after he finished the antibiotics on 4 May.
17. The RCP guidelines say swallowing difficulty is common after a stroke and it happens in 40 to 78 percent of cases. Swallowing difficulties can cause a type of chest infection called aspiration pneumonia. This happens when foreign objects such as food or drink enter the airway and lungs, rather than being swallowed, because the muscles that control swallowing are weakened.
18. The RCP guidelines say delays in the screening and assessment of swallowing difficulty lead to a higher risk of aspiration pneumonia. This means it is important that clinicians quickly detect swallowing difficulty in stroke patients.
19. The RCP guidelines say that when someone is admitted to hospital with an acute stroke, clinicians should perform an initial screening assessment of their swallow before giving them oral fluid, food or medication. This should be done within four hours of arrival at hospital. In the meantime, the person should not have any fluid, food or medications that will cause aspiration. Clinicians should consider alternative methods for giving these within 24 hours, for example with a drip or nasogastric tube (a tube that goes from the nose to the stomach).
20. This is what happened. Staff in the emergency department documented within three hours of Mr O being admitted that he was not able to safely swallow. The staff recorded that Mr O should be nil by mouth (not able to take anything orally) and they inserted a nasogastric tube. We found the Trust’s initial screening was in line with the recommendations in the RCP guidelines and there is no failing here.
21. The NICE stroke guidelines say a person should have a specialist assessment of swallowing within 24 hours of admission if the initial screening shows they are having problems. A speech and language therapist (SLT) does this assessment. Our SLT adviser said the aim of a specialist assessment is to establish the person’s swallowing ability, and to see whether they can safely eat and drink.
22. The SIGN guidelines say that during an initial specialist swallowing assessment the SLT should observe the person’s consciousness level and their ability to control their posture, oral secretions (saliva) and oral hygiene.
23. If appropriate, the SLT should then observe the person swallowing water. The assessment can progress to observing the person swallowing a selection of food and drink textures, where appropriate. This could include thickened water or soft food. The aim of this is to see whether it is safe to start oral trials (having a set amount of a certain thickness or consistency of food, a set number of times a day).
24. The SIGN guidelines also say that once an initial assessment is complete, the SLT should regularly review the patient to reassess the safety of their swallow. They should make a clinical judgement at each review about whether the person is able to take food and fluids orally.
25. The RCP guidelines say in cases where a patient needs thickened water or soft food, the SLT should reassess them and consider a specialist examination of their swallow called video fluoroscopy (VFS). This is an examination where an X-ray records a moving image of a person swallowing food and drink mixed with a dye. It can assess whether a person is aspirating when they swallow, and it helps SLTs decide what the person can eat and drink.
26. The records show us the SLT did an initial specialist assessment on 27 April, within 24 hours of Mr O arriving at hospital. This was in keeping with the NICE guidance. The SLT found Mr O was not alert enough to be assessed with any food or fluids, and he was not suitable for oral trials. There were no changes to his management plan. He stayed nil by mouth and the nasogastric tube stayed in place.
27. The SLT reassessed Mr O on 30 April and observed him swallowing thin fluids, like water, and yoghurt. The SLT found he had difficulty swallowing these, and that he should remain nil by mouth. The SLT reviewed Mr O on 3 May and the outcome was the same.
28. The SLT saw Mr O again on 8 May. At this assessment the SLT noted his function and alertness had improved slightly, and decided it was safe to start oral trials. He was started on a trial of five tablespoons of yoghurt, mousse or custard three times a day. The SLT reviewed Mr O on 10 May and decided he could now start to drink thickened fluids and eat pureed food. He no longer needed the nasogastric tube.
29. Our SLT adviser said the SLT’s initial and ongoing assessments of Mr O’s swallow and the subsequent eating and drinking recommendations were in line with the SIGN guidance. There is no evidence the Trust got anything wrong when it assessed his swallow function and decided he could start oral trials and move on to thickened food and fluids.
30. The records show that after making changes to Mr O’s eating and drinking plan on 8 and 10 May the SLT reviewed Mr O regularly. This was in keeping with the SIGN guidance. The SLT noted there was no improvement in his swallow function. Because of this, and the fact he still needed to eat modified food, the SLT arranged a VFS, which was in keeping with the RCP guidance.
31. The VFS took place on 31 May. It identified Mr O was not safe with thinner foods or fluid, and his current swallowing abilities were his new ‘normal’ level of function. The plan was for him to therefore continue drinking thickened fluids and eating pureed food.
32. There were no documented changes to Mr O’s swallow function after the VFS and the plan stayed the same for the remainder of his inpatient stay. Our SLT adviser said the recommendations from the VFS and the ongoing management plan were appropriate and in keeping with the SIGN and RCP guidance.
33. Overall, we found the Trust properly assessed Mr O’s swallow function when he was an inpatient from 26 April to 27 June, and it did consider other methods of feeding. It acted in line with the RCP guidance, NICE stroke guidance and SIGN guidance. There are therefore no failings here.
Complaint about the transfer to the rehabilitation ward
34. Mr T feels that, due to the issues with his swallow, his brother should have remained on the acute stroke unit or been cared for on an intensive care unit. In its response to the complaint the Trust explained Mr O was well enough to move to the rehabilitation ward.
35. The NICE rehabilitation guidelines say: ‘people with disability after a stroke should receive rehabilitation in a dedicated stroke inpatient unit’. Our stroke adviser explained it is normal for people to have ongoing swallowing problems when they are transferred to a rehabilitation ward.
36. An acute stroke unit is a type of ward that delivers medical care to people immediately after they have had a stroke. It is staffed by specialist doctors and nurses. The focus of care is on stabilising the person’s medical condition and treating their stroke. An intensive care unit is a ward that specialises in treating people who are seriously ill and whose lives are in immediate danger.
37. A stroke rehabilitation ward provides care for people who are medically stable but have ongoing disability. There is medical and nursing cover, but the focus of care is on rehabilitation from allied health professionals such as physiotherapists, occupational therapists and speech and language therapists. This is the type of ward Mr O went to and is the type of ward recommended in the NICE guidance.
38. Our stroke adviser said the evidence in the records shows Mr O was medically stable when he moved to the rehabilitation ward. Although he was stable, he was still suffering from disability because of the stroke. As well as problems swallowing, Mr O was having issues with his cognition, mobility, and ability to wash, dress and feed himself. We therefore found the decision to transfer Mr O to a rehabilitation ward was in keeping with the NICE rehabilitation guidelines and there are no failings here.
Complaint about the capacity assessment
39. Mr T complains the Trust did not appropriately assess Mr O’s capacity before his discharge. He says the paperwork appears to refer to another patient in parts. He says this raises concerns that the Trust did not properly consider his brother’s human rights and wishes.
40. In its response to the complaint the Trust said it needed to do a mental capacity assessment to see Mr O’s ability to decide about his discharge arrangements. The Trust said that when the outcome of the assessment showed Mr O did not have capacity to make discharge decisions, it appropriately involved his attorneys and the multidisciplinary team.
41. The MCA code of practice says mental capacity is the ability to make decisions. It applies to decisions that affect daily life, such as when to get up, what to wear or whether to go to the doctor when feeling ill, as well as more serious or significant decisions, such as where to live.
42. The MCA code of practice says clinicians should assume someone has capacity to make a specific decision themselves unless it is proved otherwise. In some cases, clinicians will need to carry out a capacity assessment to see if a person has mental capacity to make a specific decision at the time it needs to be made.
43. The MCA code of practice says a person is deemed to have capacity if they can:
• understand information relevant to the decision in question, • retain that information, • use the information to make their decision, and • communicate the decision.
44. The Trust noted that Mr O had ongoing cognitive problems because of his stroke, and he regularly showed that he had limited insight into his condition and abilities. The Trust did a capacity assessment on 22 June to see if Mr O could decide his discharge destination.
45. The capacity assessment found Mr O did not understand the information provided to him about his discharge and he could not retain the correct information for long enough to weigh up his options. He recalled information inaccurately and the stroke had affected his ability to solve problems and make plans. He did not communicate a decision about discharge. The outcome of the assessment was that Mr O did not have mental capacity to decide where he would go when discharged from hospital.
46. Our physician adviser says the Trust’s assessment of Mr O’s mental capacity was in keeping with the principles of the MCA code of conduct set out above. We have seen no evidence the Trust got anything wrong when it assessed Mr O’s capacity. There are no failings here. Because we have not seen any failings in the capacity assessment or paperwork, we have not gone on to consider the impact on Mr O’s human rights that Mr T claims.
47. We note that whilst Mr O’s name is on the front page of the assessment booklet, another patient’s name is on page six of the booklet. We can see why that would have made Mr T doubt other areas of the assessment. We have not seen anything to suggest the assessment does not relate to Mr O. The incorrect name seems to be an administrative error. We hope our explanations above provide reassurance about the assessment.
Complaint about the discharge to a nursing home
48. Mr T says Mr O should have stayed in hospital. He says a nursing home would not have been able to meet his brother’s swallowing needs, specifically his risk of aspiration. We have considered whether Mr O’s swallowing needs meant he should not have gone to a nursing home.
49. The RCP guidelines say people should continue with rehabilitation ‘for as long as they are willing and capable of participating and showing measurable benefit from therapy’. Our stroke adviser said once a patient is no longer meeting their rehabilitation goals and not showing any improvement, rehabilitation may no longer be appropriate.
50. Our stroke adviser explained it is common that people are discharged from hospital with an ongoing disability. Rather than people staying in hospital once their rehabilitation has ended, the RCP guidelines say they should be discharged to a location where their needs can be met. This could be at home with additional support, or a care home (this includes nursing homes).
51. A nursing home provides round the clock care and accommodation to residents, and there are also nurses available to provide support to those with complicated medical problems or care needs. As with nurses in a hospital, nursing home nurses can provide care for people with swallowing, mobility and cognitive problems, and those at risk of aspiration.
52. We have seen no evidence Mr O’s swallowing needs should have prevented him being discharged from hospital to a nursing home. There are no failings here.
53. We next looked at Mr T’s concern that the Trust did not provide the nursing home with adequate instructions about Mr O’s swallowing problems. The NICE rehabilitation guidelines say that when a person is discharged from hospital into the community (including to a nursing home), clinicians should provide information to the people that will be involved in their future care.
54. This information should include a summary of the person’s diagnosis and health status and their care needs. There should also be information about the person’s functional abilities, which could include their communication needs, mobility problems and swallowing status.
55. Our SLT adviser said the role of a speech and language therapist is to provide information to patients, carers and healthcare staff about impairments, disabilities, and management of swallowing problems. Our SLT adviser said this information should be included in any onward referrals or discharge information.
56. The records show that before Mr O was discharged to the nursing home, staff from the hospital were in contact with nursing home staff. The lead nurse from the nursing home came to assess Mr O on the ward. The records show the lead nurse had access to information about Mr O’s needs.
57. The nursing staff completed a written handover for the nursing home. The handover gives a range of information about Mr O’s care needs, and it specifically includes information about his ability to eat and drink. The form states that he required thickened fluids and pureed food and needed assistance with feeding. This was in accordance with the speech and language therapy care plan and was in keeping with the NICE rehabilitation guidelines.
58. The SLT completed a referral to the community SLT team. The referral gives information about Mr O’s eating and drinking, the need for regular oral care and that his chest health should be monitored. It also includes a copy of the detailed VFS report and the recommendations from that. The referral requests a review of Mr O’s swallow in the community to check he is still tolerating the modified diet, and for support with his communication needs.
59. We consider the referral to the community team ensured that as well as the nursing home being aware of his problems, the specialists that would see him in the community were also aware. This was also in keeping with the NICE rehabilitation guidelines.
60. Taking into account our SLT and stroke advisers’ views, and the contents of the medical records, we consider the Trust provided adequate information to the nursing home about Mr O’s swallowing problems, modified diet and need for assistance. This means there is no failing here.
Complaint about the chest infection
61. Mr T says his brother should not have been discharged on 27 June, because he had a chest infection, in the form of aspiration pneumonia. He said the infection got worse and this led to Mr O being readmitted to hospital on 21 July. The Trust disagreed and said Mr O did not have a chest infection when he was discharged from hospital on 27 June.
62. The NICE pneumonia guidelines apply. These guidelines say a diagnosis of pneumonia (which would include aspiration pneumonia) is based on symptoms and signs of a respiratory infection. These are a cough, a high temperature and difficulty breathing. A diagnosis of pneumonia is confirmed if an X-ray shows a hazy shadowing on the lung.
63. The records show us that a doctor saw Mr O on 26 June, the day before he was discharged. The doctor noted Mr O was feeling well and was comfortable. There was no sign of a high temperature and his heart rate and blood pressure were normal (these can be high when someone has an infection).
64. Our stroke adviser says the evidence shows Mr O was clinically well and there were no signs of infection. Taking this and the NICE guidelines into account, we found the Trust’s decision to discharge Mr O on 27 June was appropriate and there are no failings here.
Conclusion
65. Overall, we have seen no failings in the Trust’s care and treatment of Mr O. We found the assessments and management of Mr O’s swallowing problems and the capacity assessment were in line with what should happen.
66. We found the Trust’s decision to move Mr O to a rehabilitation ward was appropriate. A nursing home was an appropriate setting, and the Trust provided the right information to the nursing home. Lastly, there is no evidence the Trust discharged Mr O with a chest infection.
67. It is on this basis that we do not uphold the complaint.