Nutrition and fluid intake
17. Miss A says the Trust did not make adequate attempts to manage Mr C’s nutrition and fluid intake during his admission. She says more should have been done, including the insertion of a nasogastric tube (NGT) to aid with the provision of nutrition.
18. The Trust said it made several attempts to encourage Mr C to eat and take fluids, but he refused to do so on multiple occasions. The Trust says it attempted to insert an NGT on 21 April 2017 however Mr C pulled this out himself, and reinsertion would have been high risk because of this. The Trust then attempted to insert a further NGT on 24 April which was unsuccessful.
19. It is evident the clinical team recognised Mr C was not meeting his nutritional or fluid requirements at an early stage in the admission. We can see the clinical team identified nutritional issues at 15:39 on 6 April 2017 (first day of admission), where he refused to eat, and drink was documented. Multiple entries in the nursing notes indicate attempts were made to encourage Mr C with his eating and drinking. For example on 7 April at 17:10 it is noted that Mr C ‘ate a good lunch with assistance,’ and on 10 April 2017 at 16:00 it is documented that Mr C was encouraged to eat ‘small amounts of solid food cut up.’ After 10 April 2017 Mr C’s nutrition declined and there are multiple entries within the clinical notes showing that the Trust discussed Mr C’s on-going challenges with his nutritional care with family members. Our physician adviser has confirmed IV fluids were prescribed and administered and referrals were made to a dietician on 10 April and the speech and language therapy (SALT) team on 13 April for assessment and involvement of these practitioners.
20. The notes go on to make reference to an attempted insertion of an NGT on 21 April 2017 and on 24 April 2017, however it is noted these attempts were unsuccessful due to resistance from Mr C, and he removed the tube himself. There is also an entry in the notes which details Mr C resisted a nasal bridle (a nasal tube retention device) which would have aided the administration of nutrition and fluids.
21. We asked our nursing adviser to review the notes and records and asked her if the attempts to give Mr C adequate nutrition were reasonable and in line with what would be expected given Mr C’s presentation. Our adviser explains nutrition and hydration are basic human needs and are fundamental aspects of nursing care as per the Nursing and Midwifery Council (NMC) code section one. They explain that it is fundamental that those receiving care have adequate access to nutrition and hydration, and nurses should provide help to those who are not able to feed themselves or drink fluid unaided.
22. We are persuaded the Trust appropriately identified concerns and monitored the clinical picture for Mr C, whilst trying to encourage his oral intake. GMC guidance explains that medical professionals must respect a patient’s decision to refuse treatment and work with them to convey the benefits. Our physician adviser explains a person with dementia and difficulty in swallowing is a difficult situation and the clinicians have to consider what is in the best interests of the patient. To persist with oral feeding would increase the risk of food getting into the lungs (aspiration) while not to do so would mean the person does not receive nutrition. We appreciate there were challenges in this case and how distressing this will have been for the family. Nevertheless, we appreciate the Trust were limited in what they could do at this time. We can see from the records that there are entries documenting discussions with family members regarding the on-going challenges with Mr C’s nutritional care and options available supporting the Trust’s attempts to encourage this.
23. However, Miss A expressed concern that the NGT insertions were unsuccessful at the time they were considered appropriate. The clinical records indicate the difficulties with oral nutrition were noted and a consideration was given to alternatives. We have seen that this decision was made after asking for input from the family as to Mr C’s wishes.
24. Miss A accepts Mr C resisted the insertions but believes the Trust should have done more to provide her father with nutrition and therefore the attempts the Trust made were not adequate to meet his nutritional needs.
25. Our physician adviser explained that the option of tube feeding is not recommended by NICE (Enteral (tube) feeding for people living with severe dementia), as there is no evidence to suggest tube feeding improves how well-nourished the person is. As such, we would expect a decision to be made by clinical staff where they believe it was appropriate to try. We can see a decision was made to attempt to pass an NG tube.
26. We have also taken account of RCPE Guidance. This explains that a decision to insert a tube should be made after full sharing of facts and uncertainties about positives and negatives. They also emphasise, taking account of the patient’s previously expressed or implied wishes, beliefs and values, and those of family members or others concerned for the patient. Nevertheless, they are clear that where requests are made attempts should be made where resources allow for this. However open communication and building a trusting relationship with family members is considered to be essential to the process. We have identified above that the decision was made after input was sought form the family as to Mr C’s wishes and can see this is in line with guidelines. We also note the use of mittens was discussed however this was decided against.
27. After discussion with the family we can see the Trust attempted to insert an NG tube twice. We fully appreciate Miss A’s concerns that more should be done but can also appreciate that in light of the possible positives and negatives it was reasonable for the decision to be made not to continue attempts.
28. After considering the evidence available in relation to the concerns about nutrition and fluids, it is our view the Trust made reasonable attempts to provide Mr C with food and fluids. We fully appreciate that concerns about nutritional input would have been distressing for Mr C’s family but have not seen any failings by the Trust in the provision of nutrition and fluids for Mr C.
Deprivation of liberties (DOLS)
29. Miss A says in the light of Mr C’s presentation, and the resistance to the NGT tube, it would have been appropriate to apply DOLS, and put mittens on Mr C’s hands so he would not be able to resist the NGT tube and pull it out.
30. The Trust confirms they did not use mittens and therefore did not apply DOLS. It says it had discussed the use of mittens with Miss A, and says in the same conversation it was established Mr C would not have wished to have been treated aggressively if it meant that he was not going to be able to enjoy the quality of life before he was admitted. The Trust says it endeavours to understand what a patient’s pre-expressed wishes were in relation to their care, and often asks the family members present when a patient is acutely unwell and not able to communicate or express their wishes freely.
31. The Deprivation of Liberty Safeguards are an amendment to the Mental Capacity Act 2005. The Mental Capacity Act allows restraint and restrictions (such as mittens) to be used, but only if it is in the persons best interest (Mental Capacity Act 2005 Schedule A1 12 (1) (d)) . The Department of Health consolidated guidance clearly sets out that in an emergency situation where the person lacks the ability to consent, care and treatment should not be delayed but should only progress in the best interests of the patient.
32. In situations where a clinician must decide whether to apply for DOLS when a patient is too unwell to make decision by themselves, we would expect them to consider what is in the patient’s best interest. We can see in the notes, there was a conversation between a doctor and Miss A on 25 April 2017 in relation to the abovementioned concerns. The doctor asked Miss A to describe what Mr C would have wanted ‘if he could see himself now’, to which it is documented Miss A explained ‘it was always clear that he wouldn’t want to be like this i.e. unable to enjoy life and that he would not want to be someone who is sat in a chair all day’. It is at this point we can see Miss A asked about the use of mittens. Mittens can be used to minimise the risk of the patient removing an NGT and in such circumstances, it would be appropriate to apply for an urgent authorization for a DOLS request as mittens are considered a form of restraint. However, we appreciate the Trust considered that in light of information about Mr C’s wishes it was not reasonable.
33. While we can see this is clearly an emotional situation, we are persuaded that the Trust appropriately considered the factors in the possible use of mittens and have seen no failing in their approach to this.
Physiotherapy
34. Miss A says during Mr C’s admission, the Trust failed to provide adequate physiotherapy for Mr C’s needs.
35. The Trust says it attempted to provide physiotherapy to Mr C on numerous occasions, however Mr C did not, or was unable to engage with the physiotherapists at the times they tried to engage with him.
36. There is no dispute about whether physiotherapy was planned, instead the focus here is whether the Trust provided adequate physiotherapy. Miss A complains that her father only got out of bed three times, and this was only because she made it clear that due to Mr C’s Parkinson’s his condition would deteriorate if he did not mobilise.
37. We can see in the records attempts were made to sit Mr C on the edge of the bed on 10 April, but it is documented he had very poor sitting balance and leaned backwards, and a decision was made to transfer Mr C, when required, by hoist. Our nursing adviser explained the decision to use a hoist transfer when required was appropriate to minimise the risk of harm to him and to the staff caring for him. They referred to the Manual Handling Regulations 1992 as amended 2002, which clearly sets out the need to balance risks of manual handling against the benefits and puts duties on employers to minimise hazardous activities. Furthermore on 11, 12 and 18 April there are multiple entries of attempted physiotherapy with Mr C, often with an occupational therapist present also, however it is noted Mr C was either too sleepy or variable in his level of compliance with the therapists.
38. After considering this element of the complaint, we can see several attempts were made to provide Mr C with physiotherapy. We fully appreciate Miss A’s view that more should have been done but we can see attempts at physiotherapy were made, and in terms of limited mobilisation safety concerns for both Mr C and staff noted and alternative arrangements were made. On balance we have not found any failings in relation to the actions of the Trust for this element of the complaint.
Pressure sore
39. Miss A says Mr C developed a pressure sore, by not being adequately moved in bed during his admission.
40. The Trust told us it cannot recall the pressure sore, and it could not have been more than a grade two pressure sore. The Trust does not directly comment on the adequacy of the care Mr C received in relation to his pressure sore management, however the Trust saying that ‘it could not have been more than grade two’ suggests that they believe there was a sore. However, the pressure sore has not been documented in any complaint response, nor does it appear to have been complained about to the Trust. We have opted to consider this element of complaint as proportionate when considering the remainder of his care.
41. We have reviewed the medical records, and can see on 21 April 2017, a tissue viability nurse reviewed Mr C and confirmed he had a grade 2 pressure sore. The records suggest that this healed by 12 May 2017.
42. Our nursing adviser explained they would have expected the NICE guidelines for pressure sores to be followed in this case. The guideline recommends an adult at risk of a pressure sore should be encouraged to change their position frequently, and every six hours, with assistance if needed. It says the frequency of the repositioning required should be documented. The guidelines also state people at high risk of pressure sores should repositioned every four hours.
43. The adviser confirmed the pressure ulcer risk assessment was not completed as they would have expected, which would identify how at risk he was of developing pressure sores and the frequency of his need for repositioning not identified. Furthermore, we can see no basis to suggest that Mr C was either advised to reposition every six hours or given assistance to reposition every six hours prior to 11 April within the records, as an adult at risk of a pressure sore. As such we find a failing in the Trust’s approach to pressure sore management here.
44. Upon review the clinical records show the positioning regime charts were often sporadically recorded, with long gaps. We can see on 27 April the chart was only completed twice at 22:00 and 24:000, on 1 May the chart was completed three times between 2:00 and 7:00 and then not at all for the rest of the day. On 2 and 3 May 2017 the chart was only completed once both days at 22:00. Therefore, due the lack of entries in the positioning charts this would indicate that he was not moved frequently enough as there is no basis to say that he was.
45. We asked our adviser to consider if the lack of repositioning was sufficient to cause the pressure sore to develop. The adviser says it was not possible to establish, if this by itself led to the pressure ulcer Mr C developed. The adviser says it would be due overall to his general poor condition and lack of nutrition but it seems that lack of repositioning could contribute as repositioning is noted to be an important factor where someone is at risk of developing a pressure sore.
46. At the point the TVN reviewed him we understand he was considered to have a grade two pressure sore. The adviser explained they could see no recommendations made by the tissue viability nurse as to how often Mr C should be repositioned by this point. We find a failing in this. Our adviser says based on the current guidance this should have been at least four hourly in light of the pressure sore.
47. We do know the pressure ulcer occurred during his time in hospital, and subsequently healed. On balance, although it is not possible to determine if appropriate repositioning of Mr C would have avoided the pressure ulcer developing, the lack of frequent movement would have likely contributed to the development of the pressure ulcer and associated discomfort.
48. In light of this and in the absence of appropriate record keeping, we find a failing in the management of his pressure sore care, and as such, this is our view. We will go on to explain what recommendation we are making in light of this.
Parkinson’s medication
49. Miss A says the Trust failed to manage Mr C’s Parkinson’s adequately as he went five days without treatment. The Trust accepts there was a delay in providing medication. They say he was prescribed a drug patch on 7 April (after admission the previous day) when they realised, he had not taken his Parkinson’s medication prior to the transfer and they apologised for this. They also accepted that whilst a patch was placed in lieu of his oral medication at that point, it was at too low a dose over the early days of admission. It says this was corrected on 10 April and it was expected that the symptoms would have come under control shortly after the application of a patch at the correct dosage. The Trust say therefore that Mr C was without treatment for two days and was at the incorrect dosage until 10 April.
50. A NICE quality statement from the 2018 guideline states that ‘Adults with Parkinson’s disease who are in hospital or a care home take levodopa within 30 minutes of their individually prescribed time’. Whilst we accept this guideline came after the care Mr C received our neurology adviser explained this highlights the usual expectations around the provision of this medication.
51. We can see from the records that Mr C was considered to be unable to take oral medication when admitted to the Trust on 6 April. Our adviser explains the usual approach in this situation would be to site a nasogastric tube and provide the medications via that route. In circumstance where a nasogastric tube cannot be sited, oral medication should be promptly substituted with a rotigotine patch or occasionally via a subcutaneous infusion of apomorphine.
52. The records confirm that on 7 April a patch was ordered to replace his Parkinson’s medication which he was considered not to be able to take orally. On 8 April there was a note for a regular team to switch medication to a patch and contact the Parkinson’s nurse if he was unable to take medication orally. On 9 April there was a conversation between the Trust and Miss A who was concerned his father had not been prescribed patch until that morning and had been without treatment. On 10 April it was noted that a further patch was administered at a higher dosage. The ‘rotigotine patch’ was increased to 4mg/24 hours presumably from 2mg/24hours.
53. Our adviser explained that on 10 April the oral medication was replaced with rotigotine, but the dose offered was likely inadequate, and there does not appear to have been an attempt at titrating the dose to an optimal level (adjusting the medication to its maximum effective dose). They concluded that this may be because it was considered that a higher dose would worsen Mr C’s confusion but there is no documentation to indicate any clinical decision making around this.
54. We are persuaded that there was a failing in the Trust providing Mr C’s Parkinson’s medication promptly and to an adequate level. Our neurology adviser considered this likely had some impact on Mr C’s condition. This is because the delay in administering his medication correctly likely meant that his Parkinson’s related symptoms were not well controlled. Therefore, this would have impacted his comfort and overall condition. However, our adviser explained Mr C’s Parkinson’s disease was at a complex stage by this time and at such a time medication rarely improves this significantly. Overall, whilst we can say there will have been an impact on him, we cannot say this had a significant clinical impact on his condition.
Potassium monitoring
55. Miss A says the Trust failed to adequately monitor Mr C’s potassium during his admission, specifically when it was noticed he had low potassium on 15 May for 12 hours before a doctor prescribed potassium to correct this. She was concerned that he was put at risk of cardiac arrhythmias.
56. The Trust disputes this saying Mr C received regular potassium replacement in the form or normal saline with IV potassium chloride. The Trust says appropriate maintenance fluids (called plasmalyte), which included potassium, was administered.
57. NICE guidance for patients ‘Monitoring patients in hospital and caring for them if their health becomes worse’ is clear that your vital signs should be monitored on a twelve hourly basis during a hospital inpatient stay. Our physician adviser says he can see evidence of regular potassium monitoring through the records including the 15 May and as such based on the evidence available cannot see there was a 12-hour delay.
58. Our adviser explains that a person with a presentation such as Mr C had, would find it difficult to maintain an adequate level of potassium due to the lack of nutrition. However, we have seen evidence in the records to suggest the potassium was monitored, and with the advice from our adviser, we cannot see the Trust has failed in relation to monitoring Mr C’s potassium.
Basic nursing care
59. Miss A says that the nursing staff were unable to carry out basic care adequately.
60. After reviewing the complaint file, we can see that the Trust has not formally responded to this part of the complaint however we considered it proportionate to consider it in tandem with the remainder of the care.
61. We asked our nursing adviser if they had any concerns to the level of nursing care demonstrated by the clinical records. They explained that outside of identifying failings in relation to Mr C’s pressure sores, the nursing records provide evidence of a reasonable standard of nursing care.
62. The NMC 2015 guidance sets out what standard of nursing care is expected. It is expected that clear and accurate records are kept, patients are adequately monitored, and appropriate referrals are made. Within Mr C’s medical records our adviser reflected there is evidence of assessment, care planning, evaluation and review of care delivery. Furthermore nursing staff appropriately monitored Mr C and escalated any concerns in regard to his condition to medical staff. There is evidence that referrals were made to other members of multi-professional teams for example, speech and language therapy, dietetics and tissue viability.
63. We have seen evidence to suggest the nursing care was adequate within the medical records, and with the advice from our nursing adviser. It is our view that we cannot find any failings in relation to the actions of the Trust for this element of the complaint.
Rude nursing staff
64. Miss A says throughout Mr C’s admission, the nursing staff were rude to Mr C, her and the family. She raises a number of concerns in her complaint file about the nursing’s staff’s behaviour. She explains that when she expressed concerns about the care her farther was receiving a staff nurse said ‘if I don’t like it do it myself’ and also when she enquired about bed sores the staff nurse said ‘what do you expect, he’s bed bound and on an air mattress’.
65. After reviewing the complaint file, we can see the Trust has not formally responded to this element of complaint. Nevertheless, we considered it reasonable to consider this are of complaint when considering the remainder of Mr C’s care. 7 NMC 2015 The Code professional standards of practice and behaviour for nurses and midwives’ section 1- introductory paragraph, section 1.2, section 10.1 and 10.2 8 NMC 2015 The Code professional standards of practice and behaviour for nurses and midwives section 13.1 and 13.2
66. We were not privy to the conversations from which the allegation is made, and the attitude of staff is not documented in the medical records. In the absence of other evidence, we are not able to say the nursing staff were rude. It is important to note, by saying this we are not suggesting we do not believe the complainant but cannot point to evidence to support either account.