Parkinson’s disease medication
17. Mrs A says nurses were often late, or missed, giving her father his Parkinson’s disease medication. She says this caused delirium and confusion and led to an increased risk of falls.
18. Parkinson’s disease is a chronic neurological condition which causes a lack of dopamine (a chemical in the brain which affects a range of interactions in the body). The condition leads to difficulty controlling movement, with tremor (involuntary trembling or shaking movements), stiffness, slowness of movement and balance and posture problems as the main symptoms.
19. The Medication Guideline says Parkinson’s disease medication is time critical. This means it needs to be taken at specific times. The dosage and time are individual for each patient. The Parkinson’s Disease Guideline stresses the need for clinicians to administer medication ‘at the appropriate time.’ The Medical Adviser told us he would expect staff to administer medication within 30 minutes of the planned time.
20. On Mr T’s admission, staff noted he had Parkinson’s disease. They prescribed Stalevo three times a day and rivastigmine twice a day to treat it. They also made a referral Parkinson’s disease specialist nurse who assessed Mr T on 18 November 2014. The specialist nurse recommended an additional medication. This was co beneldopa (another Parkinson’s disease medicine), which Mr T was to take first thing in the morning.
21. The medication charts show Mr T was due to take co-beneldopa at 7.30am, rivastigmine at 9.00am and 6.00pm and Stalevo at 9.00am, 12.00pm, 6.00pm and 10.30pm each day. The records show nurses only gave these at the correct times on a few occasions. Most of the time the medication was late. Sometimes doses were completely missed without any recorded explanation.
22. Between 2 and 5 December 2014 staff recorded Mr T refused to take his tablets. On 3 December a doctor recorded their opinion that Mr T’s refusal to take medication was contributing to his delirium. The doctor asked for nurses to administer rivastigmine as a patch, and Stalevo to be dissolved in yoghurt. The doctor also wrote in the records ‘please, please, pay attention to meds as huge delays can precipitate worsening delirium’.
23. On 5 December Mrs A found some tablets in her father’s bed and raised concerns with the medical team. The doctor noted Mr T was ‘confused and distracted, unable to identify family members, unaware he is in hospital’. On that day, he had co-beneldopa at 10.50am, three hours and twenty minutes late. Three of the four doses of Stalevo that day were also late, with the first dose given over two hours late.
24. It is clear Mr T sometimes refused medication, and there were delays in arranging for changes to improve this (such as patches and soluble tablets). There is no evidence soluble tablets were dissolved into food or drink as requested by the doctor. There is evidence Mr T did not always take medication once nurses dispensed it. Incidents were noted by the family and doctors.
25. We find staff at the Hospital did not follow the Medication Guidelines or the Parkinson’s Disease Guideline in respect of Mr T’s medication for Parkinson’s disease. Nurses often gave medication late and, sometimes, did not give it at all. When medication was omitted nurses often failed to document why. They also delayed implementing medication changes when doctors asked them to do so. And there were incidents when staff incorrectly recorded medication as being dispensed.
Impact of failings in medication management
26. Mrs A says the failings in managing Mr T’s Parkinson’s disease medication increased his confusion, leading to hallucinations and an increased risk of falls.
27. The Nursing Adviser told us how, if staff do not give medication within two hours of the prescribed time, there could be a significant or catastrophic long-term impact on the patient.
28. The Medical Adviser said rivastigmine is a slow-acting medication, so it is unlikely it would have had any effect on Mr T’s cognition or his risk of falling at this time. However, he said co beneldopa and Stalevo are time critical. He said delays can lead to slowing in motor functions. If nurses regularly gave medication late this could have led to Mr T having increased muscle stiffness, leading to mobility issues and an increased risk of falls.
29. The Medical Adviser said it is unclear from the records how effective Stalevo was for Mr T. He said it is unlikely the problems with administering Stalevo led to delirium. It is more likely it would have led to some ‘slowness of thought.’ The issues with Stalevo and co beneldopa could have increased the risk of hallucinations.
30. We find that, even if the medication had been given on time, Mr T might still have fallen. This is because there are a range of factors that can cause someone to fall. In Mr T’s case he already had cognitive impairment and a lack of understanding about his situation. This meant he tried to get out of bed when it was unsafe. He was also very frail.
31. We cannot say, even on the balance of probabilities, that missing or delayed medication had a significant impact on Mr T’s health. We also cannot say he would not have fallen if the failings had not happened. We can say the failings increased the risk of Mr T experiencing hallucinations and falls. We can also see how it would have been distressing for Mr T’s family to witness some of the failings in medicines management and how they are left with doubts about what might have happened if the errors had not taken place.
32. The Trust acknowledged in its investigation there were delays in giving Mr T his Parkinson’s disease medication and inadequate documentation. It apologised for these failings during its investigation of Mrs A’s complaint.
33. The Trust told us how it has acted since 2014 to improve staff administration of Parkinson’s disease medication. It said recent audits showed no missed doses on the wards. It introduced staff training and staff now ensure they give time-critical medication within fifteen minutes of the scheduled time. It has also carried out audits showing improvements in completing documentation about medication.
34. The Trust took part in the National Parkinson Audit in 2015 and 2017. It says its own standards were higher than the national benchmark, yet it recognised it had more work to do including with time critical medication. It created an action plan to improve its services for patients with Parkinson’s disease. This included a ‘Get It on Time’ Parkinson medication project in October 2018.
35. Our view is the Trust has taken appropriate action to show there has been learning following Mrs A’s complaint. We do not ask it to do anything more in this respect. However, it has yet to acknowledge all the failings in medication management and should apologise to Mrs A for the impact these had.
36. We partly uphold this aspect of the complaint.
Falls management before the fall on 6 December 2014
37. Mrs A complains about the circumstances of her father’s fall on 6 December 2014. She recalled the ward staff contacted her that morning to say her father had fallen and suffered a suspected hip fracture. Mrs A was concerned about how nurses allowed the fall to happen.
38. The Nursing Adviser said all patients aged 65 years and over should be considered at risk of falling when in hospital. Patients with a known history of falls are at greater risk and may be affected by additional factors such as acute illness or delirium, as in Mr T’s case. Nurses should assess patients for their individual risk factors so they can mitigate the risks.
39. Nurses should follow the NICE Falls Guideline. This stresses the importance of carrying out a ‘multifactorial falls risk assessment’ for older people when they arrive in hospital. This is an assessment which should consider the patient’s history, mobility, impairments, and environment. The NICE Falls Guideline says health care professionals should consider interventions for patients who have an increased risk of falling. In Mr T’s case nurses offered various interventions and used a Hi-low bed on occasion (this is a bed that can be lowered closer to the ground if necessary).
40. Records show a nurse completed a ‘multifactorial falls risk assessment’ for Mr T on 15 November 2014. This identified Mr T had a high risk of falling. The nurses arranged for Mr T to have an ultra-low bed and placed him in a bay where he was more visible to staff over the following days. They also identified Mr T needed one-to-one nursing. The Nursing Adviser told us these actions were in line with the NICE Falls Guideline.
41. Nurses should also follow the NPSA Guideline. The NPSA Guideline sets out how healthcare professionals should act when a patient has fallen. These include reassessing the patient’s risk of falling then observing and monitoring them. They should also make referrals to doctors when appropriate.
42. The Trust Falls Policy explains how staff should respond when a patient falls in hospital. It also says staff should reassess the risk of the patient falling. They should increase the frequency of patient contact rounds.
43. The clinical records show Mr T fell on seven occasions during his admission to the Hospital. Four of the falls happened before the incident Mrs A complains about. We have looked at how staff responded to the falls before the incident in question to see whether they followed the relevant guidelines when managing Mr T’s risk of falling.
44. On 26 November 2014 Mr T fell when he could not stand and lowered himself to his knees. The records show staff witnessed the fall and arranged for a doctor to review Mr T. There is no evidence staff reassessed Mr T’s falls risk following the incident or that they increased the frequency of observations. Staff did not follow the NPSA Guideline or the Trust Falls Policy following Mr T’s fall. However, this failing did not contribute to the fall on 6 December because of the other falls that took place before that incident.
45. At 3.00am on 2 December 2014 Mr T fell from his bed. Nurses heard him fall and found he had small abrasions behind one ear and to his back. The nurses reviewed Mr T’s falls risk and decided to check on him every hour with one-to-one nursing. They also contacted the doctor on-call. Mt T fell again when trying to move from a chair at 11.00am on the same day. This fall did not result in any injury. The records show nurses arranged for a medical review. They again assessed his risk and noted that contact rounds needed to take place hourly. They followed the relevant guidelines.
46. At 1.10am on 3 December 2014 Mr T fell and cut his forehead. Nurses asked a doctor attend and recorded Mr T’s observations. They reviewed his falls risk and noted he was already receiving the appropriate level of monitoring. They stressed an ‘extra member of staff should be called so the patient is not left even for a few minutes as went from being settled to being out of bed quickly.’ In the records staff referred to this arrangement as Mr T being ‘specialed.’ The nurses placed a crash mat by Mr T’s bed. Again, the nurses acted in line with the relevant guidelines immediately after the fall.
47. The Nursing Adviser told us that when patients require one-to-one nursing this means nurses, or a health care assistant, should be with the patient throughout. The exception would be if there was an emergency, such as another patient having a cardiac arrest.
48. The fall Mrs A complains specifically about happened at some point on the morning of 6 December 2014. We will discuss the timing of the fall later in the report. The fall led to Mr T breaking his right hip.
49. We have reviewed records relating to some other patients who were on the ward during the hours before Mr T fell. These do not suggest there was any emergency that would have meant nurses leaving Mr T unobserved. Staff statements, from the two nurses on duty, say there were two other patients who needed close observation at the time and nurses recalled they were attending to another patient when Mr T fell. They left Mr T unobserved because they thought he was asleep.
50. There are gaps in the nursing record for the morning of 6 December 2014, particularly between 4.00am and 6.00am. This is despite the plan to provide one-to-one nursing for Mr T. This could mean nurses failed to complete the records rather than an indication that observation did not happen. At this point in time we cannot establish exactly what happened. But it is clear the nurses were not observing Mr T when he fell, despite the plans that were in place.
51. We find the nurses did not follow the NPSA Guideline when they failed to supervise Mr T in line with the plan following the fall on 3 December 2014. Had nurses adhered to the plan and observed Mr T when he attempted to leave his bed it is possible they could have prevented his fall. However, it is also possible Mr T could have fallen before the nurses had the opportunity to act.
52. This means we cannot conclude, on the balance of probabilities, that nurses would have prevented the fall if the failings had not happened. We cannot say the fractured hip was avoidable. But Mrs A and her family are now left with doubts about what might have happened if the failings had not taken place. This is a significant injustice to them. We partly uphold this part of the complaint.
53. The Trust has already acknowledged its failings relating to the fall and apologised to the family that the fall resulted in a fracture. It made recommendations following its root cause analysis (RCA) investigation. It planned to review falls training for ward staff and improve record keeping.
54. The Trust told us it updated its falls training for staff in February 2015. It audits the wards monthly to try and ensure staff are adhering to the relevant policies. The Trust also carries out daily spot checks to ensure staff complete documentation appropriately. The Trust shared information with us that showed a reduction in falls from 1,024 in 2013-14 to 700 in 2017-18. We are satisfied the Trust has taken appropriate action about this issue and we do not ask it to do anything further.
Timing of the fall
55. Mrs A says the Trust has given five different accounts about when the fall happened. She says a whistle-blower from the Hospital contacted her in July 2015. This former member of ward staff said the fall had taken place at 9.00pm on 5 December 2014 when nurses had left her father unattended. Mrs A said another member of staff working that night recalled a fall resulting in a fracture.
56. The Trust’s investigations and complaint responses have stated various times for the fall. This has clearly led to confusion for Mrs A and her family. The Trust’s most recent investigation considered the fall happened shortly after 6.00am. It confirmed there had been another fall for a different patient the night before, but it had not resulted in a fracture.
57. The first mention of Mr T’s fall in the clinical records is at 7.50am on 6 December 2014, when a nurse recorded the events of the fall. A doctor recorded their assessment at ‘8.20pm’. This is clearly a typographical error as staff made the notes which follow on later that morning. Our view is this entry should read 8.20am.
58. There is no evidence in clinical records or staff statements to suggest the fall took place on 5 December 2014. There was an employment tribunal relating to the whistle blower and during that process her account of events relating to Mr T’s fall was not accepted by the tribunal.
59. The records of nursing contact rounds show that a nurse observed Mr T sleeping at 6.00am. The Trust’s incident reporting database shows the fall happened at 6.00am but it is not possible for us to establish when staff entered this information. A nurse reported the fall in the clinical records at 7.50am. There is no evidence of any other records between those times. We can only say the fall happened between 6.00am and 7.50am. It is unlikely at this stage that any further interviews or enquiries would result in a more accurate timing given the passage of time.
60. We recognise the lack of any definitive timing of Mr T’s fall is unsatisfactory for Mrs A and her family. We can see how this is a source of continued distress to them. We will refer to the Trust’s investigations later in this report. The Trust has already acknowledged the discrepancy in timings and recognised and apologised for the distress caused. We do not consider any more action is needed in this respect.
Pressure area care
61. Mrs A complains her father developed severe pressure ulcers during his admission to the Hospital.
62. A pressure ulcer is a localised injury to the skin or underlying tissue, usually over a bony prominence. It is the result of pressure with several possible, often complicated, contributory factors. This means pressure ulcers can develop even when patients receive an appropriate level of care.
63. The Nursing Adviser told us nurses should have followed the Pressure Ulcer Guideline when managing Mr T’s pressure areas. This says healthcare professionals should carry out and document an assessment of pressure ulcer risk for all adults in hospital. They should offer patients who are assessed as being at a high risk of developing a pressure ulcer a skin assessment by a trained professional.
64. The Pressure Ulcer Guideline says healthcare professionals should develop and document an individualised care plan for patients assessed as being at high risk of developing a pressure ulcer. This should refer to the patient’s ability to reposition themselves. It says staff should encourage patients at high risk to change their position frequently and at least every four hours.
65. The Pressure Ulcer Guideline also sets out how staff should manage pressure ulcers once identified. This includes using appropriate devices to redistribute the patient’s weight. It says staff should use high-specification foam mattresses when appropriate.
66. The Trust Pressure Ulcer Policy says staff should refer patients to a tissue viability nurse when they identify a grade three or four pressure ulcer. It defines Grade Three pressure ulcers as those where there is full tissue loss, but bones, tendons or muscles are not visible. A Grade Four ulcer is a deep and extensive wound where some of those tissues are visible.
67. The records show, when doctors admitted Mr T to the Hospital, nurses established he was at risk of developing of pressure ulcers. They carried out an initial assessment in line with the Pressure Ulcer Guideline.
68. The records also show nurses inspected Mr T’s skin almost every day and they regularly updated his risk rating. However, they failed to complete a specific care plan in terms of how they intended to prevent pressure ulcers. They did not document whether Mr T could reposition himself or how frequently he needed to change position. In this respect they fell below the requirements in the Pressure Ulcer Guideline.
69. The Nursing Adviser said there were entries in the clinical records showing the nurses made attempts to reposition Mr T. On occasions he declined their intervention and sometimes refused to allow a skin inspection.
70. The Nursing Adviser said it was evident the nurses were looking at risks as a whole and trying to balance the risk of falls with the risk of developing pressure ulcers. This is significant because a specialised air mattress cannot be used with a Hi-low bed. When nurses used the Hi low bed for Mr T they used an appropriate high-specification foam mattress. Nurses also took appropriate action to alleviate the pressure on Mr T’s heels.
71. Nurses first identified Mr T had pressure ulcers on his lower back and both heels on 10 December 2014. They carried out a wound assessment the next day and noted these were Grade Two pressure ulcers (meaning an abrasion or blister). By 30 December doctors noted Mr T had a Grade Two pressure ulcer on his lower back and Grade Four pressure ulcers to both heels. Doctors made a referral to a tissue viability nurse the same day.
72. The clinical records show nurses used an appropriate chart to assess Mr T’s wounds. They also took photographs, regularly reviewed the wounds, and arranged for a tissue viability nurse to attend on 30 December 2014. These were all in line with the Pressure Ulcer Guideline and the Trust Pressure Ulcer Policy.
73. We have considered how staff managed Mr T’s pressure ulcers as a whole. Nurses fell below the required standard in terms of documenting a specific care plan or fully recording position changes. But we can see the nurses reviewed Mr T’s skin at least once a day throughout the admission. We find the nurses provided a good standard of pressure area care in line with the relevant standards. Unfortunately, despite this, Mr T developed pressure ulcers. Our view is these were unavoidable.
74. We do not uphold this part of Mrs A’s complaint.
The Trust’s investigation of the fall on 6 December 2014
75. Mrs A is dissatisfied with the outcome of the Trust’s investigations into her father’s fall. We have already set out our views about the fall and when it happened earlier in this report.
76. NHS organisations should have taken account of the RCA Guideline when carrying out root cause analysis investigations. This has since been replaced by updated guidance, but the principles are broadly the same. The RCA Guideline describes three different types of investigation. In this case two of the types were used. The first was an initial review of the incident using the Trust’s DATIX system. The second was an internal ‘60-day’ investigation.
77. The RCA Guideline specifies the types of incidents that require root cause analysis. It says initial investigations must be reported within two days of the incident. A second stage investigation should lead to a report within 60 days. The second stage investigation should be of good quality and show there has been a robust investigation.
78. The records show the first investigation started within two hours of Mr T’s fall. Three members of nursing staff completed an incident report (DATIX) at 7.50am on 6 December 2014. This described the incident as ‘patient came out of bed stood up to mobilise on his own then he fell when we were attending other patient in same bay.’ The Datix form prompted the staff using it to identify ‘root causes.’ They made a referral for the incident to be investigated further. They followed the RCA Guideline by identifying root cause analysis was required and in carrying out the initial investigation promptly.
79. The next investigation was an RCA investigation on 9 January 2015. The ward manager completed the RCA report within 60 days. It is unclear from the report whether staff were interviewed about their recollections. The implication is that at least one member of staff offered a statement that helped inform the report. It appears other staff were not asked to contribute until the Trust decided to look at the issues again following Mrs A’s complaint. The Trust did not follow the RCA Guideline in this respect.
80. The RCA report also included incorrect information about Mr T’s previous falls. It also incorrectly suggested there was no gaps in observations and said Mr T saw physiotherapists throughout his admission. The RCA investigation report suggested the fall happened at 7.50am. However, it later said the fall ‘happened overnight.’ The Trust has since recognised these were examples of ‘careless, inaccurate reporting.’
81. The RCA report set out the reasons for Mr T’s fall. These included Mr T’s delirium and Parkinson’s disease. They also included the gap in nursing observation which meant staff could not prevent the fall. However, there was a lack of detail about why staff were not present. There was insufficient analysis of how staff allowed the failings to happen. This meant the root causes were not properly investigated.
82. In October 2015 the Trust’s Chief Executive wrote to Mrs A. She confirmed the fall took place at 6.00am. She established this by obtaining the recollections of the nurse in charge of the shift who could recall the incident. She acknowledged previous communications had contained discrepancies about the timing of the fall. She apologised for any confusion or distress this caused to the family. The Trust repeated these apologies at meetings with Mrs A and in later correspondence.
83. We find the Trust did not follow the RCA Guideline. Its investigation was not of good quality or robust. It contained inaccurate information, did not involve all relevant staff, and failed to establish the root causes of the incident. We can see how this would have been confusing and distressing for Mrs A and her family.
84. We can see the Trust has already accepted its investigation was inadequate and has apologised for the impact it had. But we have not seen evidence that there has been learning from the complaint to try and ensure the same mistakes do not happen for other investigations in the future. We partly uphold this part of the complaint.