Continence care
15. Mrs U told us when her father was a patient on Ward 4 at the Trust it did not appropriately care for his continence needs. She says nursing staff did not listen to her or her mother when they told them her father could not use bottles and needed a catheter. Mrs U has told us on three occasions she arrived at the ward and found her father in a soiled bed. She says the poor continence care meant that he developed pressure ulcers (also known as bed sores) which were avoidable.
16. The Trust says when Mr A was transferred to Ward 4, on 9 December, it used Conveens at night as Mr A was using a bottle on his own in the day. A Conveen is a type of external urinary catheter. In addition to this, it used continence pads. It has apologised that Mrs U found her father in a dirty bed. It has said that this is not how it would want any of its patients to be found and it is not the highest level of care it aims to provide.
17. The Trust’s Pressure Ulcer Prevention and Management Policy says there is a link between incontinence and pressure ulcers. This is because when incontinence is not managed, and the skin becomes wet, it is more vulnerable and more easily damaged.
18. The policy says that any patient with a category 2 pressure ulcer (an open wound or blister) and faecal incontinence with mild or severe diarrhoea should be considered for a faecal management system and/or urinary catheterisation.
19. We have reviewed Mr A’s records. According to the records, between 9 and 13 December the Trust used a Conveen to manage Mr A’s urinary incontinence.
20. Mrs U told us Trust staff did not understand her father was not capable of using a bottle which meant when she visited him, he was sat in urine. We do not doubt that when Mrs U and her mother visited Mr A, he had suffered incontinence and that the bed was soiled. We understand how distressing this must have been for Mrs U and her mother. It is possible when people use a Conveen they can slip off and therefore soil the bed. As such we cannot say that the fact Mrs U witnessed Mr A in a soiled bed meant he was using a bottle.
21. There is no record of Mr A using a bottle, or record of Mrs U telling Trust staff her father could not use a bottle in his medical records. There is one reference to a conversation between Mrs A and Trust staff on 9 January. The records say Mrs A told Trust staff she managed her husband’s incontinence with a Conveen at home.
22. We do appreciate how frustrating it must be for Mrs U that she recalls telling the Trust her father could not use a bottle and felt she was not listened to. There is no reference to this conversation in the records. The medical records do not refer to Mr A using a bottle in the daytime, but do refer to him using a Conveen in the daytime. However, the Trust’s response letter does refer to her father using a bottle in the day. We cannot reach a robust view on whether the Trust properly listened to Mrs U, because the evidence is limited and conflicting. We will go on to explain why we have concluded that Mr A did not develop pressure ulcers as a result of failings with continence care.
23. On 13 December, the Trust began to use a urethral catheter. This is a flexible tube used to empty the bladder and collect urine in a drainage bag. The urology team made this decision after diagnosing Mr A with urosepsis. This is a type of sepsis caused by an infection in the urinary tract.
24. The Trust did consider trialling Mr A without a catheter, however that did not happen as he was too immobile.
25. The records show the Trust used pads to manage Mr A’s faecal incontinence. The Trust recorded his bowel movements on bowel chart documents. It shows Mr A’s bowel movements varied between normal and mild diarrhoea, although much of the time they were normal. This management of Mr A’s continence care is in line with the Trust’s pressure ulcer prevention guidance. We have not seen failings in the continence care provided to Mr A.
26. The Trust’s pressure ulcer guidance says that when a patient has been identified at being at risk of developing tissue damage their skin should be inspected and assessed regularly. It says that a qualified clinician should inspect the skin on admission and once a day during admission. The records show the Trust acted in line with this guidance and carried out daily pressure area skin assessments and assessed Mr A’s risk of pressure ulceration. This was due to his decreased mobility and urine and faecal incontinence.
27. When the Trust admitted Mr A on 9 December, he was suffering from a category 1 pressure ulcer on his sacrum. This is an area of redness affecting the top layers of skin. The Trust noted he had a category 3 pressure ulcer on his spinal area. This is a deeper wound reaching the deeper layers of the skin. Mrs U has told us this wound was caused by a basal cell carcinoma which had been removed and not a pressure ulcer. The records also note Mr A told Trust staff that the wound on his spine was caused by a mole falling off and not a pressure ulcer.
28. Having reviewed the records and taken account of our nursing clinical advice, we conclude that Mr A was admitted with skin damage to his sacrum and spinal area which did not deteriorate during his admission. The evidence does not indicate that Mr A developed pressure ulcers during his admission.
29. The Trust moved Mr A to ward 9 on 10 January. On 13 January the records show a new instance of skin damage. It is documented that Mr A had sustained damage to both his thighs. Trust staff thought this was likely to be caused by hoist straps. It was also noted that he had a ‘graze to left buttock due to the hoist sling’. We note that Mr A was catheterised on 13 December. As such it is unlikely that incontinence caused this instance of skin damage noted four weeks later.
30. Mrs U has told us how distressing it was for her and her mother to witness her father receive poor care which led to pressure ulcers
31. When a patient is left in soiled conditions for long periods, or if this happens frequently, their skin breaks down and they develop pressure ulcers. Having seen Mr A in a soiled bed, we can understand why Mrs U was concerned that this had led to his skin damage.
32. In this case, we have seen no evidence that poor continence care caused Mr A to develop pressure ulcers. When the Trust admitted Mr A, he already had areas of damaged skin, and these did not deteriorate during the admission. He did develop some skin damage, but it is likely this was caused by a hoist sling rather than incontinence. We did not find evidence of failings in the Trust’s management of Mr A’s continence care. We cannot link the incidents of incontinence Mrs U witnessed to Mr A’s skin damage.
33. We will not uphold this complaint.
January Discharge
34. Mrs U says the Trust did not follow the correct discharge process for her father in January. She says it tried to discharge him home without appropriate support in place. She says this led to a delayed discharge. She is concerned that the Trust pressured her mother to agree to care for him at home when she had made them aware, she could not care for him overnight.
35. The Trust said that it is hospital policy to discharge patients as soon as they are well enough to be discharged. It explained the urology team reviewed Mr A on 16 December and they were happy to discharge him. On 19 December, the Trust reviewed him again, and again concluded he was well enough to go home. It explained when Mr A was medically fit for discharge a Continuing Health Care assessment (CHC) took place. It was recommended that his package of care increase to two carers, fours time a day.
36. We have reviewed Mr A’s records. They show that prior to this hospital admission Mr A had two carers visiting him twice a day. The records document Mrs A’s concerns about caring for her husband if the Trust discharged him home with the same level of care.
37. The records show Mr A’s discharge would be ‘a complex discharge’. Department of Health guidance says that for a complex discharge:
‘Ward staff may need support from health and social care colleagues who have more specialist knowledge and understanding of the local community services and choices available. The majority of complex transfers can be managed effectively by the core multidisciplinary team.’
38. The Trust considered Mr A’s discharge ‘complex’ because he needed increased care at home and additional equipment. Following an assessment, the Older Persons Assessment and Liaison for Dementia (OPAL) team decided Mr A required an increased care package. This meant carers visiting him fours time a day. A multidisciplinary team managed Mr A’s discharge which is in line with the above guidance.
39. NICE guidance on involving carers in discharge decisions says:
‘The hospital and community based multidisciplinary teams should recognise the value of carers and families as an important source of knowledge about the person's life and needs.
With the person's agreement, include the family's and carer's views and wishes in discharge planning. If the discharge plan involves support from family or carers, the hospital based multidisciplinary team should take account of their:
· willingness and ability to provide support
· circumstances, needs and aspirations
· relationship with the person
· need for respite.’
40. The records show the Trust was planning to discharge Mr A home with an increased care package. This is because Mr A had told them he wanted to go home.
41. Mrs U has told us that both her and her mother wanted to care for her father at home. However, as he required two hoists it was not possible. She told us that there was not enough room to fit one hoist through the internal doors, and there was not enough room to store two hoists in separate parts of the house.
42. Prior to discharge the Trust conducted a home visit. The Trust assessed whether Mr A could be cared for at home with a care package. The Trust decided following the home visit that it was unlikely that Mr A would return home due to family concerns. The Trust decided to transfer Mr A to a respite bed over the Christmas period with a referral to a community occupational therapist for home visits and equipment needs.
43. We have not seen any evidence in Mr A’s medical records to indicate the Trust was trying to discharge Mr A before it arranged care and made a proper discharge plan. We do acknowledge that this is not Mrs U or Mrs A’s recollection or how they felt at that time.
44. We have seen that doctors considered that Mr A was medically well enough for discharge on 16 December. The Trust assessed him and decided he had additional support needs. A multidisciplinary team managed the discharge. Our adviser said the Trust’s handling of Mr A’s discharge was in line with Department of Health guidance. They also said the Trust considered Mr A’s and his family’s wishes when planning the discharge, which is in line with NICE guidance.
45. We were sorry to read that Mrs A felt pressured into caring for her husband at home when she had told staff she was unable to do this overnight. We do not underestimate how stressful this time must have been for her and Mrs U.
46. The records say Mr A wanted to be cared for at home. Following a home visit, it was determined that this would not be possible and alternative arrangements were made. We understand that Mrs A felt pressured into looking after her husband at home. We have seen the Trust asked Mr A where he wanted to be discharged to and tried to make arrangements to respect his wishes. We have seen the Trust explored this option, however ultimately Mr A’s family and the Trust decided it was not appropriate and he was transferred to a care home.
47. We understand how concerned Mrs U was that the Trust would discharge her father without a suitable care package, and that her elderly mother would have had to care for him. We also understand how distressing this period must have been for Mrs U and her family. Having considered the evidence we have seen and taking in to account the views of our adviser, on balance we do not think the evidence as a whole supports a view that there were failings in the Trust’s discharge or discharge planning in January.
Equipment
48. Mrs U says the Trust conducted an occupational therapy assessment at her father’s home in August, before the admission we are considering. Mrs U tells us it was decided he needed a specific height of chair and an extended bed due to his height. The Trust ordered a bed extension and delivered it to Mr A’s home. However, as he refused to accept a specialist chair at this time as he already had a lift and rise chair at home the occupational therapist was happy for him to continue to use this.
49. Mrs U complains the Trust did not check the prescribed equipment was in the care home before it discharged Mr A in January. She also told us the care home only became aware of the prescribed equipment once her father was at the home and she raised it with the care home staff. She says this meant her father could not lift himself out of his chair and the standard sized bed meant he suffered from pressure sores on his feet.
50. The Trust said when a care home accepts a patient, they accept the care for the patient and their care needs. It said the care home has a responsibility to provide adequate equipment to meet the care needs of the patient.
51. NICE Guidance on patient discharge says: ‘The discharge coordinator should discuss the need for any specialist equipment and support with primary health, community health, social care and housing practitioners as soon as discharge planning starts. This includes housing adaptations. Ensure that any essential specialist equipment and support is in place at the point of discharge.’
52. We have reviewed Mr A’s records. The OPAL team assessment note that Mr A had an extended bed at home. On 29 December an Occupational Therapist completed a ‘Moving and Handling Care Plan’. This care plan said if the decision is made to discharge Mr A to a care home ‘then manual handling care plan to be used with hospital bed with extension, hoist, sling, wendyletts and bariatric commode provided by care home’. Wendylett is a type of sheet used for transferring patients. This care plan is labelled ‘copy for care agency/care home’. There is another version of the care plan in the notes labelled ‘copy for notes’.
53. The records say on 23 January, Trust staff spoke with the care home manager. In this conversation it was identified that Mr A’s daughter would deliver the mattress Mr A had been using at home to the care home. The notes of 23 January say the plan was for discharge the following morning ‘due to equip move’. Mrs U told us she did transfer this equipment to the care home. However, she tells us she did not agree to this until after her father had been discharged to the home.
54. We have reviewed the notes from the occupational therapy assessment which took place at Mr A’s home in August and found no reference to a specialist armchair. The moving and handling care plan says:
55. “If d/c [discharge] destination is Mr A’s home, equipment will need to be ordered. Mr A could be hoisted onto the existing commode and wheeled from his bedroom to the lounge and then hoisted onto the existing rise and recliner chair.”
56. “If d/c destination is care home, manual handling care plan to be used with hospital bed with extension, hoist, sling, wendlyletts and bariatric commode provided by care home”.
57. It also goes on to say Mr A should be transferred out of a chair using a hoist. Specifically, it says:
58. “Oxford Major electric hoist required due to Mr A’s height and weight. Sling to be left in situ when hoisted from bed to chair therefore will be in place for hoisting from chair.”
59. Mrs U has told us that her father was unable to lift himself out of a standard chair and he required a specific height chair. She has said that as a result of this his mobility decreased and he had to be hoisted from his bed to a chair.
60. We can see that as of 29 December Mr A’s care plan said he should be hoisted from to and from a chair. Therefore, he would not require a specialist chair to help him stand independently.
61. We also reviewed the records from Mr A’s next hospital admission. The Trust assessed him in October the following year, and it found he did not require a specialist armchair.
62. Our nursing adviser said the Trust had a responsibility to discuss equipment needs with carers before discharge and ensure equipment was in place. This is in line with the NICE guidance referred to above. The records show the Trust spoke with the care home before discharge and discussed Mr A’s equipment needs. We have also seen a copy of Mr A’s care plan which was labelled ‘copy for care agency/care home’. We consider that this indicates the Trust had made information about his needs available to the care home.
63. Mrs U has told us the care home did not have a copy of her father’s care plan prior to the discharge. She says even when he was in the home, they did not know he needed an extended bed. We have seen evidence in Mr A’s medical records that the Trust had written a care plan and that there was a copy for the care home. We acknowledge this does not necessarily confirm the care plan was provided to the home. However, when taking into account the record of the conversation too, on balance we think there is enough evidence to show the equipment needs were discussed and relevant arrangements made.
64. We have also considered the Care Quality Commission Regulations which say that care homes should find out what a person’s needs are, which includes from handover meetings and discussions with healthcare professionals. In this case we see that the care home also had responsibility to make sure it could care for Mr A and to understand what his needs were.
65. We have seen a record that Mrs U agreed she would deliver the specialist mattress he had been using at home to the care home, indicating that arrangements were in place to ensure Mr A had the equipment he needed. We note that Mrs U said she did not agree to this until after the transfer, and we accept that this is her recollection. It does conflict with the Trust’s record that this conversation took place the day before discharge. In these circumstances, we consider what we think is more likely to have happened on balance. Given that the Trust documented the conversation in the medical records at the time of these events, we think it reasonable to place more weight on those.
66. We do understand Mrs U’s concerns and how distressing it must have been to witness her father suffer from pressure ulcers on his feet. We have seen the Trust had prepared a care plan and discussed it with the care home prior to her father’s discharge. We have also seen the care home has responsibility to make sure it is meeting a patient’s day-to-day health and wellbeing needs. Our investigation has not considered the care provided by the care home.
67. Having considered the evidence we have seen and the views of our adviser, on balance we do not think the evidence as a whole supports the view that the Trust did not consider what equipment Mr A needed before it discharged him. Or, that it did not communicate Mr A’s needs to the care home.
68. We understand how concerned Mr A’s family were when the Trust transferred him to a care home, and we can see they wanted the best care for him.
November Discharge
69. Mrs U complains the Trust did not follow the correct discharge process for a patient with dementia and a Health and Welfare Lasting Power of Attorney (HW LPA) in November. She said she believes the ward doctor was provided with insufficient records about her father’s dementia to reach an accurate conclusion on his ability to plan his own discharge. She is also concerned the Trust did not invite her to attend any assessments as it told her Mr A had capacity to make his own decisions.
70. Mrs U told us she had concerns about the Trust discharging her father in November as the care home would only care for her father from bed. She says when she raised these concerns, they went directly to her father to ask his opinion. She says it had been determined a year previously that Mr A could not make decisions relating to his discharge. She does not believe he therefore could have regained capacity over this period given he suffered from a degenerative disease.
71. The Trust has said the doctor on duty on 2 November assessed whether Mr A had capacity to make decisions about discharge arrangements. They said Mr A could communicate the decision back to the doctor and could understand relevant information. The Trust said the doctor followed the principle that if an adult has the capacity to make a voluntary and informed decision to consent or refuse a particular option, their decision must be respected.
72. The Mental Capacity Act 2005 says ‘every adult has the right to make their own decisions if they have the capacity to do so. Family carers and healthcare or social care staff must assume that a person has the capacity to make decisions, unless it can be established that the person does not have capacity’.
73. It goes on to say, ‘a person’s capacity must be assessed specifically in terms of their capacity to make a particular decision at the time it needs to be made’.
74. The Trust needed to decide whether Mr A had capacity to make decisions about his discharge. The records show that two separate capacity assessments were carried out at the start of November.
75. On 1 November at 3pm, the Trust identified Mr A lacked capacity to understand the Continuing Health Care process and a Best Interest form was completed. This is a checklist which outlines what someone needs to consider while a person lacks capacity.
76. The records do not show that the Trust was aware that Mrs U had HW LPA at this stage. We know Mrs U had HW LPA for her father’s health and welfare from two years before the admission being considered. The records document several conversations between Mrs U and the Trust about the discharge process and CHC assessment. She is listed on the Best Interest form.
77. On 2 November, the Trust carried out a second capacity assessment. This was related to a decision on where to discharge Mr A to. The records show that Mr A had a diagnosis of dementia at the time of the assessment. However, it is noted that he “can retain information about care home, can weigh up the benefit of going back to the care home, says he likes it there ‘food good’, can communicate the decision back to me, is able to understand the relevant information” The Trust decided at this time he had capacity to make a decision on where he would like to be discharged to.
78. We sought clinical advice on this matter. Our nursing adviser said based on this capacity assessment Mr A had capacity to make a decision about his discharge back to the care home. As Mr A had capacity to make the decision about the transfer back to the care home it was not necessary for the Trust to consult Mrs U.
79. We understand that Mrs U held HW LPA for her father. Section 5.49 of the Mental Capacity Act Code places a duty on the decision-maker to consult other people close to a person who lacks capacity, where practical and appropriate, on decisions affecting the person and what might be in the person’s best interests. In this case we have seen evidence Mr A had capacity to make this decision. Therefore, the Trust was not required to involve Mrs U in the decision making. However, the records detail several conversations with Trust staff and Mrs U about the discharge planning process.
80. We understand why Mrs U was concerned to be told that her father did not have capacity to discuss the CHC process, but several days later had capacity to make decisions about his discharge. Capacity must be assessed specifically in terms of a person’s capacity to make a particular decision at the time it needs to be made. In this circumstance taking in to account the evidence we have seen and the views of our nursing adviser we have seen Mr A had capacity on 2 November. We have not identified failings in the Trust’s actions.
Summary
81. We recognise how distressing it has been for Mrs U to lose her father and that she and her mother always wanted the best care for him. We understand how upsetting it has been for her to relive these events when pursuing this complaint.
82. We have found the Trust appropriately cared for, discharged and communicated his needs to his care home. We do not uphold this complaint.