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East Suffolk and North Essex NHS Foundation Trust

P-001121 · Statement · Decision date: 21 September 2021 · View East Suffolk and North Essex NHS Foundation Trust scorecard
Communication Communication Patient dignity and privacy
Complaint (AI summary)
Mrs L complained staff refused her entry as a familial carer to the ED and ward, were rude, and frequently woke her for observations, causing distress to her and her daughter.
Outcome (AI summary)
Failings were found in refusing Mrs L entry and providing incorrect visiting policy information. The Trust's previous response was deemed sufficient to address these, and no fault was found for waking her.

Full decision details

The Complaint

10. Mrs L complains about specific aspects of the service she and Ms U received from the Trust on 15 November 2020.

11. Specifically, she complains:

· the staff refused to allow her to accompany Ms U into the ED and onto the ward

· the staff were rude to her when she sat with Ms U on the ward

· the ward staff woke her every thirty minutes to tell her they were doing Ms U’s physical observations.

12. Mrs L says she is concerned about Ms U’s wellbeing should she need to go into the hospital again. The Trust’s decision to refuse entry into the ED and the ward caused her and Ms U unnecessary distress.

13. Mrs L wants service improvements to make sure this does not happen again.

Background

14. Ms U is blind, has cerebral palsy, epilepsy, and a learning disability. Mrs L tells us Ms U needs a familial carer as she can become agitated and distressed in new surroundings.

15. Ms U had a seizure on 15 November 2020. Ms U arrived at the Trust ED via ambulance, and staff admitted her to a ward for treatment.

16. We use relevant law, policy, guidance, and standards to inform our thinking. This allows us to consider what should have happened. In this case we have referred to the following policies:

· NHS Guidance, Visiting healthcare inpatient settings during the COVID-19 pandemic: principles 13 October 2020 Version 1

· East Suffolk and North Essex NHS Foundation Trust, Press Statement 4 November 2020.

Findings

Mrs L’s entry to the ED and ward

17. Mrs L says she is unhappy as she accompanied Ms U in the ambulance to hospital but when she arrived at the ED, staff told her she could not enter due to COVID-19 visiting restrictions. She says staff later told her she could not go onto the ward with Ms U. She says this is wrong as Ms U lacks capacity and needs a familial carer with her.

18. The NHS guidance says patients may have a carer, relative or escort where appropriate to assist in communication and to meet their health needs.

19. On 4 November 2020, the Trust released a press statement saying it was restricting visiting in all its hospitals due to an increase in COVID-19 cases in the local community and in the hospitals. The statement says the aim of the policy is to reduce the spread of COVID-19.

20. The statement says there are exceptions to this rule which includes carers to patients with learning disabilities. The statement says a nurse in charge will decide and authorise admission for carers.

21. The evidence available to us shows indications the ED staff member was wrong to refuse Mrs L admission to sit with Ms U. There are indications the ward nurse was wrong to tell Mrs L she could not enter the ward to stay with Ms U, following her admission.

22. We are pleased to see staff eventually allowed Mrs L access to the ward to stay and care for Ms U, but there are indications the staff should have allowed her to accompany Ms U when she arrived at the Trust.

23. In its complaint response, the Trust admits its staff were wrong to refuse Ms L admission to the ED and says the nurse was wrong to tell Mrs L she could not enter the ward and stay with Ms U.

24. Before we decide if we should investigate a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right.

25. We can see the Trust has a done enough to put right the impact of these events, in line with our Principles of Good Complaint Handling and Principles of Remedy.

26. We acknowledge the Trust’s actions caused Mrs L and Ms U unnecessary distress and we acknowledge Mrs L’s concern about Ms U’s wellbeing if she visits the Trust again for care and treatment.

27. However, we think the Trust’s response goes far enough to address her concerns and distress and provides assurance this will not happen again. This is because it acknowledges what went wrong, apologises and outlines what it did at ward level to prevent it happening again.

28. We are pleased to see the Trust’s speciality nursing staff put an alert on Ms U’s electronic records to say she must have a familial carer with her. This should make all staff aware of Ms U’s needs when she visits the Trust in the future.

Staff waking Mrs L and rudeness towards her

29. Mrs L says the nursing staff continually woke her up during the night to tell her that they were taking Ms U’s physical observations. She says there was no need for the staff to do this as the equipment was on the other side of the bed (contrary to the complaint response which said she was in the way of the equipment).

30. In her complaint form Mrs L says the nurses were rude to her throughout the night and showed no interest in the fact their approach to the visiting policy may cause Ms U distress.

31. We understand Mrs L wanted to rest. We acknowledge she feels the staff were rude to her and could have avoided waking her up. We understand it was a very difficult time and she was tired after providing care and support to Ms U.

32. We cannot say if the ward staff could have taken observations from the other side of the bed or avoided waking up Mrs L.

33. The clinical observation forms do not ask staff to record the location of the equipment or the side of the bed the staff take observations from.

34. Even if we could say the staff should have taken Ms U’s observations from the other side of the bed, we cannot say conclusively that this would have prevented Mrs L from waking up. The Trust admitted Ms U to its emergency assessment unit which is likely to be noisy at times given the nature of the ward.

35. Although we recognise this situation was upsetting for Mrs L, we are not critical of the ward staff for waking Mrs L. This is because there is no debate about whether the observations were necessary, and their focus was Ms U. We do not think it would be possible for staff to guarantee performing observations so quietly they did not wake a visitor.

36. The medical notes do not contain any account of a dispute between staff and Mrs L. There were no staff witness statements taken at the time of the events that we could rely upon.

37. We accept Mrs L’s account that she felt staff were rude to her. This was a difficult situation, and we understand she was not happy with the communication towards her.

38. In circumstances like this, it is difficult for us to say with certainty what happened, and even when we know what was said it can be hard to determine whether a staff member was intentionally rude. Because of this, we have decided we cannot say there are any indications anything went wrong.

39. In summary we have decided not to take any further action on Mrs L’s complaint.

Our Decision

1. We carefully considered Mrs L’s complaint on behalf of her daughter Ms U, about East Suffolk and North Essex NHS Foundation Trust (the Trust) and we have decided not to take any further action on the complaint.

2. We can see indications of failings in the staff member’s decision not to allow Mrs L to accompany Ms U into the Emergency Department (ED) as her familial carer.

3. We can see indications of failings in the information the ward nurse provided to Mrs L about the Trust’s visiting policy. We can see the visiting policy had exemptions and Ms U’s needs made her exempt from the Trust’s ban on visiting due to COVID-19.

4. We understand the actions of the care staff in relation to the visiting policy caused Mrs L and Ms U unnecessary distress.

5. We are sorry Mrs L is concerned the events may happen again if Ms U needs future treatment at the Trust.

6. We think the Trust’s response to Mrs L’s complaint is enough to put right the impact of this indicated failing, and provide reassurances about Ms U’s future visits to the Trust.

7. We understand Mrs L was frustrated the staff woke her to take Ms U’s physical observations, because she was tired and trying to rest between delivering care and support to Ms U. We understand Mrs L feels the staff were rude to her while she was on the ward.

8. We can see no indications the staff did anything wrong when they woke Mrs L while they took Ms U’s physical observations.

9. We are sorry Mrs L found the staff were rude to her. We accept her account, but it is difficult for us to say with certainty what happened or to determine whether a staff member was intentionally rude. We therefore cannot say there are indications something went wrong.

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