Nursing care
Toileting and personal hygiene
19. Mrs W says nurses did not assist her husband with toileting and personal hygiene needs. She says that on one occasion whilst on Ward C, a nurse advised her husband to soil the bed. Mrs W says she received harrowing telephone calls from her husband, particularly in the last few weeks of his life where he told her that nurses were leaving him to soil bedding. She says at one stage, her husband told her he was not going to eat to avoid this happening. We understand why Mrs W was so worried about this.
20. Our nurse adviser explained that toileting and personal hygiene are fundamental aspects of nursing care. She explained that nurses should assess patient needs so that they can effectively deliver care in a timely way. This is in line with the NMC Code which states nurses should:
· deliver the fundamentals of care effectively
· deliver any treatment, assistance, or care without undue delay.
21. Mr W’s medical records show the nurses assessed his needs on admission and found that he needed help with his fundamental aspects of care. They documented his mobility was poor, he used a scooter before admission, and Mrs W usually delivered his care. They also completed a moving and handling plan which outlined the equipment he needed to transfer to the toilet.
22. After Mr W’s admission to ICU, nursing staff assessed his needs again. They documented Mr W needed a hoist to transfer and the assistance from two nurses. His care plan concluded that he required full assistance with going to the toilet and his hygiene needs. He also had a urinary catheter in place.
23. Regarding the day-to-day provision of toileting, personal hygiene, and comfort, the medical records show that nurses were performing checks every two hours for Mr W from 3 March to 29 March. Following each check, the nurses completed a chart in his medical records. Our nurse adviser explained these charts document that the nurses met Mr W’s needs in line with the NMC Code.
24. Our nurse adviser explained that a nurse should not tell a patient to soil the bed as a nurse should always uphold a patient’s dignity. Nurses should instead offer a bed pan or transfer the patient to the toilet or commode if it is safe to do so. This is in line with the NMC Code which says to:
· treat people as individuals and uphold their dignity
· treat people with kindness, respect, and compassion.
25. We have reviewed the medical records and we cannot see any documented evidence of nurses asking Mr W to soil the bed. We acknowledge it is unlikely nurses would have documented asking a patient to do this in the medical records.
26. Mrs W has provided a compelling account of what her husband told her. We acknowledge what she has told us would have been distressing to Mr and Mrs W.
27. Having carefully weighed up the available evidence, it is difficult to say, even on the balance of probabilities, whether nurses said this or not.
28. What we can say, having considered the relevant evidence including the medical records, is that the overall assistance nurses provided to Mr W for his toileting and personal hygiene needs was in accordance with national guidance (as explained in paragraph 23). We have not found any failings in relation to this aspect of the complaint.
Bedside table
29. Mrs W complains that nurses frequently left Mr W’s bedside table out of his reach. There is no specific national guidance in relation to this. However, we would expect nurses to ensure patients have access to their personal belongings and bedside table. This is in line with the NMC Code as outlined earlier in paragraph 20.
30. Our nurse adviser explained that most hospital Trusts have developed care rounding charts known as ‘intentional rounding’. Intentional rounding involves the nursing team carrying out regular checks with individual patients at set intervals.
31. We can see in Mr W’s medical records that the Trust did have intentional rounding records in place for nurses to complete. These records include a section on checking ‘possessions’ and includes questions such as ‘can I get you anything?’, ‘is everything within reach?’ and ‘call bell to hand?’.
32. We can see nurses fully completed these sections of the records for Mr W every two hours from 3 March to 29 March. This indicates Mr W’s possessions were within his reach most of the time.
33. We acknowledge there may have been occasions, as described by Mrs W, where Mr W’s bedside table was not in reach. We appreciate this would have been frustrating to both Mr W and subsequently Mrs W. However, overall, we have not seen enough evidence to suggest there was an overall failing in nursing care here.
Poor communication about Mr W’s care
Lack of updates
34. Mrs W says the ward did not contact her to provide updates at a time when she could not visit her husband due to the COVID-19 pandemic. She says no one at the hospital answered the phone despite ringing many times.
35. We can see the clinical team documented Mr W had the capacity to make decisions about his care and understand what was happening. As such, and in line with the Mental Capacity Act, we would expect the clinical team to communicate with him about his care initially. He would then be able to relay any important information to his relatives.
36. GMC guidance also says:
· you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support
· when you are on duty you must be readily accessible to patients and colleagues seeking information, advice, or support
37. Mrs W tells us, she was requesting information and contacting the hospital but received no reply. She also did not receive any updates.
38. In the Trust’s complaint response, it acknowledged its communication fell below the usual standard it expected to provide. It said it has missed normal communication that would take place when the family of patients visited. This was due to the restrictions on visits which were in place at the time. We acknowledge this was a difficult time for NHS staff who were facing a pandemic which was overwhelming available resources.
39. Having weighed up the evidence provided by Mrs W, and the Trust’s own admission that its communication was poor at the time, we conclude there was a failing in communication. This is because it appears Mrs W was contacting the Trust for updates and receiving no response. This was not in line with the GMC guidance.
40. We can see that this poor communication was distressing to Mrs W at an already difficult time. The Trust has already acknowledged this failing and apologised to her. It also explained that since that time, it had put mandatory measures in place to call the families of patients once a day following the ward round and update them.
41. We consider the Trust had already made good progress in addressing this failing. It has also taken the correct steps to prevent this happening again. However, we have made an additional recommendation to the Trust at paragraph 78 to put this right for Mrs W.
Staff not considering Mrs W’s views
42. Mrs W also says staff would not consider her views as her husband’s carer. From the medical records, we can see that on admission the clinical team completed a patient assessment for Mr W. They documented that he was able to communicate his needs and preferences and that he had capacity to make his own decisions regarding his care.
43. When a patient has capacity, and can communicate their needs, it should be the patient that outlines these preferences during the assessment and not the carer. This is in line with the Mental Capacity Act.
44. The clinical team also documented that Mrs W was her husband’s main carer. We can see occasions where staff documented her input and that of Mr W’s other family members in the medical records. This suggests that staff did consider their views on occasions, despite Mr W having capacity to speak to those caring for him himself.
45. In summary, we would have expected those caring for Mr W to only seek input from Mrs W if he had lacked capacity or if he had been unable to communicate himself. Mr W did have capacity though. There is also some evidence that staff still took account of Mrs W’s views on occasion. We have not found any failings in relation to this area of the complaint.
Conflicting information given
46. Mrs W also says staff gave her confusing information such as incorrectly advising that her husband had cancer.
47. The GMC’s Good Medical Practice says doctors should communicate effectively by:
· responding honestly to the patient’s questions
· giving the patient information they want or need to know in a way they can understand
· being considerate to those close to the patient and being sensitive and responsive in giving them information and support
48. We can see from the medical records that during the admission there was an occasion following Mr W’s CT scan where the clinical team were considering lymphoma (blood cancer) as a possible diagnosis. The haematologists arranged a biopsy to rule this out.
49. When seeking consent from Mr W for the biopsy, the clinical team clearly documented in the medical records that his symptoms could either be due to cancer or an infection. This was in line with Good Medical Practice which says doctors should be honest with patients and give them the information they need to know.
50. We can also see evidence of a documented conversation with Mrs W where a doctor discussed the possible diagnosis. The doctor told Mrs W (in the company of her daughter) that they suspected cancer, but the changes could be due to an infection as well.
51. We are not critical of the Trust for sharing this suspected diagnosis with Mrs W. In doing so, the clinical team were acting in accordance with Good Medical Practice by communicating the relevant information to her. We acknowledge this was incredibly distressing news for Mrs W though.
DNAR
52. Mrs W says doctors did not tell her they had put a DNAR order in place for Mr W.
53. The relevant guidance regarding DNAR orders is the GMC’s ‘Treatment and Care towards the end of life: good practice in decision making’. This says doctors should:
· base decisions about whether CPR should be attempted on the circumstances and wishes of the individual patient. This may involve discussions with the patient or with those close to them, or both, as well as members of the healthcare team
· document any discussions with a patient, or with those close to them, about whether to attempt CPR, as well as any decisions made, in the patient’s medical records.
54. We can see doctors placed a DNAR order in Mr W’s medical records on 26 March. We cannot see any documented evidence the doctors discussed this decision with either Mr or Mrs W at the time though.
55. When completing the DNAR order form, the doctor did not complete the sections to answer if they had discussed the DNAR with the patient or family. We also note the Trust acknowledged in the complaint response that the communication in relation to the DNAR order was poor.
56. Overall, we have found there was a failing in communication around the DNAR order. This is because there is no evidence the doctors treating Mr W discussed the DNAR order either with him or with Mrs W. In line with the GMC guidance, the clinical team should have discussed this with them prior to making the DNAR decision.
57. We acknowledge the Trust informed Mrs W of the decision to put the DNAR in place later that day. Our physician adviser also confirmed a DNAR was medically appropriate for Mr W as there was little chance of him recovering from a cardiac arrest. As such, any discussion with Mr or Mrs W is unlikely to have changed this decision.
58. However, better communication may have provided Mrs W with some reassurance. Instead, we can see that the poor communication has been a source of distress to her. We have made some recommendations to the Trust to address this.
Support for mental and emotional welfare
59. Mrs W says the Trust did not look after Mr W’s mental and emotional welfare during his stay. She says she requested that someone sit down with him and check on his mental state and offer reassurance, but she does not know if anyone ever did this.
60. We cannot see any evidence of this request within Mr W’s medical records. That is not to say we dispute that Mrs W asked for this as we acknowledge the staff member she spoke to may not have documented it.
61. Our nurse adviser explained that nurses should offer reassurance during the provision of nursing care. However, she explained this is generally informal and rarely documented. If the patient raises any specific concerns, they should escalate this to medical staff in line with the NMC Code which says:
· treat people with kindness, respect, and compassion
· respect the skills, expertise, and contributions of your colleagues, referring matters to them when appropriate.
62. As such, we would have expected nursing staff to act if Mrs W made a request for someone to check on Mr W’s emotional welfare. However, we cannot see any evidence of this request in the medical records. We also cannot see any further documentation in the medical records to show that Mr W raised any concerns. This means we cannot conclude there were any failings here.
63. We appreciate this may be disappointing to Mrs W though and we do not doubt that this was an incredibly difficult time for both her and Mr W.
Disposal of belongings
64. Mrs W complains that following her husband’s death staff threw away some of his belongings. She says she contacted the Trust numerous times and staff told her they would be kept safe. She says when she received Mrs W’s belongings back (after six weeks) several items were missing including a new dressing gown, slippers, underwear, shorts, a hairbrush, a blanket, and tops.
65. Public Health England published guidance in March 2020 around the care of the deceased with suspected or confirmed COVID-19. This guidance does not say what hospitals should do with the belongings following death.
66. However, the guidance states that it should be read in conjunction with the Health and Safety Executive guidance for managing infection risks when handling the deceased. This says:
‘The deceased’s clothing is usually passed to the family by hospital or funeral services staff, unless it is soiled. In this case discuss the issue sensitively with the family and if they do not wish it returned, dispose of it as healthcare waste’.
67. As such, we would have expected the hospital staff to return Mr W’s items to Mrs W. If any of the items were soiled, we would have expected the Trust to have a discussion with Mrs W about this and reach an agreement on what to do with the soiled belongings.
68. In the Trust’s complaint response, it said it returned Mr W’s mobile phone, radio, aftershave, a small wallet, and a card. It said to the best of its knowledge, the only items that it disposed of were Mr W’s clothing and toiletries.
69. The Trust explained that due to unprecedented times it was facing because of the pandemic, property was accumulating in the ward areas and posing a potential risk therefore clothing and toiletries were discarded with an expectation that family had been contacted.
70. Whilst we again acknowledge this was a demanding time for the hospital, we have seen no evidence anyone from the Trust had a discussion with Mrs W before disposing of her husband’s personal items. We consider this to be a failing as this was not in line with the HSE guidance.
71. Mrs W tells us she was devastated and heartbroken the Trust discarded her husband’s personal belongings. She tells us the hairbrush, which Mr W had for many years, had sentimental value. She also tells us many of the items of clothing were new (which she estimates she spent approximately £500 on), and she would have liked to keep them or share them with her grandchildren.
72. We recognise the Trust’s disposal of these items caused Mrs W distress at an already difficult time. We have made some recommendations to the Trust to address this.
Complaint handling
73. Mrs W also complains she feels the Trust brushed aside her complaint and did not answer some issues such as her question about the DNAR order.
74. The NHS complaints regulations state that when handling a complaint, a written response should be provided which summarises the nature and substance of the complaint and summarises the conclusions reached.
75. We can see that following receipt of Mrs W’s complaint, the Trust offered her a meeting to discuss the concerns raised. At the meeting, the Trust discussed the issues with Mrs W in turn. Following the meeting, it sent her a copy of the minutes taken during the meeting which set out what they discussed.
76. We can also see that following this, Mrs W remained unhappy and so she wrote to the Trust again. We can see the Trust responded to Mrs W again and addressed the additional issues she raised in writing. This was in line with the NHS complaints regulations.
77. We can see Mrs W is particularly unhappy the Trust did not answer her questions about the DNAR order. However, having reviewed the complaint correspondence, we can see the Trust answered the questions Mrs W asked. This included the date the doctors had put the DNAR order in place and the criteria they had used to make the decision.
78. Mrs W is also concerned the Trust refused to offer her financial recompense to put right that it disposed of some of Mr W’s belongings. We can see that Mrs W requested this during the complaint process, but the Trust declined. It did not provide any reason why other than that it was unable to do this.
79. This was not in line with the Ombudsman’s Principles that say organisations should consider financial compensation for direct or indirect financial loss, loss of opportunity, inconvenience, distress, or any combination of these. We consider the lack of further consideration of this to be a failing.
80. As outlined below, we are recommending the Trust pay Mrs W compensation for the distress disposing of the items caused her. The Trust lost the opportunity to do this during the complaint handling process, adding to Mrs W’s distress.
81. Overall, we have found no failings in most areas of the Trust’s handling of the complaint. We have found the Trust should have considered Mrs W’s request for financial compensation more carefully though.