Assessment at A&E on 2 November 2019
20. Mrs T says that, following a fall on 2 November 2019, the ANP did not refer her for an X-ray or follow up examination after the assessment at A&E. She also says the ANP did not provide appropriate treatment and care following her fall, considering Mrs T’s head injury and clinical background.
21. In the response dated 29 April 2020, the Trust apologised for the disappointment with the service, however, it says the ANP assessed and treated Mrs T appropriately.
22. The RCN defines advanced level nursing practice as including the following:
· receiving patients with undifferentiated and undiagnosed problem and making an assessment of their health care needs, based on highly developed nursing knowledge and skills, including skills such as history taking, advanced assessment, physical examination, referral and treatment, including prescribing independently, and discharge · ordering necessary investigations, and providing treatment and care both individually, as part of a team, and through referral to other agencies · working collaboratively with other health care professionals and disciplines · referring to other health care professionals for ongoing management or identified care needs
23. The NICE guidance for ‘Preventing falls in older people’ states in cases where a patient is over the age of 65 and has experienced a fall, they ‘should be offered a multifactorial falls risk assessment’.
24. This assessment should be performed by ‘a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service... [as a] part of an individualised, multifactorial intervention’.
25. This may include the identification of falls history and the assessment of the following:
· gait, balance and mobility, and muscle weakness · osteoporosis risk · older person's perceived functional ability and fear relating to falling · visual impairment · cognitive impairment and neurological examination · urinary incontinence · home hazards · cardiovascular examination and medication review
26. The NMC guidance states a nurse must:
· ‘make sure that any information or advice given is evidence-based including information relating to using any health and care products or services’ (paragraph 6.1) · ‘respect the skills, expertise and contributions of their colleagues, referring matters to them when appropriate’ (paragraph 8.1) · ‘share information to identify and reduce risk’ (paragraph 8.6) · ‘keep clear and accurate records relevant to their practice’ (paragraph 10) · ‘make a timely referral to another practitioner when any action, care of treatment is required’ (paragraph 13.2)
27. Finally, the NICE guidance for ‘Patient experience in adult NHS services’ explains what steps a clinician should take to provide care and treatment which is tailored to the patient’s individual needs.
28. It says the clinician should ‘give the patient information about relevant treatment options and services that they are entitled to, even if these are not provided locally’.
29. The records show that when Mrs T attended A&E, she was assessed by an ANP. They documented she had ‘tripped and not lost consciousness’ and had the following symptoms:
· laceration to the chin which has continued to bleed · no bony tenderness to the face (mandible and maxilla) · no complaints of headaches or dizziness · some bruising on the inside of the cheeks but no cuts seen · superficial cut to the knee, fully mobile · no loss of consciousness
30. NICE guidance for ‘Preventing falls in older people’ refers to a specific assessment based on Mrs T’s age and her fall.
31. There is no evidence in the records to show the ANP conducted or referred Mrs T for a full falls risk assessment as per this guideline.
32. There is no information on whether this was Mrs T’s first fall. We can also see the records are unclear about the cause of the fall. The records show the ANP recorded that Mrs T experienced ‘no loss of consciousness’, but they have not explicitly explored what caused her to trip or documented this in the records. This is also a different version of events to Mrs T, who told us she ‘blacked out’ and lost consciousness during the fall.
33. We consider the ANP did not correctly carry out or refer Mrs T for a full falls risk assessment in line with NICE guidance. Instead, it appears the assessment solely focused on treating the visible injuries to her chin, mouth, and teeth.
34. The NMC guidance also says a nurse must ensure ‘any information or advice given is evidence-based’.
35. The RCN says advanced nursing practice involves making an assessment of the patient’s health care needs including a patient’s clinical history and symptoms.
36. We can see no evidence the ANP took these guidelines into consideration when assessing Mrs T. Specifically, the ANP did not record that Mrs T was actively receiving chemotherapy, had a hospital card, or a history of bone marrow problems. The ANP did not record whether Mrs T was experiencing pain, or the severity of her pain levels.
37. The NICE guideline for ‘Patient experience in adult NHS services’ refers to the advice a clinician should provide regarding services and treatment available to a patient.
38. The NMC guidance says a nurse must ‘keep clear and accurate records’. Our nursing adviser explained the follow up advice usually would be noted in the records.
39. The records do not show the ANP provided any worsening care advice or clearly explained what symptoms Mrs T should look out for, and when to seek further treatment if her condition deteriorated.
40. The NMC guidance says the nurse must refer matters to colleagues when appropriate and share information to identify and reduce risk.
41. The RCN also recognises the ANPs, as part of their advanced practice, need to ‘work collaboratively with other health care professionals and disciplines’.
42. We asked our nursing adviser if the ANP should have made Mrs T’s GP aware that she had experienced a fall. Our nursing adviser told us the GP should have been made aware to monitor and follow this up. The records do not show this happened.
43. We consider the ANP did not provide appropriate advice before discharge. Instead, the limited advice to ‘see a dentist’ was not in line with the above guidelines. It also prevents the opportunity to rectify and clarify the discrepancies on whether Mrs T blacked out or tripped and fell.
The X-ray and further investigations
44. The NMC guidance says a nurse must ‘make a timely referral to another practitioner’ when required.
45. The RCN recognises that ANPs need to order necessary investigations, treatment and care, or make a referral where appropriate.
46. The clinical records indicate Mrs T presented with significant injuries to her face. This included bruising to the inside of her cheeks, a laceration to her chin with active, heavy bleeding, and she had lost some teeth.
47. In light of the significant injuries to Mrs T’s face during the examination, our nursing adviser said it would appear appropriate and reasonable to refer Mrs T for an X-ray to rule out any further injuries which may not have been identified during the visual assessment. This did not happen.
48. On the balance of probabilities, had the X-ray happened, it is likely Mrs T’s jaw fracture would have been diagnosed in November 2019 rather than February 2020.
49. We consider Mrs T was incorrectly discharged without undergoing further investigations which could have potentially indicated other, non-visual injuries. Instead, the ANP focused on treating injuries which were identified by visual assessment only.
50. We asked our nursing adviser whether the appropriate assessment would have raised any ‘red flags’. Our nursing adviser told us had the assessment been carried out in line with all relevant standards, this would have raised ‘red flags’.
51. Those ‘red flags’, if any, together with the visual injuries, would have led the ANP to make a further referral for diagnostic tests, if appropriate. This would allow the ANP to establish the reason for the fall, and to rule out or diagnose any underlying health conditions or other injuries.
52. We consider there is evidence of failure in the Trust’s actions during Mrs T’s assessment at A&E on 2 November 2019. The failings are as follows:
· the ANP did not correctly carry out or refer Mrs T for a full falls risk assessment in line with NICE guidance for ‘Preventing falls in older people’ · the ANP did not consider Mrs T’s symptoms and medical history in line with the NMC guidance and the RCN standards · the ANP did not arrange appropriate investigations or diagnostic tests in line with the NMC guidance and the RCN standards · the ANP did not provide any worsening care advice or clearly explain what symptoms Mrs T should look out for, and when to seek further treatment if her condition deteriorated, in line with the NICE guidance for ‘Patient experience in adult NHS services’ and the NMC guidance · the ANP did not make Mrs T’s GP aware that she had experienced a fall so they could monitor and follow this up, in line with the NMC guidance and the RCN standard
Impact
53. Mrs T believes that the examination on 2 November 2019 resulted in the delay of a fracture diagnosis, prolonged pain, and ‘missing a window’ for the fracture to heal correctly.
54. Mrs T says she struggles with daily activities, for example eating or talking.
55. She says she would require major surgery to rectify the damage. She says a maxillofacial surgery consultant advised her against the surgery due to its invasive nature and her age. She says she fears this will be a life-long problem.
56. Mrs T says she was let down by the level of service provided.
57. We asked our surgeon adviser whether the fracture could have been caused in November 2019. Our surgeon adviser explained the records indicate the jaw fracture and, on the balance of probabilities, it is more likely to have been caused in November 2019. This is particularly likely in association with the nature of the fall, and the chin laceration.
58. We also asked our surgeon adviser whether the inappropriate assessment caused delay in diagnosis. Our surgeon adviser told us that the lack of investigations, particularly the X-ray, at A&E on 2 November 2019 consequently led to the lack of referral to the maxillofacial surgery service and caused a delay in diagnosis.
59. However, our surgeon adviser said that in Mrs T’s case, a surgery would not be appropriate. It is most likely she would have had conservative treatment, had the diagnosis been made earlier.
60. We asked our surgeon adviser about the impact of the delayed treatment. Our surgeon adviser said that if a fracture of this nature is not treated properly, then the dental bite can be deranged permanently. The sooner the bite is dealt with, the better the outcome would be.
61. Our surgeon adviser also explained that there would be pain from the joint, but once healing had occurred this should improve. Eating would be affected on a long-term basis if the bite is not improved by conservative measures.
62. We recognise the dentist, who Mrs T saw two weeks after attending A&E, was not able to do an X-ray, which also contributed to the delay in diagnosis. We understand the Trust is not a sole contributor to the delay and severity of the impact Mrs T suffers from.
63. At this stage, we deem it reasonable for Mrs T to depend on the assessment from A&E. This is because Mrs T had not received any worsening care advice.
64. The failings also confirm Mrs T was let down by the level of service provided.
65. As an outcome of the complaint, Mrs T would like service improvements.
66. The Trust apologised for the disappointment with the service and the unsatisfactory outcome of its investigation.
67. While it is encouraging to see that the Trust has apologised, it has not acknowledged any failings.
68. We do not believe the apology is enough to remedy the impact Mrs T still experiences due to the Trust’s failings. There are failings which we can link to Mrs T’s claimed impact. As such, we uphold this complaint and make recommendations.