University Hospitals Birmingham NHS Foundation Trust

4. Ms X complains about the care and treatment the Trust provided to her mother, Mrs X, between January 2019 and April 2019.

5. Ms X complains the Trust failed to appropriately monitor or treat Mrs X’s weight loss or manage her nutrition. Specifically, she says the Trust:

• failed to note in a timely fashion that Mrs X was partially sighted and delayed providing her with a ‘red tray’, used to notify staff of patients needing extra attention when eating or needing foods that have a modified texture. She says this meant staff placed food out of Mrs X’s sight and reach on several occasions. She is concerned this happened more often than she or her sister were aware, as they could only attend the hospital on weekends • estimated Mrs X’s weight, rather than weighing her • failed to provide Mrs X with Fortisips, a nutritional supplement for people who cannot consume enough solid food to maintain a balanced diet • failed to refer Mrs X to its nutrition team more quickly • failed to have its nutrition team review Mrs X before it discharged her to a community hospital.

6. Ms X says Mrs X’s condition deteriorated on transfer to the Trust’s rehabilitation ward. She feels this was a direct result of the lack of nutritional support the Trust provided. She says Mrs X’s decreased weight also meant staff were unable to offer additional pain relief.

7. Ms X also complains the Trust did not provide Mrs X with appropriate treatment for a pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) she developed while an inpatient. Specifically, she says the Trust: · incorrectly graded Mrs X’s pressure ulcer (pressure ulcers are graded between one and four, with four being the most severe) · failed to create a pressure ulcer prevention plan · failed to inspect Mrs X’s skin frequently enough.

8. Ms X told us the lack of pressure ulcer treatment led to her mother experiencing: · reduced mobility, which meant she required much greater input from carers and family, which has been extremely stressful and costly for the family · additional unnecessary pain.

9. She tells us the additional pain her mother experienced led to her mother: · being less inclined to eat · having little enthusiasm to be mobile · starting to believe she was nearing the end of her life and not wanting to return home · experiencing exacerbated anxiety and depression · being unpleasant and verbally abusive to her and her sister.

10. Ms X told us witnessing her mother feeling like this in hospital led to her sleep patterns becoming very erratic, and to the family feeling very upset and unable to fully concentrate on their own responsibilities.

11. By bringing this complaint to us, Ms X would like the Trust to put service improvements in place, and to pay her financial compensation for both the distress she experienced and the increased cost of Mrs X’s care after discharge.

12. This is a summary of events to put the complaint in context. We have not included all the details as those involved are already aware of this information.

13. Mrs X was admitted to the Trust on 16 January 2019 as an emergency admission due to social/safeguarding reasons. When she was admitted to hospital staff noted she had loose stools, poor mobility, she was dehydrated, and had a reduced oral intake.

14. A stool sample identified Clostridium difficile (C. diff), a bacterium that can infect the bowel and cause diarrhoea. Staff treated Mrs X with antibiotics and intravenous fluids. Her loose stool did not settle, and the gastroenterology team recommended an enema. This opened her bowels and following this, staff deemed her medically fit for discharge.

15. On 8 March 2019, Mrs X was discharged from the Trust’s hospital and transferred to a community hospital managed by a different Trust (the community hospital) for ongoing rehabilitation.

Background relevant to nutrition and weight management

16. The day after Mrs X was admitted to the Trust’s hospital, staff carried out an initial assessment. This identified she had a reduced oral intake and the plan, on 18 January 2019, was to encourage her oral intake.

17. The 21 January clinician notes state Mrs X’s appetite was low.

18. The records show Ms X spoke with nursing staff on 23 January and said Mrs X had macular degeneration, a type of degenerative eye disease, and therefore her vision was poor. On the same day, the tissue viability nurse documented Mrs X should be referred to a dietitian.

19. The clinical records document the plan on 29 and 30 January, and on 4 to 7, and 21 February, was to encourage Mrs X to increase her oral intake.

20. The records show nursing staff spoke with a relative on 2 February, and they noted Mrs X was partially sighted. Nursing staff placed a sign above her bed in response, and the member of staff planned to speak to all staff to ensure Mrs X could reach, and be supported with, her food and drink.

21. Overall, the records made during Mrs X’s admission to the Trust’s hospital show she ate without assistance on some days of her admission, and staff helped on some days.

22. The Trust referred Mrs X to the nutrition team on 1 March.

Background relevant to pressure ulcer care

23. On 16 January 2019, the Trust’s emergency department records note Mrs X had ‘very dry heels’.

24. On 17 January, staff checked Mrs X’s skin and identified her skin was red and blanching at her heels and sacrum. Blanching of the skin is when whitish colouration remains longer than normal after pressure is applied on an area of the skin. This is a sign blood flow is restricted to an area of skin.

25. The 18 January nursing records document Mrs X’s skin was very dry.

26. The 22 January nursing records state Mrs X had a blister on her right foot and staff referred her to the tissue viability team.

27. On 23 January, the tissue viability nurse attended. Mrs X had a large blister on her right heel that should be treated as a deep tissue injury. The records state she should be nursed on an Autologic mattress. This is a mattress designed for pressure injury prevention and management. The records also document staff should reposition Mrs X every four hours. It was also recommended that staff should put a Repose heel protector in place. Heel protectors are used to prevent and manage heel pressure ulcers. Staff put these in place later that day.

28. On 6 February tissue viability staff carried out a root cause analysis (RCA) for the grade two pressure ulcer Mrs X had developed on her right heel. An RCA is a tool to help identify and address the root causes of an undesired outcome. The RCA report documents Mrs X had developed a grade two ulcer on her right heel and this had ‘deroofed’ (the external layer of skin was no longer in place). It noted there had been gaps when staff had not carried out skin inspections, that staff had not completed a pressure ulcer prevention plan, and staff had provided equipment to prevent a pressure ulcer too late. Following this, staff referred Mrs X to its podiatry team, and recommended providing absorbent dressings and pressure relief.

29. The community hospital admission records note Mrs X had a deep tissue injury on her right heel. The 9 March 2019 community hospital records describe Mrs X as having a small grade three pressure ulcer on her right heel.

Nutritional care

35. The standard relevant to this part of the complaint is NICE CG32. It states all hospital inpatients should be screened for the risk of malnutrition on admission, and staff should repeat screening weekly. It says staff should consider providing nutrition support in people who are malnourished. It defines malnourished as any of the following: · ‘a BMI of less than 18.5 kg/m2 · unintentional weight loss greater than 10% within the last 3–6 months · a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.’

36. The guidance also states staff should consider providing nutrition support in people at risk of malnutrition. Its definition of people at risk of malnutrition includes those who, ‘have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer.

37. Our nursing adviser told us the ‘nutrition support’ staff should consider, in line with this guidance, involves referring patients to a dietitian.

38. The Royal Marsden Manual of Clinical Nursing Procedures is also relevant to this part of the complaint. Page 359 states: ‘Some patients may require assistance with feeding or drinking and a system should be in place to ensure that these patients receive the required attention at each mealtime and beverage service.’

39. Our nursing adviser told us the type of ‘system’ the Royal Marsden Manual of Clinical Nursing Procedures refers to may include ‘protected mealtimes’. This means limiting interruptions to patients during mealtimes, including not providing therapeutic interventions or non-urgent ward rounds. They said the systems may also include a ‘red tray system’. This involves staff providing red coloured food trays to patients who require nutritional support. A red tray indicates to all staff that the patient requires support with eating. They also explained that the red tray indicates to domestic staff that they should not remove the tray if the patient has not fully eaten their meal.

40. The Royal Marsden guidance does not state which patients require assistance with eating and drinking. Our nursing adviser explained, in line with the guidance, staff should carry out person-centred assessments to identify if patients need, and want, assistance with eating and drinking. Staff should not insist on helping patients to eat and drink.

41. Table 1 of NICE CG32 states staff should weigh patients ‘to assess ongoing nutritional status, determine whether nutritional goals are being achieved and take into account both body fat and muscle’. In line with this, staff should always accurately weigh patients. This is because an estimated weight will give an inaccurate BMI and is therefore ineffective when used to assess a patient’s nutritional requirements.

42. Table 1 of NICE CG32 states, if staff are unable to weigh a patient, they should measure the patient’s mid-arm circumference or triceps skinfold thickness as an alternative to weighing the patient.

43. We spoke with our nursing adviser about Ms X’s concerns that staff did not identify Mrs X was partially sighted when she was admitted to hospital. Our nursing adviser told us there is no nursing standard or guidance that states staff should assess a patient’s eyesight on admission to hospital. They said, in line with good clinical care and treatment, nursing staff should ask patients if they have any problems with their eyesight and document any difficulties during the initial nursing assessment. The purpose of this is to assess if there are any risks associated with a patient’s eyesight, such as a risk of falls. Healthcare staff should not assume a person who is partially sighted needs or wants help with eating or drinking, they should always encourage independence.

44. Ms X complains the Trust failed to appropriately monitor or treat Mrs X’s weight loss or manage her nutrition. Her specific concerns are Trust staff: · failed to note Mrs X was partially sighted in a timely fashion. She is also concerned it delayed providing her with a ‘red tray’. She says this led to staff placing food out of her sight and reach on several occasions · estimated Mrs X’s weight, rather than weighing her · failed to provide Mrs X with Fortisips because the ward sister did not realise a prescription was required · should have referred Mrs X to its nutrition team sooner and should have reviewed Mrs X before it discharged her to the community hospital.

45. The Trust acknowledged, in its complaints correspondence, its staff delayed noticing Mrs X was partially sighted. It apologised for this and advised it remedied this following the family’s discussion with a ward sister on 2 February 2019.

46. The Trust say staff did not provide Fortisips to Mrs X because a sister on the ward did not know a prescription was required. It said because a prescription had not been issued, Mrs X was not provided with Fortisips.

47. The Trust has acknowledged it estimated Mrs X’s weight on occasion, rather than weighing her. It said this is not the standard of care it would expect, and it advised the nursing team they must physically weigh a patient, rather than estimate their weight whenever possible. The Trust say Mrs X lost approximately 3kg in weight while she was an inpatient.

48. The Trust acknowledges it did not refer Mrs X to a dietitian until 1 March 2019, and it should have referred her sooner. It said it aims to action all referrals within two working days. It acknowledged however, once it referred Mrs X to a dietitian, the dietitian did not action the referral and therefore Mrs X did not see a dietitian before she was discharged to the community hospital, on 8 March 2019.

49. We begin by looking at Ms X’s complaint that staff did not identify her mother had reduced eyesight when she was admitted to hospital. Our nursing adviser told us the Trust’s initial admission assessment records should include a question related to vision. The initial assessment records are not complete, and the admission records available to us do not document Mrs X was partially sighted. We also considered the Trust acknowledged in its complaint response that staff delayed noticing Mrs X was partially sighted. Mrs X was admitted to hospital on 16 January 2019. The records show Ms X spoke with nursing staff on 23 January 2019 and noted Mrs X had poor vision. The 2 February 2019 records show staff wrote a sign above Mrs X’s bed to note she was partially sighted, and the plan was to speak to all staff to ensure Mrs X could reach her food and drink and to support her with food and drink.

50. Trust staff went against good clinical care and treatment when they did not ask Mrs X about her eyesight on admission, delayed identifying Mrs X’s eyesight problem for seven days, and delayed acting in response to this information for 17 days after her admission. These issues constitute failings. We consider the impact of this later in the report.

51. We considered Ms X’s complaint that staff estimated her mother’s weight. Having reviewed the records, we can see the Trust went against NICE CG32 guidelines when it estimated Mrs X’s weight on several occasions, and this was a failing. In line with the guidance, it should have weighed Mrs X accurately on each occasion to calculate her BMI or measured her mid-arm circumference or triceps skinfold thickness as an alternative if this was not possible. This was particularly important given Mrs X’s BMI indicated she was malnourished on, and throughout, her admission.

52. We considered Ms X’s complaint that staff did not refer her mother to a dietician. CG32 states patients whose BMI is less than 18.5kg/m² are malnourished and should be referred for nutritional support (to a dietitian).

53. We calculated Mrs X’s BMI was 17.8 kg/m² the day after her admission. Mrs X continued to lose more weight during her admission, and therefore she was malnourished throughout her stay. Staff did not refer Mrs X to a dietitian for nutritional support until 1 March 2019, six weeks after she was admitted. The Trust went against CG32 guidance when its staff did not refer Mrs X to a dietitian for nutrition support on 17 January 2019, and this was a failing.

54. We considered if Trust staff should have put a red tray, or similar support, in place for Mrs X during her admission. In line with the Royal Marsden guidance, staff should have carried out a person-centred assessment to identify if Mrs X needed and wanted assistance with eating and drinking. This is particularly relevant in Mrs X’s case because she was malnourished from the day of admission, her weight continued to decrease, and her food intake was poor throughout her admission.

55. Our nursing adviser told us Mrs X needed assistance or encouragement with food intake because she had a poor food intake throughout her admission. There is no evidence in the records that staff carried out an assessment to determine if Mrs X required and wanted a support system in place to assist her with eating and drinking. There is also not evidence staff provided consistent assistance with eating and drinking to Mrs X.

56. Staff went against guidelines when they did not carry out an assessment to determine if Mrs X wanted or needed a ‘red tray’, or similar system in place, and this was a failing.

Pressure ulcer care

57. The standard relevant to this part of the complaint is NICE CG179. The guidance says healthcare professionals should:

‘1.1.2 Carry out and document an assessment of pressure ulcer risk for adults being admitted to secondary care or care homes in which NHS care is provided 1.1.3 Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk 1.1.13 Use a high-specification foam mattress for adults who are admitted to secondary care 1.1.5 Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional 1.1.9 Encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required 1.4.3 Categorise each pressure ulcer in adults using a validated classification tool (such as the International NPUAP‑EPUAP Pressure Ulcer Classification System). Use this to guide ongoing preventative strategies and management. Repeat and document each time the ulcer is assessed 1.4.26 Discuss with adults with a heel pressure ulcer and, if appropriate, their family or carers, a strategy to offload heel pressure as part of their individualised care plan.’

58. This guidance also says, when adults are assessed as being at high risk of developing a pressure ulcer, staff should develop and document an individualised care plan. It says the plan must consider: · ‘the outcome of risk and skin assessment · the need for additional pressure relief at specific at-risk sites · their mobility and ability to reposition themselves · other comorbidities · patient preference.’

59. Ms X complains the Trust did not provide appropriate treatment for the pressure ulcer her mother developed during her hospital admission. Her specific concerns are Trust staff: · incorrectly graded Mrs X’s pressure ulcer · failed to create a pressure ulcer prevention plan · failed to inspect Mrs X’s skin frequently enough.

60. In the Trust’s complaint response, it noted it carried out an RCA into Mrs X’s pressure ulcer. This identified staff did not consistently carry out skin inspections or put a pressure ulcer prevention plan in place.

61. The 16 January 2019 emergency department records contain a complete Waterlow pressure ulcer assessment tool. The primary aim of this tool is to assess the level of risk of a patient developing a pressure ulcer. This identified Mrs X was at high risk of pressure ulceration. However, staff did not carry out a further Waterlow risk assessment tool when Mrs X was admitted to hospital, and this went against NICE CG179. If staff had repeated the Waterlow assessment on admission to the ward, this would have calculated Mrs X was at high risk of developing a pressure ulcer and would have prompted staff to carry out an individualised care plan.

62. There is no evidence in the records that the Trust put together an individualised care plan, and the Trust confirmed this in its RCA.

63. The Trust went against national guidelines when it did not identify Mrs X was at high risk of developing a pressure ulcer when she was admitted to hospital, and when it did not carry out an individualised care plan. This was a failing. Had staff identified she was at high risk of developing a pressure sore, this would and should have prompted staff to carry out daily documented skin checks.

Impact

64. We go on to look at the ways Ms X tells us her mother and family were affected by the issues she raised and consider if these were caused by the failings we have identified.

Impact of nutritional care

65. We identified the following failings in nutritional support. Trust staff: · delayed identifying Mrs X’s impaired vision · did not weigh Mrs X and estimated her weight on 16 and 31 January, on 9 and 16 February, and on 6 March 2019 · delayed referring Mrs X for six weeks to a dietitian · did not carry out an assessment to determine if Mrs X wanted and needed a ‘red tray’, or similar system, in place.

66. Ms X says the lack of nutritional support the Trust provided to her mother led to Mrs X’s condition deteriorating on transfer to the community hospital. She also says her mother’s decreased weight meant staff were unable to offer additional pain relief.

67. Ms X tells us witnessing her mother feeling like this in hospital led to the family feeling very upset, and this prevented them from being able to fully concentrate on their own responsibilities, and for Ms X’s sleeping patterns to become very erratic.

68. First, we looked at the impact of staff not identifying Mrs X was partially sighted on admission to hospital. Having considered the evidence, it is our view nursing staff may have offered earlier support to her with eating, had they identified Mrs X was partially sighted sooner.

69. Similarly, had the Trust put a red tray system in place earlier, this would have highlighted to all staff that Mrs X required assistance or prompting with eating and drinking.

70. We considered the impact of the delayed dietitian referral. Ms X complains staff did not provide Fortisips to her mother. Dietitians determine the nutritional support patients require. Our nursing adviser told us dietitians commonly provide nutritional supplements, such as Fortisips, to patients with a poor intake to support them to reach their nutritional requirements. Mrs X’s food intake was poor throughout her admission and when she was transferred to the community hospital, staff prescribed nutritional supplements to her. Had Mrs X been seen by a dietitian at the beginning of her admission, she would have received nutritional support. Having weighed up the evidence, it is more likely than not that, had staff referred Mrs X to a dietician, they would have prescribed a nutritional supplement, such as Fortisips.

71. The records show Mrs X lost 6kg during her admission to the Trust’s hospital, between 16 January 2019 and 8 March 2019. This was a loss of 15% of her body weight, which is a significant amount. Even more so given she was already malnourished on admission. Once Mrs X was transferred to the community hospital, she was given nutrition supplements and put most of this weight back on. Given the evidence, it is our view that had Mrs X received assistance with eating and nutritional supplements earlier, she would not have lost weight during her hospital admission.

72. We spoke with our gastroenterology adviser about Ms X’s concerns that her mother’s condition deteriorated due to the weight she had lost.

73. Our gastroenterology adviser told us the failings in nutritional care led to staff not providing Mrs X with every opportunity to be in the best condition to enable her to achieve an optimal recovery. Informed by our adviser’s comments, we can say that, had the Trust provided appropriate nutritional care, Mrs X may have had a better recovery. However, our gastroenterology adviser was not able to say if Mrs X not lost weight during her hospital admission, her recovery would have been better.

74. Our adviser’s comments suggest that if the Trust had provided Mrs X with adequate nutritional care, her recovery could have been easier. We cannot quantify what difference it would have made. We were pleased to note there were no long-term clinical impacts as, once Mrs X was in the community hospital, she was given supplements and was able to regain most of the weight she lost. However, on balance, if she had not lost weight, she would have been in a better position to make an optimal recovery.

75. It is our view Ms X and her family would have felt upset and distressed at witnessing Mrs X losing further weight in hospital, particularly given she was already malnourished when she went into hospital. We consider this issue had an emotional impact on the family for around two months, until Mrs X started to gain weight in the community hospital.

76. We go on to consider if the weight Mrs X lost during her admission led to staff not being able to prescribe additional pain relief to her.

77. Our gastroenterology adviser told us the British National Formulary’s ‘Prescribing in the elderly’ is relevant to our consideration of this part of the complaint. This states, medical staff must use opioid analgesics (such as the codeine prescribed to Mrs X) with caution when prescribing to elderly patients. This is because the nervous system of elderly patients is more sensitive to many commonly used drugs. Our adviser told us it is therefore in line with good clinical care and treatment for doctors to start prescribing opioid analgesics to elderly patients in lower doses and slowly increase these.

78. We looked at the medical records that document the pain medication prescribed and administered to Mrs X during her admission to the Trust’s hospital, and during her admission to the community hospital.

79. There is no evidence in the Trust’s medical records that Mrs X was denied stronger medication during her admission to the Trust’s hospital. At the community hospital staff prescribed 15mg of codeine to Mrs X on 23 March 2019. Our gastroenterology adviser told us this dose is slightly lower than the average dose prescribed to adult patients. Staff later increased Mrs X’s codeine dose to an average dose level (30 mg) on 28 March 2019, when it was found 15mg of codeine was not sufficient to ease Mrs X’s pain. Our adviser told us that first prescribing a lower dose and then slowly increasing it, does not provide evidence that Mrs X was denied a sufficient dose of pain medication due to her weight. This is because it is in line with the British National Formulary guidance to initially prescribe a lower codeine dose to elderly patients and waiting to see if this is sufficient before increasing the dose. This approach ensures elderly patients do not receive too much medication that may negatively impact them. For this reason, we cannot say the community hospital would have decided to prescribe a higher dose of codeine to Mrs X had her weight been higher.

Impact of pressure ulcer care

80. We considered how the failings in pressure ulcer care affected Mrs X and her family.

81. We identified the following failings in pressure ulcer care. Trust staff did not: · identify Mrs X was at high risk of developing a pressure sore when she was admitted to hospital · carry out an individualised care plan · carry out daily documented skin checks.

82. Ms X says the issues in pressure ulcer care led to her mother experiencing additional unnecessary pain.

83. The issues we identified led to staff not identifying Mrs X had a pressure ulcer until 22 January 2019, when it was a grade two ulcer. This led to staff delaying providing a pressure relieving mattress and repose heel protectors until 23 January 2019, seven days after her admission. The Trust’s RCA identified Mrs X’s pressure ulcer had been preventable. Therefore, if the equipment was in place sooner, she would not have developed a pressure ulcer.

84. Mrs X had a grade two pressure ulcer from 22 January 2019 until at least 23 March 2019, and Mrs X experienced pain due to this. It is our view, had the Trust provided appropriate pressure sore care and treatment to Mrs X sooner, this would have prevented the additional unnecessary pain Mrs X experienced for two months.

85. It is our view Ms X and her family would have felt upset and distressed for two months due to witnessing Mrs X experiencing additional unnecessary pain.

86. Ms X tells us the additional unnecessary pain her mother experienced also led to her mother being less inclined to eat and having little enthusiasm to be mobile. She also says the issues with pressure ulcer care led to her mother experiencing reduced mobility, which meant she required greater input from carers and family. She told us this was extremely stressful and costly.

87. Mrs X had a poor appetite when she was admitted to hospital on 16 January 2019. The records also show her mobility was reduced prior to admission, and one of the reasons for admission was because she was struggling to care for herself and could not use her stairs. The nursing and therapy records made during Mrs X’s admission to the Trust’s hospital show Mrs X required assistance with her ‘activities of daily living’ and could not mobilise independently, even before her pressure ulcer developed. The community hospital records also document Mrs X was struggling to mobilise due to pain in her right knee. Our nursing adviser told us this demonstrates Mrs X would have needed carer input when she was discharged from hospital, regardless of her pressure ulcers.

88. There is no evidence to support Ms X’s concerns that when her mother developed pressure sores, she became less inclined to eat, her mobility reduced, or that she required more care input when she returned home. Therefore, we cannot say whether she would have experienced these issues and required support when she was discharged home, even if the Trust had provided appropriate pressure ulcer care to Mrs X.

89. We considered Ms X’s concerns that the additional pain her mother experienced led to her mother: · starting to believe she was nearing the end of her life and would not return home · experiencing exacerbated anxiety and depression · being unpleasant and verbally abusive to her and her sister.

90. The inadequate pressure ulcer care led to Mrs X being in pain, and she was deteriorating. It is therefore more likely than not that the care the Trust provided to Mrs X contributed to her feeling upset, angry, and losing hope in recovering.

1. We identified failings in the nutritional and pressure ulcer care University Hospitals Birmingham NHS Foundation Trust (the Trust) staff provided to Mrs X. This prevented Mrs X from having the best possible chance of an optimal recovery. We found Mrs X experienced additional unnecessary pain and this led to an emotional impact on her family.

2. We have seen nothing to suggest the failings we identified directly led to: · staff being unable to offer additional pain relief · Mrs X being less inclined to eat · a reduction in Mrs X’s mobility · her requiring more care input when she returned home.

3. It is therefore our decision to partly uphold this complaint. We explain our reasons for our decision below.

91. In considering recommendations, we have referred to the Ombudsman’s Principles of Remedy. These state, where maladministration or poor service has led to injustice or hardship, the public organisations responsible should take steps to put things right.

92. Our Principles say that public organisations should seek continuous improvement, and use the lessons learnt from complaints to ensure poor service is not repeated.

93. As a result of Ms X making the complaint, the Trust says it has: · arranged for ward staff to undergo ongoing training around tissue viability and pressure ulcer care to prevent the same thing happening to other patients · reminded staff of the importance of making timely referrals · arranged for the ward matron to continue to monitor nutrition and hydration nursing care, which includes arranging additional training around nutrition and hydration · arranged for the dietetic team leaders to review the importance of regularly recording the weights of patients, and how the use of the red tray system and oral supplements drink (such as Fortisips) can help patients with their nutritional intake and minimise weight loss.

94. We spoke with our nursing adviser about whether the steps the Trust has taken go far enough to prevent the same from happening to others. Our nursing adviser said these measures go some way towards addressing the issues we identified in the report. However, more could be done. They told us the Trust can:

· audit nutrition risk assessments to ensure they are being actioned · remind staff to provide nutrition support to patients with a BMI lower than 18.5kg/m², in line with national guidance (NICE CG32) · audit nursing assessments to ensure they are being completed on admission, and staff are taking preventative action in response to the assessments.

95. With that in mind, within three months of the final report, the Trust should prepare an action plan to address the potential impact for other patients of the failings we have identified in Mrs X’s care and treatment. The plan should identify:

· what improvements the Trust is making or will make to prevent recurrence · who is responsible for those remedial actions · the timescale for each action.

96. Our Principles state that public organisations should ‘put things right’ and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

97. Ms X is seeking a financial remedy to put right:

· the impact on her mother not being in the best condition to achieve her optimum recovery · the additional unnecessary pain her mother experienced for two months due to her pressure ulcer · the distress and upset she and her mother’s family experienced for around two months when they witnessed her mother losing weight and experiencing additional unnecessary pain.

98. To determine a level of financial remedy, we review similar cases where similar injustice has arisen, along with our severity of injustice scale. Following this review, it is our decision Mrs X and her family experienced a level three injustice in line with our severity of injustice scale. This is because this level of injustice includes cases where people have experienced:

· distress, upset or worry lasting six to twelve months · significant distress (distress which results in a degree of functional impairment) lasting from a few weeks to three months · minor pain lasting up to about three months; severe pain up to a month · loss of opportunity for a better clinical outcome in cases not involving terminal, life threatening or seriously debilitating illness.

99. In cases where we identify a Level 3 injustice, we usually recommend a financial remedy in the region of £500-950. Having reviewed cases where a similar injustice has been experienced, our decision is the Trust should pay Ms X a financial remedy of £950 in recognition of the impact on Mrs X and her family.

100. The Trust should send us evidence it has complied with our recommendations. It should also send an anonymised copy of our final report and the action plan to the Care Quality Commission and NHS Improvement.