Nursing care
24. In our primary investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
25. Ms O complains the nurse asked her and her father to leave the room, for her mother to be given suction. She believes they should have been given a choice about this. She says the nurse then left the room and ‘sauntered down the corridor and back’ to get her mother a clean nighty because she had vomited. She says the nurse did not need to do this as her mother had a clean nighty in her room, and the nurse could have asked them this. She says once the nurse changed her mother, they called her and her father back in because her mother’s breathing had changed, and her mother died.
26. Ms O says she does not know when her mother stopped breathing, or if she was left on her own in the room for her last moments. She says the Trust’s complaint handling, and communication around the time of her mother’s death has caused her significant distress and grief. Ms O feels that she was deprived of her last minutes with her mother. We understand how upsetting this period of time was for Ms O and her father, and how distressing it is for Ms O to have unanswered questions.
27. The Trust’s written response dated 15 October 2018, says the staff nurse thought it would have been too distressing for Ms O and her father to witness the suction process, and the nurse was trying to maintain Mrs O’s privacy and dignity. The response conveyed the nurse’s condolences.
28. Having listened to the full recording of the local resolution meeting on 26 February 2019, we can see the Trust apologised for the impact the nurse’s actions had on Ms O, and that it acknowledged there should have been a conversation as to whether they wanted to leave the room.
29. The clinical records show within the nurse’s entry: 'patient was struggling to breathe due to excessive secretions which was upsetting the family. I asked the family for a few minutes whilst I administered suction....'. The record goes on to that the patient vomited while being given suction and that 'when changing patient's nightgown her breathing became erratic'. The record says the nurse went to inform Ms O and her father, and when they entered the room, the patient had stopped breathing but had a pulse. ‘She then passed away with husband and daughter present’.
30. The NMC Code states that a registered nurse must treat people as individuals and uphold their dignity. To achieve this, it states nurses must:
1.1 ‘Treat people with kindness respect and compassion 1.2 Make sure you deliver the fundamentals of care effectively 1.3 Avoid making assumptions and recognise diversity and individual choice 1.4 Make sure any treatment assistance or care for which you are responsible is delivered without undue delay 1.5 Respect and uphold people’s human rights.’
31. We asked our adviser if the nurse’s actions, in asking the family to leave the room while suction was given and leaving Mrs O alone whilst getting a change of nightgown, were appropriate and in line with the NMC Code. We also asked if it would have been appropriate to ask the family back into the room sooner.
32. Our adviser confirmed the nurse was upholding the dignity of the patient in asking her relatives to leave the room while they performed personal care. The nurse was also upholding the dignity of the patient by seeking a fresh nightgown, even if this meant leaving the patient alone for a short period of time. It would have been appropriate to clean the patient, replace the nightgown, and then ask the family back into the room. The clinical records suggest that this is what happened.
33. We can see from the recording of the meeting in February 2019 that Ms O did not accept the nurse’s explanation that they were maintaining her mother’s dignity. She feels this was not necessary given she was such a close relative.
34. The NMC Code is clear that a nurse caring for a patient owes a primary duty to their patient to uphold the patient’s dignity. In this situation we do not find that the nurse’s actions were contrary to relevant professional standards so will not investigate further.
35. Ms O also complains that the clinical records were not clear as to who was in the room with her mother, and when.
36. The NMC Code (section 10) states that a registered nurse must, ‘Keep clear and accurate records relevant to your practice’.
37. Having considered the clinical records, our adviser confirmed that the nurse adequately recorded the sequence of events leading up to the death of Mrs O. It was not necessary to record which of the family were in the room at each point. It was also not necessary for the nurse to record which member of the medical or nursing team were in the room at each point in time.
38. We understand that Ms O is left with unanswered questions, and this is distressing for her. Had specific timings of staff entering and leaving the room been recorded, this may have helped her with these questions. That said, the clinical records are in compliance with the NMC Code.
Complaint Handling
39. During our primary investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have done this and we have found the Trust has already done enough to put right the impact of these events.
40. Ms O complains that despite the Trust offering numerous apologies, it did not translate these into meaningful action points or plans of action, that it could learn from going forward. She says the Trust gave her verbal assurances during the complaints process but frequently failed to follow these through, and that many of the Trust’s responses to her were inadequate and some were factually untrue and/or inaccurate.
41. She says that this prolonged and worsened her grieving process. She was forced to relive the death of her mother many times and had no option but to go through her mother’s clinical records in fine detail to try to get to the ‘truth’. She describes the ‘rollercoaster’ of the complaints process taking a significant emotional toll on her.
42. The Trust’s initial response from 15 October 2018, offered numerous apologies to Ms O. We will not list all of these, but these included apologies for poor communication while her mother was in hospital, for the delay in providing Ms O with the mortality review, for providing a cancer diagnosis over the phone as opposed to in person, and for the inappropriate actions of a member of staff on the ward whistling when her mother was struggling.
43. Within the written response, the Trust confirmed that where the apologies given related to nursing care, these areas were to be discussed at the next ward meeting. For other areas, where the Trust acknowledged care had not been provided as would be expected, the Trust provided no explanation, nor did it set out a plan of action to show how these failings would be avoided in the future.
44. In the meeting on 26 February 2019, the Trust Complaints representative acknowledged their surprise that the ‘learning points’ had not been included in the response, as was their usual practice.
45. At the request of Ms O, a local resolution meeting was held on 26 February 2019. The Trust’s response was discussed in depth. The meeting was attended by the Trust’s Associate Director of Governance, the Divisional Director of Nursing, the Consultant Geriatrician who had completed the mortality review, a member of the Trust’s Complaints Team and Ms O. The meeting lasted for over two hours.
46. Having listened to that meeting in full, we can see that during the meeting the Trust offered Ms O various assurances that action would be taken around the areas of: · improvement of staff communication · clarification of the date of the CT scan · learning being given to the doctor who gave the cancer diagnosis by phone · identification and appropriate action for the member of staff who was whistling · learning for the nurse caring for Mrs O in her last moments.
47. Ms O says that she felt optimistic and encouraged following this meeting because of the assurances she had been given. She told the meeting: ‘what you have said to me today in terms of speaking to individuals and putting in actions is important. I now know what is going to happen’.
48. At the end of the meeting, the Complaints team representative noted they had captured the actions, although no summary of agreed actions was repeated, nor was Ms O sent such a summary following the meeting.
49. The Trust’s Complaint Handling Policy states:
5.14.2 ‘The Lead Investigating Officers are responsible for preparing action plans arising from individual complaints and for ensuring these are implemented.
5.14.3 Lessons learned arising from complaints is a critical part of complaints management. Investigation officers will be responsible for providing feedback, in respect of complaint outcomes to appropriate individuals who can take action and ensure lessons are learned.’
50. In its later written response (13 May 2020), the Trust confirmed no formal action plan was completed after the meeting in February 2019. No reason or explanation for the breach of its policy was given.
51. After chasing the Trust, Ms O received the Trust’s response on 16 April 2019, following the February 2019 meeting.
52. We can see that the 16 April 2019 response did not reflect the assurances given to Ms O during the February meeting. For example, there was no reference to learning being given to the doctor who conveying the cancer diagnosis by telephone. In relation to the ‘whistling’ member of staff, and the nurse present at the end of Mrs O’s life, the response repeated what was stated in the Trust’s October 2018 response.
53. In addition, in the April response, although further information was given about the CT scan, this contradicted both what Ms O was told while her mother was in hospital, and what had been stated in the meeting in February. This further information was subsequently shown to be inaccurate.
54. Ms O says, on receiving this response, she was completely deflated and felt ‘back at square one’. We can understand this reaction and the distress this response would have caused her.
55. Ms O requested a further meeting. The Trust cancelled the original date in November 2019, and the meeting took place on 8 January 2020. This meeting was attended by the Trust’s Associate Director of governance, the previous Divisional Director of Nursing now based in the community, the current Divisional Director of Nursing, a Bereavement Nurse and Ms O. This meeting again lasted for over two hours.
56. The meeting considered Ms O’s outstanding issues and the unanswered questions she had arising from the Trust’s two written responses, and the information she was given when her mother was in hospital, which conflicted in several areas. One conflicting area was around the CT scan.
57. At the direction of Ms O, the meeting on 8 January 2019 also considered the Trust’s complaint handling process. Ms O clearly explained to the meeting how the handling of her complaint had impacted her. She described the time she had personally lost in having to review all her mother’s clinical records, and the Trust’s previous responses, to try to establish the facts. She also explained the impact on her and her father of not being able to obtain closure to the process.
58. We have listened to the full recording of this meeting and noted the discussion around the Trust’s complaint handling.
59. In relation to the Complaints process, the Trust apologised for the delay in providing its response to Ms O, following the meeting on 26 February. The Trust confirmed it now had a very different process for progressing complaints, in part resulting from its failure in handling her complaint. Under the new process, the clinical team now meet weekly with the complaints team to go through any outstanding complaints, to make sure all parties knew what stage each complaint had reached, and to get responses out quickly. The Trust confirmed its response rate had improved because of this new process.
60. The Trust also acknowledged that the written responses Ms O had received were not written in a personal way. This was because answers were obtained from several different people, before being combined into a single response. The Trust acknowledged the overall tone of the response was not appropriate and confirmed a management piece of work was already underway, within the complaints team, to address making responses more personal to each individual complainant.
61. The Trust further acknowledged that, in Ms O’s case, its written response in April 2019 made no reference, or links to the information provided in the February 2019 meeting. It apologised for this and accepted that Ms O should have been provided with a better response. It also accepted that it would have been useful for Ms O to have seen a detailed action plan following the meeting in February.
62. In the January meeting, the Trust clearly acknowledged that in Ms O’s case the complaints process had gone wrong, and this had resulted in a poor experience for her. Ms O’s process had started with the Bereavement Team and was passed to the Medical Director and then to the Associate Director of Governance because it related to the Mortality Review.
63. The Trust recognised that the issues Ms O raised should have been passed to the Patient Advice and Liaison Service (PALS) team much sooner than they were. The Trust confirmed this process had now been altered, and complaints coming via the Bereavement team are now shared with PALS immediately. The Bereavement Nurse present accepted that their team was ‘really new’ when Ms O raised concerns and confirmed that the team had also learned from the problems while addressing Ms O’s complaint.
64. The Trust explained that under its current complaints process, where concerns with clinical staff are raised by a patient or family member, these are highlighted immediately to the complaints team to advise them that this could result in a complaint. The individual will be invited in to discuss their experience, and if the Trust identifies an issue, a meeting will be suggested with the relevant team to discuss this. The Trust confirmed that this has resulted in them rarely now dealing with paper complaints.
65. The Divisional Director of Nursing apologised again to Ms O on behalf of all involved for the poor handling of her complaint.
66. We note that towards the end of the meeting in January 2020, the Trust summarised the points of action to ensure that these were agreed by everyone, including Ms O. The Trust also made clear that its third written response would address only these specific action points. The action plan was subsequently sent to Ms O in writing on 10 January for her to consider, comment on, and agree. Ms O added to these on 22 January and on 5 February the Trust confirmed ten agreed points for investigation and action.
67. The Trust responded to the ten points in writing on 13 May 2020. This response informed Ms O of her right to contact us.
68. Our consideration of the evidence shows an indication of failings in the Trust’s handling of Ms O’s complaint between September 2018 and May 2020. At times it breached its own Complaints Handling Policy in not identifying and monitoring points of learning it could take going forward. We have also seen the Trust did give verbal assurances to Ms O during the complaints process which were not followed through, and that some of the Trust’s responses to her were inadequate and factually untrue and/or inaccurate.
69. These mistakes led to Ms O having to pursue the matter further and, without doubt, increased her distress. The poor handling of her complaint led to her having to relive the distressing period leading to her mother’s death numerous times, and to devoting significant time going through her mother’s clinical records in detail to prepare for meetings and challenge the misinformation she was given. We fully understand the emotional toll this took on her.
70. By way of an outcome, Ms O has told us she wants the Trust to recognise and acknowledge the poor conduct of her complaint and to put in place meaningful service improvements.
71. We can see that during the local resolution process, the Trust took the following actions and adopted service improvements in relation to its complaint handling:
· Following the second local resolution meeting the Trust forwarded the action points in writing and sought confirmation from Ms O that these were agreed.
· The Divisional Director of Nursing apologised on behalf of all concerned at the Trust for the way Ms O’s complaint was handled and for the distress this caused her.
· The Trust introduced a new process where a representative of clinical staff for an ongoing complaint and a member of the complaints team meet weekly, to monitor progress of the complaint and to ensure response rates are appropriate.
· The Trust introduced a new process to ensure that PALS are informed immediately of a complaint where the complaint comes via the Bereavement Team or through any route that is not the complaints team.
· The Trust introduced a new process where an issue raised with clinical staff, under which the medical team let the complaints team know there could be an issue. Potential complainants are invited in to talk about their experience and meetings are arranged with the relevant clinical and complaints staff at the outset where appropriate.
· The complaints team reviewed the drafting of responses to ensure these are personal to the individual.
72. Our Principles of Good Complaint Handling say that to put things right organisations should provide an apology, explanation and an acknowledgement of responsibility, as well as remedial action which may include revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these.
73. We have seen evidence that the Trust has provided a remedy that is in line with our guidance and that these are the actions Ms O would like. We have seen it has acted in line with our principles and would not expect the Trust to do anything more. We will not take further action on the complaint and thank Ms O for bringing her concerns to us.