Communication with family
20. Mrs O complains the Trust did not inform her that it had changed its decision to discharge her mother as previously advised on 31 August 2019. She says the Trust did not notify the family for five days that their mother was still under its care.
21. Mrs O is concerned her mother was in hospital without any family support for five days. Mrs O says her mother suffers from dementia and she has Power of Attorney to make decisions on her mother’s behalf. She did not have the opportunity to be involved in her mother’s care for those five days. Mrs O says when she first visited her mother on 6 September 2019, her mother looked weak, had not been eating properly, felt dehydrated and was in an unkempt state.
22. In its response letters dated 19 November 2019 and 10 February 2020, the Trust apologised for the oversight. It says prior to her mother’s discharge on 31 August 2019, her mother’s condition deteriorated. Nursing staff requested a medical review and following this it was decided Mrs E should remain in the Trust overnight for monitoring. The Trust says it has reiterated to its staff the expectation that relatives must be kept informed of a patient’s condition or change in discharge. It says it has also discussed this complaint at its ward meeting to highlight the issue and to minimise the risk of it happening in the future.
23. Our consultant adviser explains that Mrs E’s original planned discharge back to her residential home on 31 August 2019 was initially delayed because the Early Discharge Notification (EDN) was not performed in time. EDN is the process to discharge patients as soon as possible on the same day when they no longer meet the clinical criteria for inpatient care.
24. The residential home required the Trust to reassess her before accepting her back. There is a clinic record dated 31 August 2019 at 6.45pm, stating ‘Pt did not go H due to no EDN being completed. However, sats on evening drug round show 83% so CO2 applied.’
25. The records show Mrs E’s clinical situation was not stable because she had low oxygen levels, and although mobile with assistance, there was a requirement for continued antibiotic therapy for her significant pneumonia. Our consultant adviser explained for these reasons the decision to delay her discharge was appropriate. The records show Mrs E was thin (records state she weighed 51kg and had been seen by a dietitian with supplements recommended), frail and despite improved control of her heart rate, she was vulnerable and requiring prolonged intravenous antibiotic. On this basis, our consultant adviser says the correct decision was made to delay the discharge.
26. The records dated 5 September 2019 state ‘daughter was not pleased that no one had informed her that her mother is in hospital.’
27. The NMC Code of Conduct, Section 5.5 states, ‘Nurses must share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand.’
28. NICE guidelines Section 1.1.4, states, ‘Ensure that the person, their carers and all health and social care practitioners involved in someone's move between hospital and home are in regular contact with each other. This is to ensure the transition is coordinated and all arrangements are in place.’
29. Section 1.4.3 of the NICE guidelines states ‘Hospital based practitioners should keep people regularly updated about any changes to their plans for transfer from hospital.’
30. From the evidence we can see, the Trust has not acted in line with guidance in communicating with the family that Mrs E’s circumstances had changed, and she was to remain in hospital.
31. We asked our nursing adviser about Mrs O’s complaint about her mother being in an unkempt state. Our nursing adviser explains, fundamentals of care include making sure that those receiving care have adequate access to nutrition and hydration and making sure that they are given if they are not able to feed themselves or drink fluid unaided.
32. The NMC Code of Conduct section 1.22 states, ‘Nurses must make sure they deliver the fundamentals of care effectively. The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions.’
33. It is not possible to establish from the records if Mrs E was in an unkempt state. It is evident that on 5 September 2019, she had been administered intravenous saline 500mls over 8 hours because of concerns raised by nursing staff about her poor fluid intake. Oxygen therapy was also being administered.
34. The food intake charts indicate that despite being offered food Mrs E’s intake was poor on 5 and 6 September 2019. Oral fluid intake on these dates was also variable. Mrs E’s personal care needs, including continence care were attended to on 6 September 2019 and she was repositioned 2-3 hourly. Our nursing adviser explains it is likely that Mrs E’s unkempt state was attributed to her overall poor condition and weakness.
35. We understand learning that your mother is still in hospital when you believed she was discharged would be upsetting. It is clear finding this out caused Mrs O anxiety, shock, and distress. We have found that the Trust’s communication with the family during the start of the admission was not in line with NMC or NICE guidelines. The Trust failed to inform Mrs O that it had changed its decision to delay her mother’s discharge. It did not notify the family, for five days, that their mother was still under its care. This is a failing.
36. We have found that the Trust’s identified actions regarding Mrs E’s fundamental care needs were in accordance with NMC guidance.
37. We next considered the impact of the failings we have found. Mrs O says she feels ‘let down,’ by the Trust. She says had she have known her mother was not discharged, she would have stayed with her mother and as she held Power of Attorney to make decisions on her mother’s behalf, she would have been involved in her mother’s care.
38. It is understandable that Mrs O would have felt let down and upset when she found her mother had been in hospital for five days. She was also not given the opportunity to be involved with her mother’s care during this time. We can link this impact to the failing.
39. Having visitors when you are in hospital is important. This can be particularly important when someone experiences dementia because it can be important to see familiar faces. Mrs O is concerned that her mother’s health was affected by the lack of family contact. We can see that Mrs E was physically very unwell and while visitors may have had a positive impact on her mental health, we are unable to say overall it would have made a difference to her physical health.
40. Mrs O is seeking service improvements as an outcome to the complaint.
41. In its response letters, the Trust has admitted its failings in communication. It has apologised for these. It has put in service improvements by reiterating to its staff the expectation that relatives must be kept informed of a patient’s condition or change in discharge. It has also discussed this complaint at its ward meeting to highlight the issue and to minimise the risk of it happening in the future. These are appropriate actions for the Trust to take.
42. Our Principles of Good Complaints Handling sets out the principles of what is meant by good complaint handling, and it should be used to assist those organisations within our jurisdiction to deliver good complaint handling to all its complainants. It sets out the 6 principles including, Getting it right, Being customer focused, Being open and accountable, Acting fairly and proportionately, Putting things right and Seeking continuous improvements.
43. We have seen evidence the Trust has recognised and admitted its failings in communicating with the family, apologised, and put in place appropriate service improvements. This is in line with our Principles of Good Complaints Handling and puts right what went wrong.
Admission in Ward A
44. Mrs O is concerned that when the Trust reversed its decision to not discharge Mrs E on 31 August 2019, she was transferred to Ward A. Mrs O believes on this ward, her mother did not receive the correct treatment for her chest infection and irregular heart rate. She says she did not receive the care she needed until she was transferred to the Ward B five days later. Mrs O believes her mother’s condition had irreversibly declined during these five days when she was on Ward A.
45. The Trust says the nursing team provide care for different medical conditions on Ward A. Prior to Mrs E’s move to Ward A the clinical site nurse ensured the ward could meet her medical needs. Ward A has a medical team managed by a medical consultant and they review patients throughout the week to ensure they receive a progressing medical treatment plan. It says Mrs E was seen everyday by a consultant whilst on Ward A and appropriate blood tests and X-rays were taken.
46. The records show Mrs E was first moved to a Ward A on 31 August 2019. This was because her discharge plan was considered as likely to occur. Mrs E was then transferred to a medical ward on 4 September 2019.
47. Our consultant adviser explains Mrs E’s clinical situation was not stable. The records show she had low oxygen levels and although mobile with assistance, was felt to require continued antibiotic therapy for her significant pneumonia. On this basis, a delayed discharge was made. The records also show she was thin and frail.
48. Our consultant adviser says the transfer from the admissions ward to an acute medical ward was planned which was appropriate, although ideally a specialist ‘Care of the Elderly’ or Geriatric ward was most appropriate.
49. NICE guidelines section 1.4.4 states, ‘Provide care for older people with complex needs in a specialist, geriatrician led unit or on a specialist geriatrician led ward.’
50. In line with the guidance above, a transfer to a specialist frailty ward or specialist geriatric ward for patients with dementia was indicated, given her comorbidities and this should have been a priority for Mrs E’s best care. Our consultant adviser says multiple transfers and changing care teams of nurses adds to confusion and delays recovery in patients with dementia.
51. The records show Mrs E failed to respond to appropriate antibiotic treatment of her left sided pneumonia. Our consultant adviser said this is common in the elderly. This caused her heart to fail and to develop atrial fibrillation again, a rapid irregular and less efficient heart rhythm. Despite treatment her heart struggled, in part due to prior heart disease (heart attack/myocardial infarction). Treatment was escalated with advice from microbiology and initial improvement was seen on blood tests. However, a prolonged bedbound state weakened Mrs E further, and eventually the pneumonia and heart failure began to overcome her.
52. Paragraph 15 of the GMC, Good Medical Practice, states ‘you must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs.’
53. We have seen from the records, once Mrs O was informed of her mother’s inpatient status that appropriate decisions to limit treatment were made in conjunction with her as she held Power of Attorney for health. The decision to plan end of life care was agreed and made appropriately.
54. We cannot find any evidence that Mrs E did not receive the correct medical treatment for her pneumonia and atrial fibrillation or other conditions, for the whole of her admission at the Trust. From the evidence we can see the Trust acted in line with GMC guidance regarding her medical treatment.
55. Being a carer for someone close to you, will cause you to be concerned for their safety and welfare. We understand for Mrs O, this anxiety was compounded as her mother suffers from dementia.
56. We have found, despite being on Ward A for the first 4 days, Mrs E received the correct medical treatment during the entirety of her admission at the Trust, and it was in line with GMC guidance.
57. Multiple ward transfers are not ideal for patients suffering from dementia, and whilst it did not impact on Mrs E’s medical treatment, this may have had an effect on her mental health. While it was not ideal that she had ward transfers and was not on a specialist geriatric ward, we cannot say that moving wards meant the care fell so far below what would be expected that we consider it to be a failing.
Lack of continuity of care between nursing staff
58. Mrs O complains there was a lack of communication and continuity of care between nursing staff on the ward and during handovers at the end of shifts. Mrs O says she had to update staff after each handover about her mother’s condition and she is concerned about the five days she was not present with her mother, given her mother’s limited capacity.
59. The Trust says Mrs E was reviewed by a consultant and physiotherapist daily and seen by a dietician. Medical records evidence nursing entries for every shift which evaluated the nursing care that had been provided. It apologises that it appeared that its staff were not knowledgeable about her mother’s care and treatment. It says the sister for the ward was unaware of these concerns.
60. We have seen in the records that nursing charts for fluid intake, food intake, personal care needs including continence and positioning were completed. There is a dementia patient profile in the available records, and it is evident from entries in the clinical records that staff were aware that Mrs E had dementia. There are also documented discussions with the family on the following dates, 6, 8, 11, 12, 13, 16, 17, 19, 23, 24 and 25 September 2019.
61. NMC Code of Conduct, Section 5.5 states, ‘Nurses must share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand.’
62. Our nursing adviser explains with a focus on the delivery of patient care, it would not be possible for nursing staff to contact all patient relatives daily to inform them of the progress of each patient. Enquiries made by relatives via telephone or in person would be addressed. From the records, we can see, from 6 September onwards, the Trust acted in line with the NMC guidance in communicating and updating the family.
63. Section 1.22 of the NMC Code of Conduct states, ‘Nurses must make sure they deliver the fundamentals of care effectively. The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions. It includes making sure that those receiving care have adequate access to nutrition and hydration and making sure that they are given if they are not able to feed themselves or drink fluid unaided.’
64. From the records we can see that on the day of Mrs E admission, she was prescribed intravenous saline 500mls over eight hours because of concerns raised by nursing staff about her poor fluid intake. Oxygen therapy was also being administered as prescribed.
65. Our nursing adviser says Mrs E was appropriately referred to and seen by a dietician on 4 September 2019. Food intake charts indicate that despite being offered food Mrs E’s intake was poor on 5 and 6 September 2019. Our nursing adviser explains it is likely that this was due to her overall poor condition and weakness.
66. The records show Mrs E’s oral fluid intake on these dates was also variable. Her personal care needs, including continence care were attended to on 6 September 2019 and she was repositioned every two to three hours.
67. We are unable to find any evidence that Mrs E gave any indication verbally or showed any non-verbal signs of distress because family members were not present. There is a comprehensive nursing assessment, including risk assessments in the records and these are in accordance with NMC guidance.
68. Mrs O says there was a lack of communication and continuity of care between nursing staff during handovers and end of shifts. This would naturally cause a carer concern and anxiety about the safety, health, and welfare of their loved one.
69. We have found that records were comprehensive and so nursing staff were aware of Mrs E’s dementia. We consider the identified actions regarding her fundamental nursing care were in line with NMC guidance.
70. We can see communication with the family was not in line with guidance during the start of Mrs E’s admission. From 6 September 2019 onwards there were detailed discussions between Mrs O and medical staff regarding treatment and discharge planning in line with the NMC guidance.
Mrs E’s fall in the Trust
71. Mrs O complains that the Trust did not inform the family that Mrs E had a fall in hospital until after her death.
72. In its first response letter dated 19 November 2019, the Trust says, ‘On 4 September your mother was noted to be stable, however, on the same day she had a fall, while assisted, by tripping on her trousers whilst in the toilet.’ In its second response letter, dated 10 February 2020, the Trust apologises for not informing the family of Mrs E’s fall and it explains how the fall happened.
73. The Trust’s guidelines for Falls Assessment and Core Care Plan states ‘Every adult patient must have an initial falls assessment within 12 hours of admission. The risk assessment must be reviewed at a minimum of once a week and additionally within 12 hours of transfer to a different ward, following a fall or following a significant change in the patients’ medical physical or mental condition that may impact upon their falls risk.’ The Trust’s guidelines are in line with national NICE Guidelines for Fall Assessment and Prevention of Falls in Older People 161.
74. The records show a completed Falls Risk assessment dated 30 August 2019. This indicated that Mrs E ‘requires supervision’ with her mobility and walks with a walking frame. Further falls assessments were completed on 31 August 2019, 4, 5, 15 and 22 September 2019. This demonstrates that the Trust were aware of Mrs E’s fall risk and were carrying out regular assessments of this risk in line with the Trust guidelines on falls.
75. The clinic records dated 4 September 2019 state at approximately 3pm, ‘Pt had a fall in toilet. Reports trying to pull down trousers and missed footing. Pt is alert, orientated. Not confused. Reports hitting head. Nurse present during incident.’
76. We can see a completed Incident Investigation Form regarding this fall in the records.
77. Our nursing adviser explains, when reviewed by a doctor, Mrs E reported hitting her head and was noted to have bleeding from a wound on her left elbow. Included in the medical plan of care was the requirement for an X-ray of her left arm and a CT scan of her head. The results of these investigations were normal.
78. The NMC Code of Conduct, section 5.5 states, ‘Nurses must share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way, they can understand.’
79. In line with the NMC Code of Conduct we would have expected the Trust to inform the family of Mrs E’s fall. There is no evidence in the records that the family were informed of the fall.
80. We understand that learning of the fall during the complaint process came as a shock to the family. They were already grieving the loss of their loved one and being informed she had sustained a fall, resulting in an injury would have been very difficult for them to hear.
81. We have found that the Trust failed to notify the family of when Mrs E fell, which is not in line with NMC guidance and is a failing.
82. We next considered the impact of the failings we have found. Mrs O says she feels let down by the Trust and finding out her mother had a fall was distressing.
83. Being informed that her mother had a fall, after her death during the complaints process would have been upsetting. We can also see that this would lead Mrs O to feel let down. We can link the failing to the claimed impact.
84. We have seen the Trust has apologised for not informing Mrs O about the fall when it happened. It has put in service improvements by reiterating to its staff the expectation that relatives must be kept informed of a patient’s condition. By admitting its mistake and apologising for it, we consider the Trust has acted in line with our Principles of Good Complaints Handling and is appropriate action to take to resolve the complaint.
85. We thank Mrs O for bringing her concerns and recognise how important her complaint is to her.