Accounting for Mr E’s dementia
16. Mrs E complains that staff at the hospital were not fully aware of her husband’s dementia, or did not bear it in mind, when treating him during his admission between 29 June and 1 July 2020. Specifically, she told us about one time during his stay when she called the ward to check on him. She says the nurse explained he was coping well and enjoying a food he did not usually like.
17. Mrs E also says that the Trust’s complaint responses did not refer to her husband’s dementia. She says that its letters only focussed on how hospital staff cared for his COPD.
18. Good Medical Practice says that doctors should assess the patient’s conditions and account for their medical history. In this instance, Mr E went into hospital on 29 June to treat his worsening COPD. Our adviser explained that the doctors should have accounted for Mr E’s dementia as it could have been a barrier to improving his breathing. This is because there was a risk of him forgetting to take medication or disrupting others on the ward.
19. Managing Mr E’s dementia also meant managing the risk he presented to himself. Bed Rails: Management and Safe Use says that bed rails are useful for preventing patients from falling out of bed. However, this needs to be balanced with the risk that arms and legs can get trapped and damaged, or someone’s head may become stuck. A patient’s condition needs to be assessed to determine if bed rails are suitable for them. Those at greater risk include people with confusion or delirium.
20. When Mr E was admitted to the Acute Medical Unit, staff completed a delirium care checklist. The form is designed to identify any problems with the patient’s state of mind, and it clearly records that Mr E had dementia. The notes from doctors who visited Mr E also often referred to his dementia. Additionally, there is a written note following Mrs E’s phone call to the ward. This recorded that she told the doctor that her husband’s communication was poor and he had dementia.
21. On 30 June a nurse visited Mr E to decide whether it was appropriate for his bed rails to be up. The form they completed recorded that bed rails were unsuitable due to his dementia.
22. When a consultant visited Mr E on 1 July they looked at his medical history and formed a plan of what to do next. They recorded he had dementia, as well as COPD and hypertension.
23. Throughout his time on the ward, Mr E’s prescriptions were tracked. A chart in his medical notes recorded which medication he had taken, how much of it and when. The chart would also show if he refused to take his medication. It shows that he continued to take all of his medication, and at the right time, throughout his stay in hospital.
24. We consider that staff were aware of his dementia during his time in hospital. Staff recorded this in the transfer documents and treatment plans. Throughout Mr E’s time on the ward, he took his medication as prescribed and there are no suggestions he was disruptive. Staff therefore knew about Mr E’s dementia and took appropriate action in response.
25. We have no reason to doubt Mrs E’s account that staff gave Mr E food he did not usually like. We understand why this news worried her. We also understand why this news led her to believe staff were not caring for her husband properly.
26. We consider that this is not enough to say that his dementia was not properly managed and there is a significant amount of evidence demonstrating appropriate care. We hope what we have seen in the records is of reassurance to Mrs E about how staff looked after her husband.
27. We have also looked at the complaint letters that Mrs E sent to the Trust and its responses. Mrs E is right that the Trust’s letters to her do not mention her husband’s dementia. However, this aspect of his care was not put to the complaints team. Therefore, we would not expect it to comment on this.
28. Further, the complaint team is made up of different staff to the doctors and nurses who looked after Mr E during his time in hospital. Therefore, the fact the Trust’s responses did not mention Mr E’s dementia does not reflect the entirety of the care doctors and nurses provided.
Decision to discharge Mr E
29. Mrs E complains that hospital staff decided her husband was ready to be discharged home despite not having the right care in place.
30. Good Medical Practice says doctors must provide a good standard of care. They should assess the conditions patients are in and refer them to another practitioner when this serves the patient’s needs.
31. NICE has also published guidance called ‘Transition between inpatient hospital settings and community or care home settings for adults with social care needs’. It says that planning a patient’s discharge is a key part of caring for people effectively. It recognises that a lot of patients will need continuing care at home, and this can mean providing specialised equipment or carers.
32. Our adviser explained that doctors should consider a patient medically fit for discharge if their condition can be managed well at home and they no longer need to be in hospital. Doctors should consider their patient’s blood tests and early warning score (EWS) as part of making this decision. EWS is typically based on someone’s breathing rate, the amount of oxygen in their blood, and their body temperature. A score of between zero and two is good, and a score of five or more is bad.
33. On 1 July a consultant visited Mr E. His blood saturation level was 95%, which was significantly better than the previous day’s reading. Blood oxygen saturation is how much oxygen is dissolved in the blood and a level of above 94% is generally considered acceptable for someone over the age of 70.
34. Mr E’s blood test results were also normal, his EWS was one and his lungs were clear. This was encouraging as it showed Mr E had recovered from the acute COPD episode he was admitted to hospital for. The consultant therefore decided Mr E was medically fit for discharge. In view of these findings, we consider that this was an appropriate conclusion for the consultant to reach.
35. Mrs E had told staff at the hospital that carers used to visit seven days a week until March 2020, when they had to stop their visits due to COVID-19. Since then, she had started caring for Mr E by herself but was struggling to cope. Mrs E has told us that, at the time, she had asked carers to begin visiting their home again. Although Mr E’s COPD had improved enough for him to go home, the doctor wanted to ensure Mrs E had the support she needed.
36. To do this, the consultant asked physiotherapy and occupational therapy teams to review Mr E. These are professionals who adapt surroundings and tasks to help people live better with disabilities, injuries, or illnesses. Although the visit did not happen by the time Mr E died, it was an appropriate request and in line with the applicable guidance. This was the right way to try and provide the extra help they believed was needed after Mrs E first contacted the ward.
Mr E’s death while waiting for discharge
37. Mrs E complains that staff on the ward called her and explained they were preparing her husband for discharge home but that several hours later they called again and asked her to visit the ward as soon as possible. When she arrived at the ward she was told that Mr E had sadly died while waiting to be sent home.
38. GMC’s Good Medical Practice says doctors must adequately assess the patient’s condition. They should provide effective treatments based on the best available evidence. This extends to correctly interpreting tests and acting on the information appropriately.
39. Based on Mr E’s medical notes, it was not apparent to clinical staff that he had underlying heart disease and this had not been detected previously. Mrs E says her husband had never experienced heart problems in the past despite several hospital visits. Mr E had an ECG on 30 June. An ECG can suggest that a patient has recently had a reduction of blood flow to the heart. This is an indicator that a heart attack may be about to happen soon. Mr E’s ECG from 30 June 2020 did not warn of any imminent problems.
40. We also know that Mr E was on medication called dalteparin. This is used to control someone’s blood pressure and is a routine prescription. Although it was likely used to help treat Mr E’s hypertension, it can also help reduce the likelihood of heart attacks. It is therefore likely that Mr E had a better chance of survival in hospital than at home, and the actions of doctors did not contribute to the likelihood of a heart attack.
41. We have also spoken to our clinical adviser about what happened. They explained that Mr E’s heart attack was unpredictable. It could have happened at any time before, during or after his time in hospital.
42. As Mr E was waiting to be discharged from hospital, we consider it was appropriate to tell Mrs E about the plan to send him home. Given the nature of his death we believe the medical team cared for him appropriately and could not have known of what was about to happen. Although this is no doubt upsetting for Mrs E to hear, we hope it brings closure to an extremely sad and distressing period.