Medication
19. Mrs H complains the Trust gave her father fentanyl along with oxycodone alongside his normal medications. She says the medication did not agree with him and had made him incapable of responding properly to treatment.
20. Fentanyl is a powerful opioid used as a pain medication. Oxycodone is an opioid medication used for treatment of moderate to severe pain.
21. The Trust say it was documented that Mr T had 14 medications that he was sensitive to. These were mainly antibiotics but did include codeine (a prescription pain medication used to treat mild to moderate pain). When patients have a sensitivity documented it can be because the medication has a side effect that they are not able to tolerate rather than an allergy. There was no documented record of an allergy to fentanyl or oxycodone in the record. Mr T had been prescribed oxycodone on a previous admission to hospital.
22. The records show on 14 March 2020, Mr T’s drug sensitivities were noted on a drug chart and an emergency department handover document. His sensitivities did not include fentanyl or oxycodone. The evidence shows he had a sensitivity to codeine.
23. We have reviewed guidance on pain relief. BNF chronic pain guidance says ‘although developed and validated for cancer pain, the WHO analgesic ladder is widely used to guide the basic treatment of acute and chronic pain; whilst there is little evidence to support its use in chronic pain it may provide an analgesic strategy for non-specialists.’
24. The WHO analgesic ladder sets out the order of pain relief as:
1 Non-Opioid If pain is persisting or increasing 2 Opioid for mild to moderate pain Pain persisting or increasing 3 Opioid for moderate to severe pain
25. We have considered Mr T’s pain and the medication the Trust provided.
26. We can see in the records on 16 March Mr T had a pain score of one out of ten. This would mean that he had little pain.
27. The records show on 17 March he was unable to stand due to pain. On 18 March the notes say his legs could not be touched due to pain. His pain was recorded as greater than ten. He was given paracetamol and OxyNorm 2.5mg. Paracetamol is used for mild to moderate pain and is a non-opioid. OxyNorm is an opioid.
28. On 19 March Mr T had a pain score of eight to nine and received OxyNorm and paracetamol. On 22 March Mr T had a pain score of six and was noted to be on regular analgesia. His regular prescriptions records show this was OxyNorm and paracetamol.
29. The daily nursing care record documents note on 23 March at 4pm, Mr T did not want to be moved as he was in too much pain. On 24 March at 9.20am, he refused to sit up because of pain in his legs. We can see from the records he was prescribed oxycodone on 25 March, and a fentanyl patch on 27 March. Paracetamol was stopped on 27 March. Oxycodone was to be given prior to mobilisation. Fentanyl patches were prescribed for the pain in his legs.
30. The WHO analgesic ladder says if pain persists or increases, an opioid for moderate to severe pain should be used. The records indicate Mr T’s pain had persisted from 18 March. Non-opioids had been used and were not effective. Given the pain he was experiencing and the high pain scores, the Trust were correct to proceed with opioids.
31. Our geriatrician advisor says given Mr T’s intolerance of the weak opiates (codeine) and the severity of his pain, such as not being able to move or stand as noted on 23 and 24 March, the Trust had to jump to the strong opioids. Our geriatrician advisor says this would be good practice.
32. On moving to Ward B on 7 April, his records list his drug allergies and adverse reactions. Again, fentanyl and oxycodone are not listed.
33. On 10 April Mr T declined therapy as he was in too much pain. On 13 April Mr T’s notes recorded that he was complaining of pain on movement. On 14 April Mr T was given 5mg liquid oxycodone after complaining of pain during the night. The record shows that he had refused to accept oxycodone. The nurse explained the benefits of taking medication for pain as required.
34. On 14 April the records show Mr T did not want any assistance with exercises as he had very painful knees and thighs. On 16, 17, 18 April he was given pain relief prior to therapy to help his rehabilitation.
35. On 22 April the Trust and Mrs H had a conversation regarding her father’s medication. Mrs H raised concerns about the amount of medication he had been taking. The Trust agreed to trial a period off the fentanyl patch.
36. On 23 April the records show that Mr T was unable to stand on his left leg due to pain in his left knee. Later the same day the Trust explained to Mrs H they were trying to find a compromise between keeping his pain under control without overmedicating him.
37. The evidence shows the Trust acted in line with WHO guidance. Mr T’s pain was persisting and at times increasing, therefore the Trust used opioids. It was reasonable for the Trust to use strong opioid analgesia and there did not appear be another route to treat his pain.
38. Our geriatrician adviser says with medication there can be side effects however this does not mean they cannot be used. A risk benefit ratio should be taken, and the medication of choice remained appropriate.
39. Mr T’s discharge summary on 14 May says there was no marked improvement in memory or behaviour after the removal of the fentanyl patch.
40. We do not underestimate what a difficult time this was for Mrs H and how worried she was about her father and his rehabilitation. The evidence shows the Trust acted in line with WHO guidance in relation to prescribing opioids. The records do not indicate Mr T was allergic or sensitive to fentanyl or oxycodone. The Trust listened to the family’s request and removed his fentanyl patch medication when it was requested, and no improvement was noted. We find no failings in Mr T’s pain management.
Pressure ulcers and bed sores
41. Mrs H complains a lack of movement during her father’s admission at the Trust led to bed sores and pressure ulcers. She says her father’s pressure ulcers and bed sores were not treated by the Trust during his admission.
42. The Trust said her father had a long history of leg ulcers. His wounds and pressure areas were reported, and a request was sent to the tissue viability nurse (TVN) specialist to review and advise. The TVN created a dressing care plan on 15 April. When this treatment was discussed with Mr T, he stated that he could not tolerate any compression bandages and declined to allow nursing staff to use them. The TVN Specialist was made aware of this refusal, thus the original care plan was then followed with Mr T's consent. The original care plan did not include bandages or compression.
43. The Trust said he was nursed with an airwave mattress from admission and was on a repositioning chart. Throughout his stay it is documented that he declined to be repositioned or participate in therapy at times.
44. The records show the Trust used the Braden Scale and ASKIN assessment in relation to Mr T’s pressure ulcers and bed sores. The ASKIN tool is an acronym which stands for assess, surface, keep moving, incontinence and nutrition. It is used in the prevention of pressure ulcers. The Braden Scale is a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. These are: sensory perception, moisture, activity, mobility, friction, and shear.
45. Mr T had Braden scale assessments on 14 March 2020 and every day between 9 April to 13 April. Between 15 March and 7 April Mr T had an ASKIN assessment.
46. NICE Pressure ulcers guideline sets out:
‘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.’
‘1.1.5 Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional (see recommendation 1.3.4). The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for: • skin integrity in areas of pressure • colour changes or discoloration • variations in heat, firmness, and moisture (for example, because of incontinence, oedema, dry or inflamed skin).’
47. The evidence shows the Trust used the Braden scale which is noted in the NICE guidance. The records also indicate Mr T had a tissue viability assessment on 13, 15, 25, 29 April and 4, 9, 11 May in line with NICE guidance.
48. We asked our TVN advisor if appropriate preventative measures were put in place by the Trust. The Trust have documented its risk assessments regularly and the evidence shows there were no gaps in the treatment Mr T received.
49. We looked at the treatment that the Trust provided to Mr T. The records show on 20 March 2020 an air mattress was ordered to assist with his treatment.
50. NICE Pressure ulcers guideline says:
‘1.4.9 Use high-specification foam mattresses for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface.’
51. The use of an air mattress is in line with NICE guidance and appropriate treatment for pressure ulcers.
52. To help prevent pressure ulcers a patient should be regularly repositioned. We reviewed the records to see if Mr T was repositioned appropriately by the Trust. The ASKIN assessment and Braden Scale records show each day he was offered to be repositioned. From 9 April the Trust offered to reposition him every two hours while awake. This is in line with NICE Pressure ulcers guideline which sets out:
‘1.1.8 Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.’
53. The Trust have documented each day Mr T was offered to be repositioned. The records show that Mr T did decline to be repositioned on certain days. We can see the Trust actions and documentation were in line with NICE guidance.
54. We reviewed the evidence to see if Mr T’s wounds were treated appropriately. The records show the dressing of the wound was discussed with Mr T on 7, 12, 13, 25, 29 April and 3, 9 and 14 May. The records show that on 4 May Mr T was moved to a foam dressing. This is in line with the European pressure ulcer advisory panel, which sets out:
‘Foam Dressings 1. Consider using foam dressings on exuding Category/Stage II and shallow Category/Stage III pressure ulcers.’
55. NICE Pressure ulcers guideline says:
‘1.4.23 Discuss with adults with a pressure ulcer and, if appropriate, their family or carers, what type of dressing should be used, taking into account: • pain and tolerance • position of the ulcer • amount of exudate • frequency of dressing change 1.4.24 Consider using a dressing for adults that promotes a warm, moist wound healing environment to treat category 2, 3 and 4 pressure ulcers.’
56. The Trust have documented its discussions with Mr T in line with NICE guidance. They have considered an alternative dressing which is in line with NICE and European pressure ulcer guidance.
57. Our TVN advisor said that the treatment provided by the Trust was appropriate. They explained once you get a deep tissue injury it either resolves or it evolves. Mr T’s wound went from a category two to a three. Mr T was already known to have arterial problems in his leg, therefore, preventing that deterioration would have been difficult.
58. We understand Mrs H was worried for the health of her father. The evidence suggests the Trust appropriately treated Mr T’s pressure ulcers and bed sores. The records show the treatment was in line with guidance. We have also seen evidence the Trust offered to reposition her father each day.
Physiotherapy
59. Mrs H complains that Mr T was offered little physiotherapy and that it was later removed during his admission at the Trust. She says that Mr T was left unable to walk due to the lack of physiotherapy treatment.
60. The Trust said Mr T often declined therapy which impacted his rehabilitation. It states that he was receiving physiotherapy throughout his admission.
61. The records show on 14 March a member of the therapy team completed an initial assessment. This involved collecting information regarding Mr T’s home environment, his functional ability at home prior to admission to hospital and his current discharge wishes.
62. On 16 and 17 March, the physiotherapists attempted to complete a full physical and functional assessment to measure Mr T’s current functional ability. On 16 March, Mr T completed a sit to stand with assistance of two people. Mr T was unable to mobilise due to pain in his left leg. On the 17 March 2020, the physiotherapists attempted to mobilise Mr T, however Mr T was unable to stand or use the standing aid due to pain in both lower limbs.
63. The Chartered Society of Physiotherapy Quality Assurance Standards set out:
‘Physiotherapy management and treatment 8.3 Appropriate information relating to the service user and the presenting problem is collected 8.3.2 There is evidence that information is collected to inform the physiotherapeutic process which, where appropriate, includes: • the service user’s demographic details • presenting condition/problems • history of the presenting condition including management of the problem to date • the service user’s perception of their needs • the service user’s expectations of intervention • past medical history • current medication/treatment • contra-indications/precautions/allergies/red flags • social and family history/lifestyle • documentation and evaluation of relevant clinical investigations/results to assist the diagnosis and management process 8.3.3 There is written evidence of a physical examination carried out including measurable data which includes: • observation • use of specific assessment tools/techniques • handling/palpation’
64. The records show the Trust's actions were in line with the above guidance. The therapy team performed an initial assessment to collect information in keeping with 8.3.2. There is written evidence of its assessments on 16 and 17 March as per guidance 8.3.3.
65. Our physiotherapy advisor says there are no specific standards or guidance which outline what therapy Mr T should have received given his condition. However, a qualified physiotherapist has a duty of care as a practicing health care professional to ensure that they abide to standards and guidelines. These standards are the Chartered Society of Physiotherapy’s Quality Assurance Standards and the Society’s Code of Professional Values and Behaviour.
66. We considered the therapy Mr T received at the Trust.
67. Between 18 March and 6 April, physiotherapy input was limited. During this period Mr T’s legs were painful when moved or touched and he was awaiting investigations. He was seen on 18, 22 and 26 March. He was also seen on 1 April. We consider the amount of therapy he received below. Mr T was seen regularly by the physiotherapy team from 6 April until his discharge.
68. The records show therapy sessions included carrying out functional assessments, practicing stands and transfers with a rollator frame and assistance of two people, practicing stands with assistance in a stand aid, being hoisted for transfers when he was unable to weight bear and completing bed exercises.
69. Our physiotherapy advisor says it is documented within the records that each therapy session was completed considering Mr T’s condition and his wishes.
70. Chartered Society of Physiotherapy Quality Assurance Standards say:
‘8.5 Appropriate treatment options are identified, based on the best available evidence, in order to deliver effective care.
8.5.1 Clinical reasoning is recorded that explains why a specific approach has been implemented.’
71. The physiotherapists identified the treatment options in line with quality assurance standards 8.5 and recorded them in line with 8.5.1. It is documented within the records that his lower limb leg pain, which was reported as a flare up of his osteoarthritis and gout, significantly inhibited Mr T’s rehabilitation during his admission.
72. We have also considered the amount of therapy Mr T received.
73. The records indicate that Mr T declined physiotherapy input on more than eight occasions during his admission. This would have inhibited his rehabilitation.
74. On the 27 and 28 April Mr T declined therapy input in the morning, however the physiotherapist returned to see Mr T on the afternoon of these days.
75. The records show on 10 April, Mr T refused to practice mobilising due to pain in both his knees. Therefore, the physiotherapists completed bed exercises with Mr T instead.
76. Chartered Society of Physiotherapy Code of Members Professional Values and Behaviour sets out:
‘CSP members deliver an effective service 3.1 Members put individuals at the centre of what they do • 3.1.1 Seek to understand and take account of individuals’ specific needs, preferences, expectations and goals in providing a service to them’
77. Health & Care Professions Council Standards of conduct set out:
‘Communicate appropriately and effectively • 2.2 You must listen to service users and carers and take account of their needs and wishes.’
78. In keeping with the Code guidance 3.1.1 and the Standards, the physiotherapist took into account Mr T’s preferences and needs in the service they provided. The records show that plans were changed due to his specific needs.
79. Our physiotherapist advisor says the records show the physiotherapists carried out appropriate therapy with Mr T during his admission from 14 March to 14 May. During all interventions the Trust took into account Mr T’s presenting condition and wishes.
80. We can understand how concerned Mrs H was to witness her father lose his mobility. The guidance does not say what therapy should be given or the amount. We have seen the Trust assessed Mr T in line with quality assurance standards guidance on admission. During his admission his wishes were listened to, and plans changed in keeping with Health and Care Professions Council standards and the Chartered Society of Physiotherapy code.
81. We have seen the Trust provided physiotherapy in line with guidance.
DOL and DNACR
82. Mrs H complains the Trust failed to explain the DOL (Deprivation of Liberty) order or the DNACPR (Do not attempt cardiopulmonary resuscitation) to the family. She says the family were upset that they were not told about both and that neither were fully explained.
83. The Trust said it explained Mr T had not been able to retain information or understand risks. He therefore did not have capacity to make a safe decision around discharge at that time. The Senior Staff Nurse began to explain that a referral to Adult Social Care would be made and tried to explain what a DOL order was.
84. Mrs H rang Ward B on the 23 April and spoke to the Ward Manager to get some clarity around the Mental Capacity Act and DOL order. A conversation was then held between Mrs H and the Ward Manager. The Mental Capacity Act process was explained, including the legal responsibility to put in a DOL request for anyone who was deemed to not have capacity. The DNACPR in Mr T’s record was dated on the 20 March and was completed by a consultant. This was reviewed on Mr T’s admission to Ward B and remained valid.
85. The records show on 22 March a treatment escalation plan was completed between Mr T and the Trust. The document shows that the box ‘not for resus’ had been ticked. Mr T was recorded as having capacity at the time and the decision had been discussed with him. The document confirms it had not been discussed with significant others.
86. GMC Cardiopulmonary resuscitation (CPR) guidance says:
‘132. As with other treatments, decisions about whether CPR should be attempted must be based on the circumstances and wishes of the individual patient. This may involve discussions with the patient or with those close to them, or both, as well as members of the healthcare team. You must approach discussions sensitively and bear in mind that some patients, or those close to them, may have concerns that decisions not to attempt CPR might be influenced by poorly informed or unfounded assumptions about the impact of disability or advanced age on the patient’s quality of life.’
‘134. If a patient is at foreseeable risk of cardiac or respiratory arrest and you judge that CPR should not be attempted, because it will not be successful in restarting the patient’s heart and breathing and restoring circulation, you must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. You should not make assumptions about a patient’s wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team.’
‘143. Any discussions with a patient, or with those close to them, about whether to attempt CPR, and any decisions made, should be documented in the patient’s record or advance care plan. If a DNACPR decision is made and there has been no discussion with the patient because they indicated a wish to avoid it, or because it was your considered view that discussion with the patient was not appropriate, you should note this in the patient’s records.’
87. The records show that the Doctor confirmed Mr T had capacity. The DNACPR was discussed with Mr T. In line with guidance 143, his decision and actions have been documented. At this time the evidence shows the doctor has abided by the guidance.
88. Our geriatric advisor says once the DNACPR is completed the doctor’s duty is discharged. A patient would determine if they should inform their family. If Mr T did not have capacity on 21 March, then there would likely have been a duty for the doctor to speak with the family.
89. On 21 April the records show the Trust discussed discharge with Mrs H. The notes say care at home would only be two carers, four times a day and no care at night. Mrs H agreed that a placement would be best.
90. The records show on 22 April at 9:30am the Trust discussed discharge with Mr T who was adamant that he could look after himself at home. At 12:30pm the notes say he could not recall any conversation about discharge. The doctors discussed a DOL.
91. At 3pm Mr T failed a mental capacity assessment. The notes say he needed a DOL to be submitted to remain in hospital as a place of safety until appropriate discharge arrangements are made.
92. At 7:04pm on 22 April the DOL order authorisation was given to the Trust.
93. The NHS website sets out the following information about the Mental Capacity Act:
‘In certain cases, the restrictions placed upon a person who lacks capacity may amount to "deprivation of liberty". This must be judged on a case-by-case basis. Where it appears a deprivation of liberty might happen, the provider of care (usually a hospital or a care home) has to apply to their local authority. They'll then arrange an assessment of the person's care and treatment to decide if the deprivation of liberty is in the best interests of the individual concerned.
If it is, the local authority will grant a legal authorisation. If it is not, the care and treatment package must be changed – otherwise, an unlawful deprivation of liberty will occur. This system is known as the Deprivation of Liberty Safeguards. If you suspect a deprivation of liberty may happen, talk to the care provider and then possibly the local authority.’
94. Department of Health and Social care decisions-making flowchart says if the person does not have the mental capacity to consent, is not receiving lifesaving treatment, not under continuous supervision and control and no DOL is in place then a DOL authorisation is needed.
95. The Mental Capacity states:
‘The Mental Capacity Act 2005 (“the Act”) provides for the deprivation of liberty of people lacking capacity to consent to the arrangements made for their care or treatment, who are receiving care or treatment in care homes and hospitals, where authorisation under section 4A of and Schedule A1 to the Act (“Schedule A1”) exists.
Where it appears that a person who lacks capacity is detained, or is likely to be detained, in a care home or hospital, the managing authority of the care home or hospital must request an authorisation from the supervisory body. “Managing authority” is defined in paragraphs 176, 177 and 179 of Schedule A1 to the Act. The identity of the supervisory body is determined in accordance with paragraphs 128, 180 and 182 of Schedule A1. In the case of a care home, the supervisory body will usually be the local authority in which the person is ordinarily resident and in the case of a hospital, it will usually be the relevant Primary Care Trust for the area in which it is situated or the Primary Care Trust that commissions the care or treatment.
On receiving such a request, the supervisory body must ensure that various assessments are carried out in relation to the individual concerned in order to determine whether it is appropriate to grant the authorisation. The supervisory body must select people to carry out those assessments in accordance with paragraph 129 of Schedule A1 and may only select people who are eligible in accordance with these Regulations.’
96. The notes on 22 April show that the information provided to Mrs H was the same information listed in the NHS guidance. The Trust’s actions were in line with the flowchart from the Department of Health and Social Care guidance. The Mental Capacity Regulations say ‘where it appears that a person who lacks capacity is detained, or is likely to be detained, in a care home or hospital, the managing authority of the care home or hospital must request an authorisation from the supervisory body.’ The Trust were abiding by the law and the local authority when making the decision.
97. We can see the Trust acted in line with relevant guidance and standards as set out above. It was a requirement to apply for a DOL order and if it had not this would have been a breach of the law.
98. Our geriatric advisor says DOLs exist to stop agents of the state, for example, doctors, depriving people of their liberty. This legislation is to protect people. If a doctor considers that a patient lacks the capacity to consent to stay in hospital, they have a duty to report their actions to the local authority to allow external scrutiny of that decision, and ensure that the reasons for keeping a person in hospital (who is unable to consent) are reasonable.
99. On 22 April at 3pm the notes made by the nurse say they tried to explain to Mrs H a DOL is a type of safeguarding and a legal requirement to inform local authority, it is not holding Mr T against his will.
100. On 23 April the records show a detailed conversation between the Trust and Mrs H regarding the DOL order.
101. We acknowledge the worry Mrs H experienced. We understand how upsetting it is to feel you are not being informed of the decisions being made about your father. We have seen the Trust acted within guidance for the DNACPR as Mr T had capacity to make the decision. We also consider the Trust acted in line with guidance requesting a DOL order. The evidence shows conversations were held on 22 and 23 April and this was appropriate.
CHC checklist
102. Mrs H complains after her father’s discharge on 14 May 2020 the Trust did not complete a CHC checklist until January 2021. She said she was frustrated with the timescale and COVID-19 was an unacceptable excuse not to carry this out.
103. The Trust said that it followed government guidance in that CHC checklist are carried out in the community with 28 days of discharge.
104. The records show the Trust confirmed on 24 August 2020 an NHS CHC checklist would be arranged. They stated it would ask for this to be treated as a priority case.
105. We have seen in the records the date of completion for the checklist was 25 January 2021. This does not support the Trust’s view that the CHC checklist was carried out within 28 days of discharge.
106. The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care October 2018 says:
‘86. Completion of the Checklist is intended to be relatively quick and straightforward. It is not necessary to provide detailed evidence along with the completed Checklist’
107. The evidence we have seen shows it took the Trust five months to complete the CHC checklist. This is not in line with the national framework as the guidance indicates the process is intended to be relatively quick and straightforward.
108. Our Principles of Good Administration say:
‘Public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it or explain why the cannot. They should meet their published service standards, or let customers know if they cannot’
109. The records show that the Trust did not explain why they could not complete the CHC checklist quickly. The actions of the Trust are not in line with our own Principles as they did not do what they said they were going to do. We consider this failing.
110. We will now consider the impact.
111. Mrs H says she was frustrated with the time taken for the Trust to complete Mr T’s CHC checklist. We acknowledge that it would likely have caused frustration that the Trust did not complete the CHC checklist for five months. Based on the evidence we can link the claimed impact to the failing.
112. Mrs H is seeking a financial remedy to resolve the complaint. We have considered this request in line with our severity of injustice scale. We do not think financial remedy would be appropriate as this was a single incidence of service failure, and there are no other adverse effects or ongoing wider impacts. She is also seeking an apology, and we make a recommendation below.