Issue one – Management of nutritional requirements
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We have done this and have found the Trust has already done enough to put right the impact of these events. We do not underestimate how hard this must have been for Mr E as he was worried about the nutrition Mrs E was receiving, but we hope our explanation below provides some reassurance to him about the steps taken as a result of his complaint.
16. Mr E complains the Trust did not appropriately manage Mrs E’s nutritional requirements during her admission. NICE nutrition guidelines recommend all inpatients must be screened for malnutrition. This is completed using a malnutrition universal screening tool (MUST) which is used to identify adults who are underweight and at risk of malnutrition as well as those who are obese. The scores given in the MUST are used to categorise patients for their risk of malnutrition.
17. BAPEN guidelines explain the steps that should be followed when using MUST, and how to score patients based on their height and weight measurements, and effect of acute disease to determine the risk of malnutrition and care plan. A score of zero means no/low risk of malnutrition, a score of one means a medium risk, and a score of two or above means high risk of malnutrition. Food charts (monitoring of intake) are prompted when a patient scores one or more. A dietitian referral is prompted when a patient scores four or more.
18. BAPEN guidelines also advise the encouragement and assistance of snacks.
19. The Trust did complete two MUST screenings during Mrs E’s admission, initially on 10 June, however our nursing adviser identified that this was not completed correctly. This is explained further below.
20. On 10 June Mrs E was incorrectly assessed as scoring zero on MUST. She should have scored two as it is noted in the medical records that she was refusing all intake.
21. Food charts should therefore have been implemented from 10 June but were not until 12 June. Additional interventions should also have been implemented from 10 June, including offering three meals a day and snacks, offering supplements, and providing encouragement and assistance.
22. Mrs E was incorrectly assessed on MUST and not offered encouragement and assistance with nutritional intake from 10 June. This indicates BAPEN guidelines were not followed and a failing occurred.
23. We have thought about if this had any impact on Mrs E. We did this by speaking to our physician adviser.
24. Mr E questions whether, with better care and treatment, Mrs E’s death could have been avoided or whether her life could have been prolonged. Mr E also says the poor care provided to Mrs E, was frustrating and distressing for him to witness.
25. We think the lack of nutritional management is likely to have resulted in limited nutritional intake for Mrs E during her admission. Mrs E had severe pneumonia and lung failure, and she quickly deteriorated during her admission. The limited nutritional intake during this time would not have affected her because the body has adequate reserves over a period of days to ensure an adequate immune response. The priority for patients with severe pneumonia is to give antibiotics and provide supportive care with oxygen and fluids if needed. As such, there does not appear to be a clinical impact from this indicated failing.
26. This is likely to have caused distress to Mr E as he was worried that Mrs E was not getting the nutritional intake that she required, and he telephoned the Trust to raise his concerns. It is also likely this caused him some frustration as he felt that his concerns about Mrs E’s nutritional requirements were being ignored. We recognise this was a very difficult time for Mr E.
27. Our principles say that where maladministration (fault) or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately. There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service. Remedies may be financial or non-financial.
28. An appropriate range of remedies will include an apology, explanation, and acknowledgement of responsibility.
29. We have considered the actions taken by the Trust as a result of Mr E’s complaint.
30. In its complaint response, the Trust has acknowledged that food charts should have been started earlier in Mrs E’s admission to enable her intake to be monitored to ensure she was receiving the correct nutritional support. It also accepted that the documentation during the admission had not been completed as robustly as it should have been. It apologised for these things.
31. The Trust also stated several actions that it had taken to ensure these issues will not be repeated. This includes the complaint being discussed with staff so they can utilise available tools to promote and maintain a patient’s nutritional needs to the standards that are expected. The Trust will also use a new accountability handover document, which will include nutrition and will be audited on a weekly basis. We think that these actions should ensure the guidance is met, and hopefully prevent the same events from occurring again.
32. Mr E told us he wanted the Trust to acknowledge failings, an apology, and service improvements. Given the Trust has already provided these remedies, and we think the improvements that have been made will hopefully prevent something similar happening again, we consider the Trust has already done enough to put things right. We hope this provides some reassurance to Mr E that the Trust has taken his concerns seriously and improved its service as a result of his complaint.
33. For these reasons, we will therefore not be considering this part of the complaint further.
Issue two - Recognise and administer Mrs E’s regular medicines.
34. Before we decide if we should conduct a detailed 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 have not found any indications that something has gone wrong in relation to this issue.
35. Mr E said the doctors did not recognise and administer his wife’s regular medicines during the admission. He said that, based on previous experience, he thought the Trust required prescribed medicines to accompany the patient to the hospital. So, he did this and provided a written list of them and the dosage requirements.
36. GMC guidelines state that in providing clinical care, doctors must prescribe drugs or treatment, including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.
37. NICE medicine guidelines states that in an acute setting, a person’s medication (including prescribed, over‑the‑counter and complementary medicines) should be accurately listed and medicines reconciliation carried out within 24 hours or sooner if clinically necessary, when the person moves from one care setting to another. For example, if they are admitted to hospital.
38. Medicines reconciliation is the process of identifying an accurate list of a person’s current medicines and comparing them with the current list, as well as documenting any changes, resulting in a complete list of medicines (taken from NICE medicine guidelines).
39. The medical records show the doctors recorded Mrs E’s regular medication on admission on 9 June and prescribed them. This is in line with the above guidelines.
40. During the admission, the key drugs to treat Mrs E’s acute illness were all given intravenously (medicines administered through a vein) because she was unable to drink. This includes co-amoxiclav (antibiotic to treat pneumonia), furosemide (a diuretic medicine used to treat fluid build-up), and intravenous fluids (because Mrs E was unable to drink).
41. The medical records show none of Mrs E’s usual tablet medications were given on 11 June, because she was too unwell to take them.
42. In line with GMC guidelines, doctors prescribed the medication that Mrs E needed (including her regular medicines) during the admission and when she was well enough to take them.
43. We are therefore satisfied that Mrs E’s regular medicines were recognised and administered as they should have been.
44. For these reasons, we will therefore not be considering this part of the complaint further.
Summary
45. We are sorry to hear of the impact of Mrs E’s death and we recognise how difficult this has been and the sadness it has caused for Mr E.
46. Having reviewed Mrs E’s care and treatment, we are satisfied the Trust has taken appropriate action to put things right in relation to the issue around nutrition, and there is no indication that anything went wrong with Mrs E’s medicines. We are therefore not taking further action on the complaint.