The assessment of Mrs O’s risk of falls
20. On admission the Trust assessed Mrs O as having delirium. She scored four out of ten on an abbreviated mental health test (a quick test with ten questions to screen elderly patients for possible dementia). Subsequent entries indicate Mrs O had fluctuating confusion throughout her admission. There were records that, prior to her fall, she was at times alert, talking in full sentences and able to explain events.
21. The Trust carried out a nursing patient assessment for Mrs O on 2 June which included an enhanced care plan around the risk of falls. The Trust did not fully complete the enhanced care plan in the following areas:
· Incomplete information was given regarding whether Mrs O had a history of falls, with one entry not filled in and the other not clearly marked
· The section on ‘polypharmacy’, regarding whether Mrs O had over ten medications on admission
· The enhanced care plan identified that Mrs O had a mobility deficit and fear of falling. It also recorded she had a postural drop, a fall in blood pressure after moving from a lying to a standing position which is a common problem in older people, and dizziness on standing. However, no actions were recorded on the enhanced care plan about how these were addressed.
22. The enhanced care plan recorded that Mrs O had no evidence of delirium or confusion at the time it was completed. From what we have seen, Mrs O’s confusion was fluctuating so we have not seen that this is evidence of a mistake.
23. From the nursing observations taken at 9pm it is recorded that Mrs O experienced a postural drop from 101/67mHg (laying) to 63/45mmHg (standing). It is recorded that this was escalated to the medical team and a single dose of intravenous (IV) fluids was prescribed. The Trust did not reassess Mrs O’s laying and standing blood pressure.
24. Mrs O was referred to the Trust’s physiotherapy team on 3 June. It is recorded that Mrs O had fallen four times in the previous year, that she had a fear of falling, and was receiving input from the falls clinic. The physiotherapy notes record the service had further input on each day of her admission until 8 June but that its review of her mobility was limited because Mrs O was too unwell for a physiotherapy review from 5 June onwards.
25. Mrs O continued to receive treatment for her urinary infection up until 7 June. It is noted at several points in the clinical notes that she reported feeling light-headed or dizzy. In the records for 5 June, it specifically states that she felt worse when standing up and sitting down.
26. Mrs O had an unwitnessed fall on 7 June and told staff she had tripped after becoming tangled in her catheter. The Trust removed the catheter following her fall, however she was re-catheterised at 7.30am on 8 June due to ongoing concerns about urinary retention.
27. NICE guideline CG161 says all patients aged 65 or older should be treated at risk of falling. It recommends in sections 1.2.2.2 to 1.2.2.4 that a multifactorial assessment should take place for these patients and any individual risk factors should be promptly addressed. The Trust’s ‘Patient falls Prevention and Management Policy’ reiterates the procedure from NICE guideline CG161 and also advises that ‘catheters and other devices’ should be avoided for these patients wherever possible.
28. The RCP’s ‘Measurement of lying and standing blood pressure as part of a multi-factorial falls risk assessment’ defines a positive result for a postural drop as being:
· A drop of 20mmHg for the patient’s systolic blood pressure on standing, with or without other symptoms
· A drop to below 90mmHg for the patient’s systolic blood pressure on standing even if the drop is less than 20mmHg, with or without other symptoms
· A drop of 10mmHg for the patient’s diastolic blood pressure on standing if there are other symptoms of dizziness, light-headedness, feelings of weakness etc.
Where a positive result is recorded the RCP guidance says that the medical and nursing teams should be informed, and immediate actions should be taken to prevent falls or unsteadiness. It also says lying and standing blood pressure should be taken ‘regularly’ until the postural drop is resolved.
29. The BMJ guidance ‘Orthostatic hypotension’ describes what action NHS organisations can take in an acute setting to improve a patient’s standing blood pressure and prevent falls associated with this. It says the following actions should be taken:
· Eliminating ‘aggravating factors’ by removing medication that can induce or aggravate a postural drop, such as antidepressants and diuretic medication
· Providing advice about lifestyle changes the patient could make to reduce the possibility of a postural drop
· Increasing ‘volume expansion’ by making sure the patient drinks two litres of water a day and limiting their dietary salt intake. If this does not achieve the desired result fludrocortisone (a form of steroid) can be considered as a further treatment
· When previous measures have not achieved the desired result a short acting pressor agent (medication used to treat low blood pressure) can be prescribed.
30. The RCN’s ‘Catheter Care’ guidance says a catheter should only be inserted where there is a clinical need for this. Urinary retention is listed as one clinical indication that a patient may require catheterisation. The RCN guidance also advises that as part of the risk assessment around the use of a catheter the type of catheter and drainage system in use should be considered.
31. Our decision is that the Trust did not act in line with NICE guideline CG161 and its falls policy. It only partially completed the enhanced care plan used to record the multifactorial falls risk assessment and gave no indication of what interventions had been carried out to address the identified risks.
32. Not all of the omissions from the enhanced care plan resulted in the risk factors for Mrs O’s risk of falling going unaddressed. Both of our advisers confirmed Mrs O was not receiving over ten medications at the time of her admission, so a polypharmacy review was not necessary.
33. Similarly, in relation to Mrs O’s mobility deficit, the action recommended from the Trust’s enhanced care plan is for the patient to be referred to physiotherapy. Our physician adviser confirmed this would be an appropriate intervention in line with section 1.2.2.4 of NICE guideline CG161. The Trust made this referral, even if it was not recorded in the advanced care plan, and relevant information about Mrs O’s fall history was recorded at that time.
34. In relation to Mrs O’s postural drop, the nursing team documented Mrs O’s lying and standing blood pressure on the observation chart at 9pm on 2 June and escalated this for a medical review. This was consistent with the actions recommended on the enhanced care plan, even if this was not documented on it, and was in line with the RCP’s guidance.
35. Our physician adviser confirmed none of Mrs O’s medication would have been an aggravating factor for a postural drop so there was no need to stop any of it in line with BMJ guidance. There is evidence the Trust administered IV fluids at the time of the positive result which would be a relevant treatment to provide in line with the BMJ’s guidance.
36. Our decision is that we cannot say this treatment was sufficient to resolve Mrs O’s postural drop. We have seen no evidence of further measurements of Mrs O’s lying and standing blood pressure, which is a failing when compared to the RCP’s guidance that laying and standing blood pressure should be taken ‘regularly’ until the postural drop is resolved. By failing to take any further measurements, the Trust could not know whether its actions had resolved Mrs O’s postural drop. There was additional treatment the Trust should have considered in line with the BMJ’s guidance if the IV fluids had failed to resolve the postural drop.
37. Our decision is the Trust’s handling of Mrs O’s postural drop contributed to her fall on 7 June. Mrs O’s recorded postural drop was significant compared to the RCP guidance’s definition of a positive result with a nearly 40mmHg decrease in systolic blood pressure, over 20mmHg decrease in diastolic blood pressure and her systolic blood pressure while standing being significantly below 90mmHg. Though the Trust did give some relevant treatment in line with BMJ guidance, IV fluids, the Trust did not recheck Mrs O’s laying and standing blood pressure to confirm this had resolved. Given the significant postural drop recorded on 2 June, and that Mrs O continued experiencing symptoms associated with a postural drop (such as dizziness and light-headedness) our view, on the balance of probabilities, is that Mrs O’s postural drop had not resolved and likely contributed to her fall on 7 June.
38. Finally, in relation to Mrs O’s catheter, from what we have seen there was a clinical need for her to have been catheterised at the time of the fall, in line with RCN guidance. Though the catheter was removed following the fall, this was reinserted the following day due to ongoing concerns about Mrs O’s urinary retention. Urinary retention is an indication for catheterisation as per the RCN guidance.
39. While there was a clinical need for Mrs O to have been catheterised, our decision is that there was a failing by the Trust in how it assessed the risk around the use of a catheter. Both our advisers confirmed there was no indication that hourly urine monitoring was requested so it was not clear why a leg bag had not been considered instead of a standard drainage bag. Mrs O’s ‘catheter care sheet’, completed by the Trust as part of her medical records, reminds staff to consider the use of a leg bag. But the Trust has not recorded any information on this section of the form to explain any reason why it decided not to use one. The Trust’s ‘Patient falls Prevention and Management Policy’ also identifies catheters as a risk factor for falling. As there is no evidence that this risk was considered when catheterising Mrs O, we consider the Trust’s actions were not in line with its own policy or the RCN’s guidance around considering the type of catheter to be used.
40. The Trust’s records show Mrs O fell on 7 June after becoming tangled up in the drainage tube from the catheter. As such, it is our decision that the failing to consider the use of a leg bag when catheterising Mrs O contributed to her fall.
41. In summary, we find there were failings in the Trust’s falls risk assessment for Mrs O, some of which contributed to her fall on 7 June. As such, our decision is that Mrs O’s fall was avoidable.
42. From her fall, Mrs O experienced a head injury that resulted in a skull fracture. As such, the failings we have found likely caused Mrs O avoidable pain over her last two days. Mrs H says the standard of care her mother received caused her ongoing suffering due the impact this had on her mother’s quality of life in her final days. Our decision is that Mrs O’s avoidable injury from the fall would have understandably caused Mrs H distress as she has said. Though we recognise the Trust acknowledged a number of these failings in its own investigation, we do not consider it has taken sufficient action to remedy the distress caused to Mrs H. Our Severity of Injustice Scale says we will generally find any injustice involving bereavement made worse by poor service or treatment merits a financial remedy, if the complainant wants this as an outcome. As such our decision is to uphold this part of Mrs H’s complaint and we have set out at the end of this report what we consider the Trust should do to remedy this.
The Trust’s communication with Mrs H about the impact of Mrs O’s fall or her deterioration
43. Following her fall on 7 June Mrs O was reviewed by the medical team around 10.30am. The doctor noted Mrs O was ‘answering questions sensibly but nurses think she is disorientated’. The Trust say from this assessment it was not considered that a head CT scan was necessary at that time.
44. The Trust filled out a ‘head injury observation chart’ for Mrs O following the fall. The Trust took frequent observations on 8 June. For all these observations Mrs O was recorded as having a Glasgow Coma Score (GCS) of 14 (out of 15) due to ongoing confusion. A GCS is a common scoring system used to describe the level of consciousness in a person following a possible or known brain injury.
45. In the physiotherapy records completed at 1.30pm on 7 June the Trust noted Mrs O had a fall that morning and it was not appropriate for her to be seen by physiotherapy. This entry also said Mrs O had increased confusion following the fall and needed a CT head scan because of this.
46. At 8.50am on 8 June a doctor reviewed Mrs O. It was noted she had a fall the previous day and now had an altered consciousness level. One of the actions from this review was for Mrs O to undergo an urgent CT head scan, which the Trust completed at 3.30pm. The Trust accepted in its response to Mrs H’s complaint that it should have contacted her when the skull fracture was suspected from the initial CT scan.
47. The Trust record speaking to Mrs H at 7.35pm and she requested an urgent update about her mother’s health the following morning.
48. At 8.45pm the Trust recorded that Mrs O was showing signs of abdominal pain and from its observations her abdomen appeared more distended and tender. As part of its updated plan it requested a CT scan of Mrs O’s head and abdomen and said her family should be updated. As part of the later review at 9.45pm the Trust recorded that it was still waiting on the CT scans, it said it had a ‘guarded prognosis’ for Mrs O but did not provide any further explanation about this.
49. The Trust recorded a doctor spoke to Mrs H at 10.05pm and provided an update about Mrs O’s health around her abdominal symptoms and the intention to carry out head and abdominal CT scans. The records say that as part of this conversation the doctor explained ‘If [repeat] CT shows worsening [fracture]/ICbleed etc we will liaise [with] neurosurgeons’. The Trust also records that it told Mrs H that her mother may not be suitable for a surgical intervention and if this is the case it would ‘keep her comfortable rather than try to actively treat her’. The records say Mrs H understood this.
50. The Trust placed Mrs O on end of life care on 9 June following the abdominal CT scan results. The Trust has not recorded when it told Mrs H about this. The Trust’s response said it is unclear if the initial conversation documented in the end of life care plan was the same as the conversation at 10.05pm on 8 June. From what we have seen we do not consider this is likely. The conversation recorded in the end of life care documentation refers to findings from the abdominal CT scan which were not available at 10.05pm on 8 June.
51. There are no recorded discussions between the Trust and Mrs H after 10.05pm on 8 June until 12.20pm on 9 June. At that time the palliative care team spoke to her about Mrs O’s care. We find the Trust did not tell Mrs H her mother was on end of life care until 12.20pm on 9 June, around 11 hours after it identified Mrs O as approaching end of life.
52. NICE guideline CG176, section 1.8.7, says a patient with a head injury should have observations performed and recorded on a half hourly basis until GCS equal to 15 has been achieved. Section 1.4.7 says a CT head scan should be performed within one hour where an adult sustains a head injury, and has GCS of less than 15, two hours after the injury is assessed. This process is also reiterated in appendix 3 of the Trust’s ‘Patient falls Prevention and Management Policy’.
53. GMC ‘Good Medical Practice’ says doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
54. Our decision is that the Trust did not act in line with NICE guideline CG176, or its own policy, in relation to how soon it performed a CT scan of Mrs O’s head. It is worth making clear at this point that our investigation is not about the timeliness of the Trust’s CT scan, but how promptly it performed that investigation has a bearing on how soon it was able to tell Mrs H about the impact of her mother’s fall. Our decision is the Trust’s non-adherence to these standards led to failings in the amount of time the Trust took to inform Mrs H about her mother’s skull fracture.
55. In line with the NICE guideline CG176 and its own policy the Trust should have referred Mrs O for a CT head scan within one hour if her GCS was still below 15 two hours after the injury was assessed. Though we are aware Mrs O was confused at points during her earlier admission, this was fluctuating and so a period of sustained confusion following her fall should have been of concern. This is reflected in the physiotherapist records for 7 June which say Mrs O will need a head CT scan due to increased confusion. It is unclear why the Trust did not act on this. If the Trust had referred Mrs O for a head CT scan within one hour, at the time of its observation at 12.45pm (two hours after the fall), the basal skull fracture should have been identified by the early afternoon of 7 June. The Trust would then have been able to tell Mrs H of it at that time. Our decision is that this was a failing by the Trust. It was not considerate of Mrs H as required by the GMC guidance.
56. But we do not think the Trust failed to tell Mrs H about the fracture at all before Mrs O’s death. The evidence in the Trust’s records suggests it told Mrs H of her mother’s skull fracture at 10.05pm on 8 June. Mrs H disputes the Trust told her this and says it did not mention that her mother had a skull fracture. She says she would have made arrangements for her and her family to visit Mrs O sooner if this information had been given to her.
57. We cannot know exactly was said as part of the discussion and we do not consider that there is further evidence we could obtain in relation to this. Based on the evidence available, our decision is that we cannot say there was a failing in the Trust not telling Mrs H about her mother’s skull fracture before her death, though as above we do consider the Trust failed to inform her of this sooner.
58. In relation to informing Mrs H about her mother’s deterioration, GMC ‘Good Medical Practice’ does not give specific timescales for giving relatives of the patient information about their care. However, from what we have seen Mrs H requested on 8 June that the Trust provide an urgent update about her mother’s health next morning. Yet there was 11-hour gap in telling Mrs H her mother was end-of-life. In this context our decision is that the Trust was not responsive in giving her information and support in line with section 33 of GMC ‘Good Medical Practice’, which is a failing.
59. In terms of the impact of these failings, due to the COVID-19 pandemic the NHS had suspended the visiting of patients in hospital except in exceptional circumstances such as where the patient is recognised as being end of life. As Mrs O was identified as being at end-of-life at 1.45am on 9 June the Trust could have reasonably refused a request to visit her before that time. Since end-of-life care was started following the identification of her bowel perforation and the lack of a surgical option to address this we do not consider that an earlier CT head scan would have a bearing on when this was completed.
60. However, our view is that had the Trust identified the skull fracture sooner, and had it told Mrs H about this sooner, she would have had more opportunity to inform her family and make arrangements to visit Mrs O if her condition deteriorated. Mrs H says she, her sister, and niece made arrangements to visit Mrs O on the morning of 9 June, but it took around five hours to reach the Trust and several other family members were not able to visit due to how little notice the Trust had given them of her mother’s deterioration. We have no reason to doubt that account. As such our decision is that the failings we have seen caused a missed opportunity for Mrs H’s family to have visited Mrs O on the morning of 9 June.
61. Mrs H told us by the time of the end of life visit Mrs O was unconscious, which affected their last memories of her. In terms of Mrs O’s condition, her end of life care records describe her as being ‘drowsy’ in the morning of 9 June, indicating she was still conscious to some degree. Our decision is that, on the balance of probabilities, the failings we have seen had an impact on Mrs H’s last memories of her mother and if she had the opportunity to visit on the morning of 9 June, she may have had a more meaningful end of life visit.
62. The Trust has not acknowledged the failings we have seen, or taken any action to put these right. As such, our decision is to uphold this part of Mrs H’s complaint and we have set out at the end of this report what we consider the Trust should do to remedy this.
Trust’s communication with Mrs H about its investigation into the fall
63. Our physician adviser told us it was not obvious that Mrs O’s fall may have caused significant harm. Once it was identified from the CT head scan that Mrs O had received a basal skull fracture this should have prompted an investigation.
64. From the Trust’s ‘multidisciplinary inpatient fall investigation tool’ its investigation into Mrs O’s fall began on 10 June. The Trust’s falls prevention team provided comments on 17 June. The case was discussed at the Trust’s Serious Incident review panel on 22 June where Mrs O’s fall was considered to have been an ‘avoidable incident resulting in serious harm’.
65. In relation to duty of candour, the Trust recorded on the ‘multidisciplinary inpatient fall investigation tool’ that it had told Mrs H of her mother’s basal skull fracture on 8 June and sent her a letter on 16 July. Though we have seen a record that the Trust told Mrs H her mother had a skull fracture on 8 June there is no indication it told her that her mother’s fall was being investigated at this time.
66. The letter dated 16 July told Mrs H an investigation was being carried out into Mrs O’s fall. The letter says it had telephone calls with Mrs H on 12 June and 19 June. Though we requested the Trust provide us with records around its internal investigation and its communication with Mrs H about this, we have not seen any records of the telephone calls on 12 and 19 June.
67. Appendix 6 of the Trust’s ‘Patient Falls, Prevention and Management Policy’ says that when a patient sustains a serious head injury following a fall the next of kin/relatives should be informed on the day of the fall and the family should be ‘advised of the investigatory process’ within the first two days.
68. Our decision is that there is a failing by the Trust compared to its policy. From what we have seen, the Trust did not tell Mrs H about the planned investigation for around a month which significantly exceeds the two day timescale set out in the policy. Though the Trust says that there were telephone calls with Mrs H about this on 12 and 19 June we have seen no evidence of these conversations, or what was discussed.
69. In terms of the impact, our decision is that delay of a month in being informed of an investigation into a serious incident involving a relative would likely have caused distress as Mrs H has described. This would be exacerbated in the context of her bereavement.
70. The Trust has not acknowledged the failings we have seen or taken any action to put these right. As such our decision is to uphold this part of Mrs H’s complaint and we have set out at the end of this report what we consider the Trust should do to remedy this.
Information provided by nursing staff during end of life visit
71. From the Trust’s daily communication notes for 9 June, it is recorded that nursing staff contacted Mrs H at 2pm to tell her Mrs O had tested positive for COVID-19, and the procedure that would have to be followed if they still wanted to visit. After this there are no further communication records until after Mrs O’s death later that evening.
72. Section 5.5 of the NMC Code 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’. In the context of the COVID-19 pandemic our nursing adviser stated that nursing staff should have greeted the family and reiterated the need for protective equipment due. In addition, the nursing staff greeting the family should have ascertained what Mrs O’s family knew about her condition, advised them of the current situation and escorted them to her room.
73. NHSE’s ‘Clinical guide for supporting compassionate visiting arrangements for those receiving care at the end of life’, was published on 13 May 2020 as guidance for supporting compassionate visits in the context of the COVID-19 pandemic. It says that emotional support should be provided to visitors during end of life visits which could include providing comfort, providing information about what will happen after their loved one dies and signposting opportunities to prepare for death.
74. Mrs H says that on their arrival nursing staff just pointed them to where Mrs O was, and no further information or support was provided. There are no records available from the Trust which would provide a different account of the information or support provided during the end of life visit.
75. We recognise the Trust gave Mrs H some information about Mrs O’s condition and the COVID-19 procedures in place before the end of life visit. However, our decision is that, on the balance of probabilities, the Trust’s nursing staff did not act in line with the NMC Code or NHSE guidance due to the lack of recorded information or support that was provided to Mrs H or other family members.
76. In terms of the impact, it is understandable that a lack of information or support from nursing staff during an end of life visit would be likely to cause distress. The Trust have apologised in general terms that Mrs H found ‘some staff behaviours and attitudes to be unacceptable’ but has not offered any other remedy.
77. Considered against our Severity of Injustice Scale we do not consider that the Trust’s apology is sufficient to put things right. This is because we will generally find any injustice involving bereavement made worse by poor service or treatment merits a financial remedy, if the complainant wants this as an outcome. As such our decision is to uphold this part of Mrs H’s complaint and we have set out at the end of this report what we consider the Trust should do to remedy this.