13. Before we decide if we should investigate a complaint in more detail, we look at whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. When we see indications of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.
14. If we think the failings had an impact that has not been put right, we will usually investigate in more detail.
15. Having done this, we have decided the Trust has already done enough to put right the impact of events Mrs O witnessed while a patient at the hospital. The Trust has agreed to write to Mrs O again to put right the impact of her concerns with her catheter, her cannula, and the electronic system for recording medication.
Electronic medication records
16. Mrs O explained that, while she was a patient, she overheard nursing staff talking about difficulties they were having operating a computer which kept electronic records of the patients’ medication. She said that it sounded like the nurses could not see what patients had already received, so they had to ask the patients to remember. She also said that the nurses did not seem to be able to get the computer to move onto the next item to dispense, and suggested recording that she had refused her medication in order to get it to keep dispensing.
17. At the resolution meeting, Mrs O was able to discuss these concerns with Trust staff, but she told us she was disappointed that they were not specifically addressed in the subsequent letters sent by the Trust. In the meeting, the Trust acknowledged that staff were getting used to a new system at the time. The Trust also confirmed to us that this was a new system which had been introduced at the time of Mrs O’s stay, and it appears that staff were still becoming used to operating it.
18. We saw nothing which suggested Mrs O had received the wrong medication or missed medication as a result of any difficulties with the electronic drug charts. Mrs O was understandably concerned that the problems with the electronic records could have led to medication errors, and we can see how this contributed to her poor impression of her care as a whole.
19. Our Principles of good complaint handling say that organisations should be open and accountable. There is unfortunately no objective evidence for us to say whether anything went wrong. However, both the Trust and Mrs O agree that, at the least, there were problems implementing the new system. While it does not appear that Mrs O’s care was negatively affected, her confidence in that care was.
20. The Trust was not aware that Mrs O felt it should have addressed this point in its letters. It has agreed to write to her with an explanation to account for what she heard. This is in line with our Principles, and we consider that this will resolve this point of Mrs O’s complaint.
Catheter Care
21. Mrs O said that one day her catheter stopped draining urine, even though she drank three jugs of water during the day. She said she was getting more and more uncomfortable, was in pain, and her stomach was swelling, but the nurse wouldn’t help her and said it was okay. She explained that, eventually, she asked a nurse if they would call a doctor. The nurse told her that the doctor would ask if she was constipated, and she would need to have an enema first.
22. Mrs O felt the way the nurse carried out the enema was cruel. She said they brought two other nurses to help, and they were all laughing while they were doing it, even though she was in agony. The enema did not resolve things and Mrs O said she eventually told staff that if they did not get the doctor, she would pull the catheter out as she was in so much pain. The doctor came and when they looked at the catheter, they said it was in her vagina. He placed a new catheter and immediately a large volume of urine drained off. Mrs O also said that the bladder scanner was out of battery so staff could not perform a bladder scan as they had wanted to do.
23. In the resolution meeting, the Matron advised she did not consider an enema was necessary, although she would talk to the nurse about their thought process. They said that they would ask the nurse to reflect on what happened, including the behaviour of staff during the enema, and they would consider whether there was any training need.
24. In the first response the Trust apologised for the pain Mrs O had experienced because the catheter was misplaced and for the bladder scanner not being available. It confirmed what the Matron had said at the resolution meeting and said that these conversations had been held with staff, and this had led to further training being undertaken. It also said that staff had been reminded of their responsibility to ensure this type of equipment is charged.
25. In the second response the Trust said the Matron had disputed Mrs O’s version of events. It said when the catheter had stopped draining it was removed and replaced by a nurse. When the new catheter did not drain, a doctor was asked to review Mrs O as it was apparent she had lost trust in the nursing staff since she would not allow them to conduct a bladder scan or to remove the catheter. The Trust said it accepted that bladder discomfort had built up during the day, but staff had dealt with this as soon as she allowed.
26. Mrs O was understandably unhappy with the contradictory responses from the Trust, in particular that it disputed her version of events.
27. The events appear to have happened on 13 August. The records show that both a nurse and a doctor completed a catheterisation that day. The doctor replaced the catheter as they found it was in the vagina. This record also says that the doctor had requested the enema, rather than the nurse making that decision themselves. There is no record about the bladder scan being requested or refused, although there are notes on 17 August to say there were no bladder scanners available to perform a planned scan that day.
28. Our Principles of Good Complaint Handling say that when organisations get things wrong, they should take steps to put things right. This can include an apology, explanation, and acknowledgement of responsibility. Our Principles also say that organisations should seek to learn from complaints, so they contribute to service improvement.
29. The Trust had acknowledged that something had gone wrong and apologised for it. It also explained how both the individual nurse and the staff as a whole would learn from the complaint. This is in line with our Principles. Unfortunately, the explanation it gave in the second response was different to the first and included information about the bladder scanner, and Mrs O’s loss of trust in the nursing staff which was not recorded in her medical record. It appears the Trust could have done better here.
30. We spoke to a complaint manager at the Trust about this. They explained that some of the information had been gathered during the complaint handling and came from the recollections of staff. They acknowledged that, ideally, this information should also have been noted in the clinical record.
31. The Trust has agreed to write to Mrs O again to explain why it arrived at this view. Although the Trust and Mrs O have a different recollection of some of the events, they are agreed that the catheter was misplaced in her vagina, and Mrs O experienced significant discomfort when she was unable to pass urine. Even if we were to investigate this aspect of the complaint, we would never be able to learn more about what happened and reconcile these views. Considering this, we think that by writing to Mrs O again, the Trust will have done enough to put this right.
Cannula care
32. Mrs O said that during her stay she became concerned about her cannula (a tube inserted into a vein in her arm to deliver medication or fluids), because the site of the cannula became painful and swollen. She said that nursing staff took too long to respond to her concerns, or change the cannula site so that the discomfort went on for much longer than necessary. She said she was concerned that this could have caused cellulitis (a bacterial infection of the skin).
33. At the resolution meeting the Trust apologised if this had occurred and said that if these symptoms were present the cannula should have been removed. As with the medication dispensing issue, Mrs O was disappointed that the Trust did not include a response to this point in its letters.
34. Mrs O complained about this to PALS on 10 August, but unfortunately the date of the event itself is not recorded. Mrs O’s clinical records include cannula assessment records, and these show that on 7 August at 12:40pm Mrs O’s cannula was removed from her because it was ‘tissued’, and the Visual Infusion Phlebitis (VIP) score was noted as zero to one. As no other incident has been recorded in relation to the cannula it seems likely that this is the event Mrs O complained about.
35. When a cannula has tissued, this means that the infusion is leaking into the surrounding tissues. The chart indicates that a VIP score of zero means no signs of phlebitis and one means possibly first signs of phlebitis, which it defines as pain or redness near intravenous (IV) site. The chart instructions say that at level zero or one staff should continue to observe the cannula but do not say staff should resite the cannula until the score reaches level two, a level which was never recorded in Mrs O’s chart. We can see that staff resited the cannula before it reached level two. While we acknowledge that this was painful and worrying for Mrs O, there is no indication anything went wrong here.
36. While the Trust was not unreasonable in thinking that it had addressed this point at the resolution meeting, Mrs O felt it had not. The Trust has agreed to address this again when it writes to Mrs O about the other matters. We consider that this is customer focussed and therefore in line with our Principles of Good Complaint Handling, and so it goes far enough to resolve the complaint.
Nursing behaviour
37. Mrs O said that some of the nursing staff were careless with patients’ notes. She said that it appeared that they were throwing notes onto the end of patients’ beds in a rush to get out at the end of their shift. She added that on one occasion this resulted in the wrong notes being on her bed, so the consultant initially talked to her about a procedure another patient had had. She said she had to correct the doctor and she was concerned that some other patients could not do this, for example if they had dementia.
38. When she attended the resolution meeting in May 2021, Mrs O also talked about her concerns that some nursing staff were indiscreet and talking to ‘favourite’ patients about other patients on the ward. Additionally, she gave two examples of night time disturbances. She said one nurse was joking with a patient about a time that patient did the nurse’s hair at midnight, which annoyed all the patients, and the nurse suggested they should do it again. She also said that some patients were escorted off the ward for cigarettes in the middle of the night on a regular basis, which disturbed other patients, left the ward understaffed, and was also against the Trust’s no smoking policy.
39. Our Principles of Good Complaint Handling say that when organisations have got something wrong, they should take steps to put it right. This can include and apology, an explanation and acknowledgement of responsibility. Our Principles also say that organisations should seek continuous improvement by using feedback and complaints to contribute to service improvement.
40. When these concerns were addressed at the resolution meeting the Trust said that joking about disturbing patients was unacceptable and that nurses should not be discussing patients with other patients. It apologised if this had happened.
41. It explained its approach to patients who were also smokers. It said that it did not condone smoking in general and that it is dangerous to light a cigarette in hospital because of all the oxygen [cylinders and other equipment]. But it explained that staff had to carry out an informal risk assessment on a case-by-case basis. If a patient was accustomed to smoking many cigarettes a day, they may need to go off the ward to smoke. Some patients were very challenging and could not calm down without a cigarette. They might not be able to safely go outside unattended and there was a risk they would attempt to smoke on the wards if they could not get a cigarette. As Mrs O pointed out, escorting a patient for a cigarette was a risk too as the ward may be shorthanded. In each case the staff would need to decide which was more risky, to take the patient for a cigarette or not.
42. The Trust explained it could not say what should have happened in the case which Mrs O mentioned. More generally, the Trust said it would feedback on her concerns to staff on the ward. When the Trust’s Chief Executive wrote to Mrs O following the meeting, they restated the Matron’s apology for the behaviours she witnessed and added their own apology. They said they were disappointed to note this behaviour. They said that this would be on the agenda at the next team meeting to remind staff of the level of care and professionalism they should be providing.
43. We recognise that it would be very difficult for the Trust, or us, to work out exactly what happened on these occasions. The Trust has taken Mrs O’s concerns at face value and apologised for what happened. It has also told her how it will learn from her complaint and address these with staff. These actions are in line with our Principles of Good Complaint Handling, and therefore it appears the Trust has done enough to put this right.
Attitude to other patients
44. Mrs O told us that she witnessed vulnerable patients receiving poor, even abusive, treatment from nursing staff. She said that one nurse told off a patient for being incontinent twice in the night and purposely left the patient naked on the bed while cleaning them as a punishment. She also said that a small group of nurses were very rough when dealing with a patient who also had poor mental health and often appeared to be suffering delusions. She said that they ignored the patient screaming that they were hurting them.
45. She explained that as well as feeling very upset at witnessing these events, they also contributed to her feeling unsafe while she was in hospital.
46. It is not possible for us to complete a robust investigation into what happened on these occasions. Even if we got more evidence, on balance, it is extremely unlikely that staff will have recorded these events in a way that accords with Mrs O’s perception of them, and so we will likely be left not being able to robustly say what happened, beyond the facts that have already been established. Even if we did investigate further, we could not inform Mrs O of our findings while respecting the privacy of the individuals concerned. Therefore, we considered whether the Trust responded appropriately to Mrs O’s concerns.
47. The Trust’s patient information leaflet about the PALS and Complaints department explains that initially the Trust will try and address concerns immediately and suggests that patients or relatives try to raise their concerns directly with staff involved with their care. If this is not possible, or if the patient prefers, it explains that it also has a formal complaint process. It promises to give complainants a timescale in which it will respond and the opportunity to meet with senior staff to discuss the complaint.
48. Mrs O initially raised her concern about the patient with incontinence while on the ward. She later called PALS to lodge her concerns and mentioned it again then and also discussed it in the resolution meeting in May.
49. It is unclear whether staff at the Trust took any action when Mrs O first raised this concern while on the ward. When she raised her complaint with PALS shortly after she was discharged from hospital, PALS contacted relevant staff in order that it could address her complaint. In regard to this point, it asked for confirmation the incident had occurred, that it had been logged and that the nurse had been identified and appropriate action taken.
50. At the resolution meeting a Trust representative apologised to Mrs O as this point had not been escalated when it was first raised. However, they added that they had now looked into what had happened and identified that the nurse was a ‘bank’ nurse. This means they were not directly employed by the Trust, but by an agency providing cover nurses to the Trust. They said this nurse was no longer allowed to work at the Trust. Mrs O had also complained that another nurse was laughing about what happened, but the Trust said that unfortunately it could not identify who this was from her description. It thought it likely that this was also a bank nurse.
51. It was at this same meeting that Mrs O mentioned she had witnessed poor treatment of the second patient. A consultant present at the resolution meeting said that they sometimes had issues with bank staff, but they always took immediate action.
52. Following the meeting the Trust sent its response to Mrs O. It said that it had contacted the first patient about her concerns and taken the necessary action. It also explained that more generally it shared the concerns she had raised with staff on the ward so they could reflect on what had happened. It added that it generally uses concern and complaint information to inform training sessions and meetings so that ‘lessons are learnt, improvements to practice made and action taken where appropriate’. The Trust repeated its apology for what had happened.
53. The Trust acknowledged what had happened, apologised for it, and explained it would ask staff to reflect on what they could learn from this complaint. This is in line with our Principles. We can see that it might not be very satisfying for Mrs O to have little detail about what the Trust did – in this case, as the complaint involved a third party, the Trust could not give as much detail as it could if the concern only involved Mrs O. Nonetheless, we were reassured to see that the Trust appears to have taken her concerns seriously and thought about how it might use her complaint to improve its service. Although we can see why Mrs O raised her concerns, we saw no reason to consider this aspect further.