18. 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 seen any signs that something went wrong. We have explained below how we reached this decision for each of the complaint issues.
Trust 1
Discharge
19. Ms T told us she spoke to the physiotherapist who told her and Mrs K that a care package would be put in place to help Ms T care for Mrs K. Ms T told the Trust she was going to care for Mrs K temporarily.
20. NICE guidance, ‘Transition between inpatients hospital settings and community or care home settings for adults with social care needs section’ says as soon as people with complex needs are admitted to hospital, intermediate care or step-up facilities, all relevant staff should start assessing their health and social care needs. They should also start discharge planning.
21. The guidance states the discharge coordinator should make sure the discharge plan takes account of the person’s social and emotional wellbeing, as well as the facts of daily living. Including:
• details about the person’s condition • information about the person’s medicines • contact information after discharge • arrangements for continuing social care support • arrangements for continuing health support • details of other useful community and voluntary services.
22. We reviewed the medical records. The physiotherapy team reviewed Mrs K on the 26, 27, 29 and 30 March 2021. On 27 March Mrs K was assessed as being able to go to the toilet and back with her Zimmer frame and help from one person. The physiotherapist noted that when Mrs K is back at home, she would need close supervision and help to get to the bathroom. It is documented that Mrs K would benefit from a reassessment.
23. The physiotherapist spoke to Ms T to discuss the discharge plan. The physiotherapist noted the following ‘[Ms T] states she is going to move in with patient when home to assist with personal care/domestic tasks. [Ms T] states she intends to do this for 2 days but will be willing to stay longer if needed’. The physiotherapist informed Ms T that Mrs K would benefit from a reassessment. It is noted the physiotherapist discussed rehabilitation calls to get Mrs K back to baseline (an assessment tool for multiple sclerosis in adults) and Mrs K and Ms T stated they were happy to be called if it was needed.
24. On 30 March, the physiotherapy team reassessed Mrs K. She told the physiotherapist she had a recliner, a suitable bed, and pads at home. Mrs K was observed independently transferring off the bed, standing with her Zimmer frame, going independently to the bathroom, and returning to her bed. The records show Mrs K was able to get out of bed and walk to the bathroom with help and that Ms T was going to stay with her. We have seen no evidence in the medical records that the Trust would arrange a care package when Mrs K was discharged. We would expect it to be noted if a care package been agreed and discussed with Mrs K.
25. We also reviewed the discharge summary. It is documented for action to be completed by the GP but there is no mention of any other agency being involved in Mrs K’s care.
26. We understand how concerned Ms T was about Mrs K’s care and how she wanted to make sure she had the support she needed. Having considered the medical records and clinical advice, the Trust had assessed Mrs K’s mobility before she was discharged. Mrs K could independently mobilise and apart from the support of Ms T, she did not need any extra support from the community. We listened to what Ms T told us but we have seen no evidence in the records to support this. Mrs K was correctly discharged in line with the NICE guidance. We are not investigating this issue further.
Communicating the discharge
27. Ms T told us that when she visited Mrs K’s GP, they did not know Mrs K had been in hospital and discharged the day before the visit. Ms T also says the Trust did not tell social services about the discharge.
28. We have considered whether the Trust did tell Mrs K’s GP in good time. The discharge process involves sending an immediate discharge note to the GP (and the patient should be given a copy). It should include the primary diagnosis, any important secondary diagnosis, any operations or procedures done, medication, necessary action for primary care, and follow up arrangements.
29. We reviewed the medical records and made enquiries with the Trust. We have seen a copy of the discharge summary addressed to the GP. We have also seen a screenshot of the audit trail of the Trust sending the discharge summary to Mrs K’s GP.
30. The Trust discharge policy states the immediate discharge summary should be given to GP within 24 hours of patient discharge.
31. We cannot comment on when the GP received the discharge summary, but we can see the Trust did what it should have and sent the discharge summary on the day of Mrs K’s discharge.
32. We have also considered whether social services should have been told. Within the medical records, there is no mention of involvement from social services and on the discharge summary there was no action required from social services.
33. We recognise Ms T was upset to learn the GP did not know about the hospital admission. From the evidence we have seen the Trust did send the discharge summary to the GP within the expected timeframe. There was no need for the Trust to tell social services as Mrs K was not getting support from them. We do not think the Trust did anything wrong.
Trust 2
Leaving Mrs K on her own
34. Mrs K fell at home and was admitted to Trust 2. On 11 and 14 April, the physiotherapy team and occupational therapy team assessed Mrs K and found she could walk with a frame with the help of one staff member. They found Mrs K did not need supervision throughout the assessment. The physiotherapy team assessed Mrs K as being able to walk to and from the toilet but recommended supervision when moving from bed to chair or on and off the toilet.
35. We reviewed the Trust’s incident report. It is documented, ‘patient was taken to the toilet which was in her room and was advised to ring the buzzer when she finished so that she would be taken back to bed. Patient did not ring the buzzer, instead the patient decided to take herself back to bed. On her way she lost balance and fell on the floor. Patient sustained a skin tear to the right arm and a small depression at the back of her head. Patient was helped by three staff off the floor to bed. Doctor was called to review the patient’.
36. The NICE CG161 guidance says older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context, and characteristics of the fall/s (how it happened). Older people who need medical attention because of a fall, or report frequent falls in the past year, or show abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be done by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service.
37. We reviewed the Trust’s local policy. It states a falls multifactorial risk assessment should be completed within six hours of admission and repeated after any in-patient falls or ward transfers.
38. Our nurse adviser told us a moving and handling risk assessment should also be completed. Moving and handling risk assessments help identify where injuries could happen and what to do to stop them. They are mandatory requirements.
39. We reviewed the medical records. Mrs K was over 80 years old at the time. Our nurse adviser told us she would have been considered at ‘high risk’ of falls and a multifactorial risk assessment should be completed as per NICE CG161. The medical records show she was admitted to the ward in the early hours of 11 April. A multifactorial risk assessment was completed shortly after admission and repeated on 14 April after her fall. The timing of the assessment was in line with the Trust’s policy.
40. Looking at the risk, it is recorded that Mrs K’s mobility was reduced and she lacked confidence. Lying and standing blood pressure, to check for postural hypotension, could not be completed because Mrs K refused to have blood taken. Mrs K was alert with no mental decline and she had capacity. Mrs K’s moving and handling risk assessment concluded that she could weight bear but needed one nurse to help when moving or walking.
41. Having considered the records and clinical advice, the Trust took the right actions to reduce Mrs K’s risk of falls.
42. Stopping patients from falling is a particular challenge in hospital, because patient safety has to be balanced against their right to make their own decisions about the risks they are prepared to take, and their dignity and privacy. Rehabilitation always involves risks and a patient who is not allowed to walk without staff, may become a patient who is unable to walk without staff. We note Mrs K was able to call for help. She had the capacity to make her own decisions. We note Mrs K did need help from one person when moving, but there are no signs (such as increased confusion or mental decline) that she needed a member of staff to wait with her while she used the toilet.
43. We considered whether the Trust could have done more to keep Mrs K safe. Mrs K could use the nurse call bell after she used the toilet. She had the capacity to decide if she would use the bell or attempt to move by herself. Our nurse adviser told us that even if a nurse was outside the door, it may not have stopped the fall. There is no national guidance or standards about giving one-to-one support for patients at risk of falls. It is not a recommendation of the Royal College of Physicians.
44. We recognise how concerning it was for Ms T when Mrs K fell. Having considered the above, we can see the Trust had correctly assessed Mrs K’s risk of fall in line with guidance. We note Mrs K had the capacity to make her own decision, was advised to call for help when she finished using the toilet and was given a buzzer. We recognise Ms T feels a staff should have stayed with Mrs K. The Trust apologised for the distress the fall caused. We do not think the Trust did anything wrong and we are not investigating this further.
Delayed in reporting the fall
45. National Patient Safety Agency guidance says communicating with patients, their family and carers is a vital part of the process of dealing with patient safety incidents.
46. CQC guidance says you must:
1. Tell the relevant person, face-to-face, that a notifiable safety incident has taken place 2. Apologise 3. Provide a true account of what happened, explaining whatever you know at that point 4. Explain to the relevant person what further enquiries or investigations you believe to be appropriate 5. Follow up by providing this information, and the apology, in writing, and provide an update on any enquiries 6. Keep a secure written record of all meetings and communications with the relevant person.
The guidance does not give a timeframe for telling a family about a patient safety incident.
47. We looked at the Trust policy. It states the patient’s next of kin must be informed of a fall as soon as possible, in line with the patient’s wishes and when the patient is seen to not have capacity.
48. The fall happened at 7.25pm and was documented at 8.30pm. Ms T was told at 8.55am the next day. As the fall happened in the early evening, it is expected that Ms T would be told on the same day. We have seen no explanation from the Trust for not telling Ms T on the evening of the fall, in line with its own policy. This is a failing. When there is a failing, we look at how this affected the person. We looked at the impact on Ms T.
49. Ms T told us she was disappointed to be told 13 hours after the fall.
50. We looked at the Parliamentary and Health Service Ombudsman’s Principle of Remedy (our principles) which say where maladministration (fault) or poor service led to an injustice or hardship, the organisation responsible should take steps to give an appropriate and fair solution. We also looked at our severity of injustice scale. Our scale says an apology is a fair solution to a level one injustice. A level one injustice is where a person has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience normally because of a single or one-off incident of maladministration or service failure. The effect is only for a short period and there are no other negative effects or ongoing wider impact.
51. Being told the next day caused Ms T and she wants the Trust to improve its process. While there is no national guidance on when patient’s family should be told, we can see Trust 2 already has a policy in place for when they should tell a patient’s family. In this case, the Trust did not follow its own policy.
52. In its complaint response, the Trust accepted that its communication had fallen below its expected standard and it was unacceptable to delay telling Ms T. The Trust said the matron has spoken with the ward sister and to the ward team about the delay in communication. The Trust also apologised for the distress caused to Ms T. We consider this is a reasonable solution and in line with our principles we do not think the Trust needs to do anything more.
Lack of compassion from the ward staff 53. Ms T told us there were nurses who were kind, compassionate and understanding towards Mrs K. But, there were also some nurses who were rude, nasty, and hurtful. Ms T says there was a lack of compassion shown by these nurses.
54. In its complaint response, the Trust apologised to Ms T. It explained Trust employees are expected to show kindness and compassion throughout all care and interaction. The Trust stated it was unacceptance this did not happen for Mrs K and the matron has spoken to the staff about the Trust values and staff attitudes.
55. We can see the Trust has listened to Mrs K’s experience during her stay at the ward. This is appropriate action to take. We have considered whether is there any other evidence to look at what happened. We reviewed the medical records and there are no records of this issue being raised as a concern.
56. We recognise how upsetting it was for Ms T to learn not all the ward staff had shown compassion to Mrs K. We were not there at the time and do not have any other evidence to look at to tell us more about what happened. In the circumstances, it is unlikely we could make a decision about what exactly happened. Because of this, it is unlikely we would be able to come to a decision supported by evidence, if we were to investigate this further. We are pleased the Trust has already taken action to make sure any poor behaviour of this kind does not happen.
57. We recognise how important Ms T’s complaint is to her and thank her for bringing it to us to consider.