Failure to provide an identification wristband
10. Mr O complains that on admission the Trust did not provide him with a wristband highlighting his lactose intolerance. He says this led to staff giving him milk products to eat and drink, which he is allergic to. The Trust does not dispute that it did not provide him with a specific, colour-coded wristband to highlight food intolerances and allergies. The Trust says it did not record Mr O’s lactose intolerance at the time of admission and that, if he advised staff of this dietary need, he should have been provided with a ‘red’ wristband on admission. The Trust acknowledges this did not happen.
11. We note Mr O says he was given milk products, which he says had an adverse effect on him during his stay. The records and Mr O’s account confirm this was after the Trust had provided him with the wristband. Having reviewed the records, we have seen no record of Mr O being provided with or reacting to lactose up to this point. Mr O’s hospital records did not identify lactose intolerance or milk allergy at the time of admission for the staff to consider.
12. We certainly do not dispute Mr O would have been frustrated, and we accept he was angry at not being provided with a wristband, but we would consider this an oversight rather than a failing. We are unable to say the result of this affected Mr O beyond frustration and anger, so a detailed investigation would not be reasonable.
13. In this case, the Trust has provided Mr O with an apology, advice and evidence that service improvements in communicating with patients would be made in this respect. Accordingly, we are persuaded the injustice here has been remedied and no further action would be appropriate.
Failure to provide appropriate food
14. Mr O complains the Trust gave him a milk-based feed via his NG tube to which he was both allergic and intolerant. He says this made him vomit and remain malnourished. The Trust has responded there no was record of Mr O being allergic to milk, with only paracetamol recorded as an allergen.
15. We do appreciate the Trust did not record his lactose intolerance at his first admission, and did not provide an appropriate red wristband, as identified above. The Trust has explained the milk product used on his NG feeding tube was a product called Jevity. The manufacturer’s product information describes this as a high-fibre and high-calorie, tube-feed meal product used in cases of malnutrition. It is a fibre-based and gluten-free product, meaning it does not contain lactose and is not milk-based. We find no sign of a link between the vomiting reaction Mr O says he experienced and his allergy or intolerance. Furthermore, having considered common side effects in the use of Jevity, we can see vomiting is one of the more common side effects of its use, considering the formula is used to counter malnutrition.
16. We do fully accept Mr O experienced a period of vomiting and appreciate this would have been frightening and unpleasant for him. We turn to what may have been the cause of this reaction. In our consideration of the medical records (both hospital and GP) relating to Mr O’s admission on 11 June 2020, we note the admission was due to malnutrition resulting from Mr O having chronic vomiting and being unable to keep solids or fluids down for several weeks. It appears reasonable then to suggest the records support the cause of the vomiting following the administering of Jevity may have been related to the cause of the admission rather than the feed. Furthermore, on reviewing the side effects in the use of Jevity, nausea and vomiting are recognised common side effects and would be considered a reasonable cause of Mr O’s reaction.
17. Mr O says that on his second admission, between 23 August 2020 and 7 September 2020, the Trust continued to provide inappropriate foods without considering his milk allergy, and he felt as if he was being left to starve. The Trust says that, on his second admission, the nursing notes recorded Mr O said he was lactose intolerant but had not mentioned a milk allergy.
18. We have again considered the hospital records and Mr O’s own account of events. We have also reviewed Mr O’s GP notes. We can see he was again admitted with chronic vomiting symptoms together with hypokalaemia (low level of potassium in his blood). Accordingly, we would expect the Trust to take account of Mr O’s needs. This obligation is explicit in both the NMC professional code of practice in terms of prioritising people and effective practice.
19. The records show an attempt to provide an NG tube with lactose-free milk derivatives, but Mr O said this was not suitable. Mr O told the clinicians he was able to eat but would vomit afterwards. During this admission, the Trust identified a short segment of inflamed Barrett’s oesophagus (which means some cells in the lining of your food pipe have started to change), and a biopsy of this was taken. We also note a record of Mr O eating small meals but saying this made him vomit soon after. The clinicians say they did not observe Mr O vomiting after meals during his stay, and this is recorded. Mr O is recorded as refusing all offered food supplementation until discharge.
20. While we fully accept Mr O would have been worried by his symptoms and weight loss, we must consider here that the complaint raised is the Trust failed to provide appropriate food. He has explained to us that he is both lactose intolerant and has a milk allergy. While we can see a record of a note made about his lactose intolerance, leading to the offer of lactose-free milk products, we have been unable to confirm in the hospital records or in Mr O’s GP notes prior to his admission that Mr O told the Trust of his milk allergy. Mr O has confirmed he did not inform the Trust specifically of his milk allergy. We are unable to say the Trust failed in its offer of food and drinks in relation to this.
21. The records show, and Mr O has explained, that he ate meals, but these made him vomit. Considering his recent medical history and the reasons for his admission, it is not reasonable to say his vomiting was the result of being given inappropriate food. We accept Mr O may have been given a cup of tea with milk in it, as he has detailed, but he has explained to us he did not drink it. We are unable then to say this had a direct effect. We have not seen evidence in the information provided to us to support Mr O’s complaint that his ingesting or being offered products to which he was allergic, of which the Trust had no knowledge, was due to a failing on the part of the Trust.
Incorrect removal of an NG tube
22. Mr O complains a nurse removed an NG tube incorrectly, causing physical damage to his mouth and throat, and he continues to experience a sore throat and chronic mouth and throat ulcers as a result. The Trust has not disputed a nurse pulled out Mr O’s NG tube quickly due to him vomiting and conceded that such a removal would likely result in some local minor soft tissue trauma. The Trust disputes Mr O’s chronic mouth and throat ulcers are the result of an incorrect NG tube removal.
23. There is clearly a difference of opinion between Mr O and the Trust about the effect of the NG tube removal and the cause of the chronic symptoms Mr O continues to experience. To come to a view here, we have considered both Mr O’s and the Trust’s versions of events, and we have reviewed both Mr O’s inpatient and GP records.
24. There is no dispute a nurse removed the NG tube quickly and on an emergency basis nor that this was distressing for Mr O. Mr O explains he began to vomit, resulting in the NG tube dislodging and protruding from his mouth in a loop while still being attached through his nose. It is not disputed the duty nurse came to Mr O’s aid and attempted to remove the tube.
25. Having considered various resources, we have seen NG dislodgement is a regular occurrence that usually results in some short-term soft tissue trauma. A safety alert notice published by NHS England in July 2016 alerts clinicians of the risks of NG tube misplacement and the importance of swift and immediate removal.
26. The NMC professional standards say a nurse must make sure any treatment, assistance or care for which they are responsible is delivered without undue delay. Both Mr O and the Trust say the NG tube became dislodged during vomiting and the nurse attended Mr O very quickly. While it is not disputed a nurse removed the tube roughly, because Mr O was vomiting and the tube had dislodged, we cannot say the nurse failed to act appropriately in providing assistance and care without undue delay. We accept Mr O experienced pain and sore throat, but these are recognised symptoms of a dislodged NG tube.
27. While we fully appreciate the experience was unpleasant for Mr O, the removal of the tube was in reaction to symptoms (vomiting) and displacement, for which an NG tube removal is recommended to reduce risk of harm to the patient. In this case, the risk to Mr O through delay was potentially greater. We turn then to consider the effect of the NG tube on Mr O in terms of his chronic mouth and throat ulcer symptoms.
28. Our clinical adviser has explained there is nothing apparent in the current medical literature or historical case reports supporting Mr O’s belief the removal of an NG tube could result in chronic and ongoing sore throat, ulcers of the mouth and throat or any other similar conditions. They also advised of the many underlying causes for oral and oropharyngeal ulcers, including vomiting, vitamin deficiencies and other systemic disorders. People with the conditions Mr O says he has been diagnosed with and is receiving treatment for may experience those symptoms, as stomach acid from vomiting (a symptom of both acid reflux and Barrett’s oesophagus) can affect the oropharyngeal lining (at the back of the mouth). While we do not dispute or in any way belittle Mr O’s experiences, and we accept the removal of the NG was both uncomfortable and upsetting, we are unable to say this led to the long term problems Mr O has experienced.
Assault by another patient
29. Mr O says another patient assaulted him following his admission to the ward, and staff moved him to another bay as a result. He says the staff did not speak to him about the assault or ask him to sign paperwork to report it, and the Trust did not call the police. He says this caused him significant anxiety that staff were not taking the incident seriously or not considering it at all.
30. The Trust has said that, on a senior nurse’s review of the hospital records, it agrees staff moved Mr O to another bay, but it disputes this was in response to an attack on Mr O. The Trust says beds being moved on a ward can be for a range of reasons, more commonly those of ward layout when space is needed for specific or urgent admissions. The Trust has advised there is no record of another patient assaulting or attacking Mr O. It says it has interviewed all staff on duty at the time Mr O says the incident occurred. None could recall the incident Mr O says happened or any discussion with Mr O about it.
31. The Trust explained in its letter of 15 September 2020 that the expectation in such events would be for staff to inform it about the event and for follow-up to take place with the patients affected. The Trust also explained no follow-up paperwork would be signed by the patient unless formal police action was required. This meets the Trust’s policy and guidance to staff in ‘Management of Aggression and Violence (Adult Patients)’. The process chart provided in that document for dealing with such situations is explicit and confirms the Trust’s expectations. We can see no reason why this policy would not have been followed had Mr O reported the incident as an assault, and no records support this incident being reported to staff.
32. We certainly do not dispute Mr O had an altercation with another patient and agree this would have been a frightening experience for him, particularly in view of his vulnerability. Having reviewed the hospital records, we have seen no record or report of an assault or similar incident to allow us to come to an impartial view that ward staff knew about the event and failed to record it as a violent incident.
Failure to record macular degeneration
33. Mr O says the Trust failed in its duty of care to record his macular degeneration accurately on his ward chart. He says this concerned him, and he was very frustrated and angered by this. The Trust concedes it did not include Mr O’s macular degeneration in his ward chart information, but it says it was aware of Mr O’s poor eyesight and the macular degeneration was clear to staff in his medical records. They have apologised to Mr O for this and explained that ward staff have been advised ward charts should include all relevant information. We can see a sign of a failing in this.
34. We turned to consider the effect of this on Mr O and whether the omission of this information would have had a bearing on his treatment. Mr O was admitted for gastrointestinal reasons, not because of his vision, and the records do not show Mr O raised issues at admission regarding his vision.
35. The effect of the Trust not including macular degeneration (which Mr O concedes was in his records) on Mr O’s chart is low. We accept this would have been frustrating for Mr O, but given the low effect of the Trust’s oversight, we do not consider it would be reasonable for us to take further action. We can see the Trust has issued Mr O with an apology and assured him service improvements will be made. We believe this to be an appropriate and reasonable outcome.