4. Miss X complains a nurse lifted her father’s head and ‘shoved’ a pillow underneath it, knowing he was recovering from a neck fracture. She says this made him cry out in pain and his temperature rise.
5. Miss X believes the nurse’s actions caused her father’s death and he would have lived longer otherwise.
6. Miss X wants the Trust to accept the nurse was at fault, an apology and service improvements.
7. Miss X’s father suffered a fall at his care home in August 2019 and fractured the C2 bone in his spine. This bone helps support the head. Miss X’s father was admitted to hospital but it was decided to treat him without surgery.
8. Miss X’s father was admitted to hospital again on 4 April 2020, when he was diagnosed with sepsis. Miss X says on 27 April a nurse lifted her father’s head and ‘shoved’ a pillow underneath and this made him cry out in pain and increased his temperature. Miss X’s father sadly died in May and COVID-19 was recorded as the primary cause of death.
9. Miss X complained to the Trust about the nurse’s actions and attitude. The Trust responded twice, in 2020 and 2021, but Miss X is unhappy with this and has complained to us.
14. Miss X’s father was readmitted to hospital on 4 April after being discharged the day before. It seems he was unwell but fracture management was not a problem or a reason for his admission, although he was still using a hard collar to support his neck.
15. A neurology nurse saw Miss X’s father on 10 April. After discussion with a neurosurgeon the decision was made to remove the hard collar as it was over three months since his injury. It was agreed Miss X’s father did not need to wear a soft collar and it seems his neck fracture had mended.
16. There is no mention of neck risks, manual handling or using a collar in any of the general care plans or multidisciplinary team communication sheets relating to Miss X’s father while he was in hospital. There is no evidence in his 22 April referral to palliative care his neck fracture was still a problem.
17. The nurse’s statement relating to the complaint says no special moving and handling instructions were given and Miss X’s father was not wearing a neck brace while on the ward.
18. The nurse says they were called into the room by Miss X because she thought her father was struggling to breathe and appeared uncomfortable and in distress. The nurse said there was nobody else available to help reposition him, but this was essential so they used a pillow to slightly reposition his shoulder and neck until another staff member arrived. The Trust carried out a safeguarding investigation into the incident and concluded the nurse acted in Miss X’s father’s best interests by protecting his airway and this had not caused any harm. Miss X says it was not an emergency, as the nurse claimed, and more care should have been taken to move her father.
19. It may be Miss X was unaware of the decision on 10 April to remove her father’s neck collar because the fracture had healed. So when she saw the nurse lift her father’s head and place the pillow underneath she understandably would have been concerned this could harm him, particularly if, as she says, he cried out in pain. But the indications are the nurse did not carry out a damaging solo manoeuvre, instead doing some minor repositioning that was not dangerous for either the nurse or Miss X’s father.
20. Our nursing adviser says general repositioning should be done by two nurses so the nurse was right not to attempt a manual lift of the patient on their own as this would breach manual handling guidance and it seems using the pillow was reasonable at the time. We do not consider the manual handling issue would have triggered an increase in temperature or affected Miss X’s father’s sad outcome. Miss X’s father was clearly unwell and nearing the end of his life.
Conclusion
21. In summary, Miss X’s father was a very frail patient with a repaired C2 neck fracture. He was immobile and nearing the end of his life. We have looked at the evidence carefully to see if we should investigate this matter, but taking into account the available evidence and guidance, there is no indication of failings by the Trust. We recognise her father’s death was a distressing experience for Miss X and we hope we have clearly explained the reason for our decision.
1. The Parliamentary and Health Service Ombudsman has considered Miss X’s complaint about Lancashire Teaching Hospitals NHS Foundation Trust (the Trust).
2. We have looked at the available evidence to see if we should carry out a detailed investigation of this matter. After considering the evidence carefully we have not seen any indications of service failure so will not be carrying out a detailed investigation.
3. We recognise the death of Miss X’s father was distressing for her and we are sorry for any additional upset caused by our decision.