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Bolton NHS Foundation Trust

P-001798 · Statement · Decision date: 9 February 2023 · View Bolton NHS Trust scorecard
Nursing care Communication Abuse Confidentiality, privacy and safeguarding Nursing care Care safeguarding systems Care home nutritional choice Complaint record keeping failures
Complaint (AI summary)
Miss I complained her late mother received inadequate care, including poor nutrition support, lost hearing aids, denied visits, and an uninvestigated assault by another patient.
Outcome (AI summary)
The complaint was resolved and closed as the Trust agreed to Miss I's requested outcome of a meeting to discuss her mother's care and lessons learned.

Full decision details

The Complaint

3. Miss I complains about the treatment and care her late mother, Mrs T, received during her admission to the Trust from 9 June 2021 to 6 August 2021. Miss I specifically complains the Trust:

• failed to support her mother with eating, leading to her losing almost 6 stone in less than two months, which the staff did not inform her of • lost several pairs of hearing aids, leading to her mother having new ones fitted on multiple occasions • told Miss I she could visit her mother but then turned her away • allowed her mother to be assaulted by another patient despite her mother raising complaints about the patient for several days, and • did not conduct an enquiry into her mother’s assault.

4. Miss I says because of what happened her mother was very weak when she left hospital and was put on end-of-life care a few days after she was discharged. Miss I says she has suffered experienced as she was not able to help her mother while she was in hospital.

5. Miss I would like a meeting with the Trust to discuss what went wrong with her mother’s care and what the Trust has learned from this.

Background

6. On 9 June 2021 Mrs T attended the emergency department with bleeding after a blood transfusion the day before. She had these transfusions twice monthly. Miss I feared a blood vessel had burst. The Trust has said an ultrasound scan showed a longstanding hepatic vein dilation caused by Mrs T’s chronic heart failure.

7. During the time Mrs T spent on the first ward, Miss I was allowed to visit her mother and did so on 17 and 20 June 2021. Miss I says her mother liked this ward and was not happy when she was told she would be moved.

8. On 21 June Mrs T was moved to a second ward for assessment. The staff on the new ward told Miss I she would be able to visit her mother on this ward, but she was unable to visit her mother in the hospital from this time onwards.

9. On 23 June Miss I was allowed to take her mother to receive laser eye surgery. Miss I was unhappy that, although she could not visit her mother on the second ward, she was not required to do a COVID-19 test before collecting her mother for the appointment. At this time Mrs T told her daughter about the patient who had stood at the end of her bed during the night, shouting at her. Upon return to the hospital Miss I spoke to a nurse about the patient, saying she did not think her mother was safe around this patient. The nurse assured her that although they could not move the patient, Mrs T and the patient would not be left alone together.

10. On 24 June Mrs T reported to a nurse she was assaulted by another patient. Mrs T had previously raised complaints about this patient, who had been verbally abusive to her. A nurse then called Miss I to tell her about the assault. The Trust has said they were unable to move the patient at the time due to a lack of beds but moved them at the earliest opportunity. The assault was reported to the internal incident reporting system and local authority safeguarding team, but they were advised they did not need to take further action.

11. Later that day Mrs T was moved to a third ward, a cardiology ward, as she had heart failure. Mrs T was reviewed by a doctor and found to have fluid in her lower body. Her weight at this time was recorded as 11 stone seven pounds. She was given antidiuretic medication (medication used to control the balance of fluid in the body) to remove this fluid. The doctor said her weight should be monitored daily.

12. On 25 June Miss I contacted the Trust’s complaints team and was told she had up to 12 months to make a formal complaint. As she was worried a complaint might affect her mother’s care, she did not make a complaint at this time. She was also told she would receive a copy of the hospital’s enquiry regarding her mother’s assault within 35 days, but she never received this.

13. Following the assault Miss I contacted Greater Manchester Police to report the incident. They contacted the Trust on 28 June and the Trust agreed to co-operate with their enquiry.

14. Miss I asked nurses on several occasions during her mother’s time in hospital if she could take a COVID-19 test so she could see her mother. However, she was not allowed to visit, and on some occasions she was not called back after speaking to a doctor or nurse.

15. On 5 July Mrs T was fitted with two new hearing aids as they had been lost. The Trust did not have any information about when or where the hearing aids went missing.

16. On 6 August, upon leaving the hospital, Mrs T weighed 5 stone 11 pounds. Shortly after she left hospital Miss I asked for her GP to visit her mother to see how frail she was. The GP said her mother should not have been on the amount of paracetamol she had been on previously (two tablets, four times a day) due to her weight, as this could have harmful effects on her body.

17. Following her discharge Miss I says her mother was very hungry and would eat small meals often. Miss I believes this shows her mother was not eating properly during her time in the hospital. Mrs T sadly passed away in August 2021.

Findings

19. Before we decide if we should investigate a complaint, we should consider trying a resolution that could, with minimal intervention, achieve a satisfactory result for the complainant. This could include arranging a meeting between the complainant and the Trust.

20. On 7 February 2023 we called Miss I to discuss her complaint. We discussed the outcomes she was seeking from bringing her complaint to us. She said she was happy for us to contact the Trust to ask if they would consider meeting with her to discuss her complaint.

21. We then contacted the Trust to ask if it would consider arranging a meeting with Miss I to discuss her complaint. It told us it is happy to do this and gave us information to pass on to Miss I about who to contact at the Trust to arrange the meeting.

22. Based on the evidence we have seen, and the agreed actions by the Trust, we have decided not to take further action on this complaint as it has been resolved. We hope this gives Miss I the outcomes she was seeking to address her complaints.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Miss I’s complaint about Bolton NHS Foundation Trust (the Trust). We were sorry to hear of Miss I’s concerns about the care provided to her mother and the distress these events caused.

2. Miss I told us she, as an outcome to her complaint, would like a meeting with the Trust to discuss what went wrong with her mother’s care and what the Trust has learned from this. The Trust has agreed to a meeting with Miss I. We have therefore agreed action with the Trust to resolve Miss I’s complaint. Based on this we are satisfied Miss I’s complaint has been resolved and will take no further action.

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