Delay in bringing Mr L out for a family visit in August 2020
15. Before we decide if we should carry out a detailed investigation into a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so, we have found signs of service failings from the Trust, which did lead to an injustice for Mrs M and her family. However, we consider the Trust has already done enough to put right the impact of these events. We explain why below.
16. Mrs M says the family were given permission to visit Mr L in August for his birthday. This took place in the hospital garden due to COVID-19 restrictions. Mrs M says they were kept waiting for 90 minutes before her father was brought out. She says the Trust gave conflicting excuses for the delay. She said for example, it said it could not find the keys to the double doors, the doors were not wide enough, or he may have gone for a scan. She also says Mr L’s lunch, which had been brought out to him 20 minutes earlier, was left to go cold. Mrs M says they were very shocked at the condition he was in. He did not have his glasses or his hearing aids on, so he could not hear or see properly and did not recognise them, which was extremely upsetting for them all. She says he was not able to talk, just kept ‘mouthing’ things which they could not understand. She says he looked like he had aged ten years in just a few days. She says it made her and her sister feel very guilty at having to leave their father in the hospital.
17. The Trust has apologised for the delay in bringing Mr L out to see his family and for the meal that went cold. It said the delay in bringing Mr L outside to see his family was at a time when no visiting was allowed in the ward, to help with infection control. It says sister D was disappointed to note the events that took place when the family came to visit their father, and it recognised it was unacceptable to expect Mr L to have cold food. It said because of Mrs M’s complaint, sister D had sent communications to all her staff to highlight the importance of making sure patients have hot meals.
18. We can see how it would have been frustrating and worrying for Mrs M and her sister while waiting for their father, and then to see him served food that had already gone cold. We also recognise how much of a shock it must have been to see their father had deteriorated. We can see this incident did lead to an injustice for Mrs M and her family.
19. We have to consider where this injustice most accurately fits on our ‘Severity of Injustice Scale’. We have decided this level of injustice falls into level one on this scale. This says: ‘A case will generally be level one if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases.’
20. There is no sign of a more serious level two injustice, which ‘will typically arise when what has gone wrong has had a relatively low impact on the person affected and will often result in a degree of distress, inconvenience or minor pain. This could also include instances where an injustice was more serious but only took place once or was of short duration.’ In this case, the injustice to Mrs M and her family was frustration and worry. But as there were no other adverse effects or ongoing wider impact, and the impact was not serious, it does not meet the criteria for a level two injustice.
21. Our ‘Principles for Remedy’ say: ‘Putting things right where poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If, as in this case, that is not possible, an appropriate range of remedies will include: • an apology, explanation and acknowledgement of responsibility • remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these.’
22. In this case, we know the Trust has accepted and apologised for its failings in relation to the family visit in August. It has also shown how it has learned from the complaint and made service improvements in relation to the unacceptable temperature of the food given to Mr L.
23. We feel, in terms of remedying the distress caused by the Trust’s failings that day, the Trust’s apology and the service improvements it has made in response to this part of the complaint, are enough to put things right. So, there is no injustice that has not been put right.
Dehydration
24. Mrs M says at Hospital A, her father twice showed signs of dehydration. The first time was on the day of the family visit in August 2020, as discussed above. Mrs M says when her father was brought into the garden to see them, she noticed he could not hold a cup properly, so she asked staff for a beaker for him. Staff brought one out and Mr L drank four full cups of water and juice. Mrs M says she suspects drinks were left out of his reach.
25. She says the second time was two days later, when Mrs M called the ward and the nurse said her father was unsettled, agitated and aggressive, and they were considering sedating him. Mrs M said she objected to him being sedated and asked if she could come in to see him instead. Staff agreed to this, so her and her sister went in and found her father very disorientated, confused and clearly unwell which she found upsetting. They asked staff for a beaker for fluids again, which he drank. After a couple of hours, Mr L was still unsettled and hallucinating, so they agreed to let staff sedate him to allow his body to rest. She says it was very distressing and worrying to think her father may not have had enough fluids.
26. The Trust says tests carried out by Mr L’s consultant during his admission did not show any evidence of dehydration. It said although Mr L was able to swallow, he was not eating well due to his dementia and his fluid was supplemented with intravenous fluids which meant he had an average of 2,000ml per day. The Trust explained how his food intake had decreased greatly in line with his dementia and he was refusing meals and needed a lot of encouragement to eat. We know this would lower his fluid intake too, as fluid comes from our food intake, not just through drinks.
27. We have reviewed the clinical records and cannot see any references to dehydration. As discussed above, when the family visited for their father’s birthday in August 2020, we know from Mrs M it was a hot summer’s day, and it took staff an hour and a half to bring him out. So, whatever the reason for that delay, this is perhaps why Mr L was then, naturally thirsty. Two days later, we know from Mrs M that her father took a drink readily when she offered it, but this was during a period of extreme agitation and aggression which may have exacerbated his thirst.
28. It would no doubt have caused worry and concern for Mrs M and her family to think Mr L may not have got enough fluids. They were already disturbed at the deterioration they saw in their father when he came out to the garden and then seeing him agitated and confused a couple of days later would have been very worrying and upsetting for them.
29. The impact of their concern about their father being dehydrated would be level one on our ‘Severity of Injustice Scale’, as, again, a case will generally be level one ‘if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases’.
30. In this case, both incidents were of short duration. If Mr L were dehydrated on either of these occasions, the injustice for Mr L was for very limited periods, and on both occasions, his thirst was quickly relieved. This level of injustice was not so serious as to fit with level two of our ‘Severity of Injustice Scale’, and in this case would not warrant financial compensation. As the Trust has given explanations and an apology, we consider the Trust has adequately resolved this matter.
Wrong milk given
31. Mrs M says at Hospital A her father was given dairy milk despite her telling the emergency department staff he only drank soya milk. She has told us her father was not allergic to dairy milk, but he did prefer it and she says she told the nurse that drinking dairy milk could cause him to have diarrhoea and discomfort.
32. Mrs M says the family were angry the information about him needing soya milk was not put on his notes for the ward. She says, Mr L did have a few cases of diarrhoea while in Hospital A, which might not seem too serious, but it is very undignified for the patient and could have been avoided if the information had been put on his records. She questions what would have happened if a patient had a serious allergy to dairy, and this had not been written on their notes.
33. The Trust says at Hospital A, Mr L had a very poor appetite due to his multiple underlying medical conditions and dementia. It says the preference for dairy milk was noted at the emergency department, but that particular information was not included in the handover documentation to the ward. It apologised for this and said the team was now taking steps to improve the admission documentation which is completed after admissions to the ward. This will involve ward staff contacting the families of any confused patients to establish their preferences.
34. We have reviewed the clinical notes, and there is no record of Mr L experiencing any reaction to drinking dairy milk. We understand Mrs M’s concerns about patients with severe allergies, but we cannot consider what might have happened to someone else who may have had a serious allergy. We can only look at what did happen in this case, not what might have otherwise happened.
35. We do recognise it would have been upsetting for Mr L’s family to think their father was not getting his preferred choice of milk, especially when he was already eating very poorly and intermittently. But again, for the reasons discussed above, this injustice would not exceed level one on our ‘Severity of Injustice Scale’, where an apology is usually enough. It is also in line with our ‘Principles for Remedy’. This is because the Trust has already accepted responsibility for this service failure, apologised for it, and has also committed to making service improvements to avoid this happening again. We consider this to be a sufficient way of remedying the impact of its service failure.
Insufficient physiotherapy
36. Mrs M says her father should have had more physiotherapy treatment while in Hospital A. She says before his admission, Mr L had been independent, living in his own flat. He did not have any paid carers, just regular family visits. She says he deteriorated quickly after his admission. She blames this on not enough physiotherapy, and she says she had been told by the Trust he would receive ‘intense physio’.
37. She says the family feel let down that Mr L did not receive daily treatment from the physiotherapy team when they had been informed he would. She says there were no obvious reasons why he could not walk, for example, there were no broken bones, so if Mr L had received more physiotherapy his mobility may have improved. Before being admitted to hospital, he was frequently out and about in the village where he lived, so for him to decline so fast and have no mobility at all in ten days, was alarming for the family. Mrs M told us the family felt he would not be able to go back to his own home, and that the thought of this was devastating.
38. The Trust has said an integrated referral for physiotherapy and occupational therapy was received for Mr L two days after his admittance. It said a physiotherapist contacted Mr L’s next of kin that day for a pre-admission history. From then until his discharge, Mr L was reviewed eight times by the therapy team. The Trust has apologised to the family, that in a meeting with the medical team in August 2020, the family were wrongly told Mr L would be seen by physiotherapists every day. It apologised that this information was incorrect, and the family should not have been told that. It said it recognised the confusion and frustration this caused and apologised for its communication error.
39. Having reviewed the clinical records for this period, we have seen the records for these eight reviews. The daily records describe how difficult and risky it was to mobilise Mr L, due to his lack of balance, and so it was considered best not to mobilise him. The plan was to increase his mobility using a Zimmer frame. But he was sometimes too confused when the therapists attended, so this was often not possible. His balance and confusion deteriorated each time. He was sometimes too tired to do physiotherapy and the plan was to consider residential rehabilitation once he was medically fit for discharge. We can see that during these sessions, Mr L’s sitting balance, standing and stepping were reviewed and practiced. His mobility was limited by his reduced balance, both in sitting and standing, along with an increase in his confusion.
40. We can understand how it would have been frustrating and confusing for Mrs M and her family, as they had been misinformed and were expecting daily therapy. We know they were very distressed at their father’s deterioration and were likely expecting faster progress with the physiotherapy. The complaint is about how often Mr L was seen, but this was based on receiving wrong information in the first place and the family’s expectations should have been better managed. If the family had been told physiotherapy was more likely to be every second or third day, then they would not have suffered such confusion and frustration. So, we can see there was an injustice to Mrs M’s family.
41. This level of injustice fits with the criteria for a level one injustice on our ‘Severity of Injustice Scale’. As explained above, a case is level one where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. In this case, the failing was caused by a miscommunication which led to misleading expectations by the family. When an error has led to a level one injustice, we will usually consider an apology to be an appropriate remedy. In this case, the Trust has apologised and accepted its service failure.
Staff were rude and unhelpful
42. Mrs M says when Mr L was admitted to Hospital B, she found the staff unhelpful, unprofessional and rude, and the family felt they were being ‘fobbed off’ with false information about whether COVID-19 tests had been done. She says, once, when she called the ward, staff even told her they did not think they had a patient with her father’s name on that ward. She says at the time, this was their only way of finding out how their father was, what his condition was and so on. They were upset and frustrated about the attitude of some of the staff when they called. She says to be spoken to like that was disgraceful.
43. The Trust says the ward manager apologised for Mrs M’s experience. It said this is not the standard it would expect and is not in keeping with the Trust’s values, which focus on taking personal responsibility and being caring and compassionate. It said Mrs M’s concerns have been raised with the relevant staff who have given assurance it was not their intention to be unprofessional in any way and how they were very sorry for the upset this had caused Mrs M and her family.
44. The Trust also says, in relation to the information about Mr L’s COVID-19 tests, the ward manager had explained that Mr L did have two COVID-19 tests during his admission. Although the first test was negative, the second test was positive for COVID-19. But it said no test is perfect and the COVID-19 tests will miss some cases.
45. The Trust also says Mr L’s chest X-ray, taken on his admission in October 2020, was consistent with COVID-19 infection and this was considered to be a likely diagnosis throughout his admission. It also explained that due to his confusion on admission, resulting from him being unwell, it had not been possible to safely obtain a swab on his first day in hospital. Regarding the family being told by staff they were not sure they had a patient of that name on the ward, the Trust said it was sorry this happened, and there was nothing in the notes about this telephone call.
46. We can see from the clinical records, there is no reference to this telephone conversation taking place. We do not doubt it happened, but we accept it is not something that would always be documented. It is understandable that without knowing which staff member took the call, it is difficult to do anything other than apologise. The mistake was put right very quickly, as we understand from Mrs M the staff member did, in the same call, find Mr L was on the ward list after all.
47. In relation to staff attitude more generally, this is always very difficult to evidence in any meaningful way, especially so long after the event. The Trust has apologised and accepted it is not in line with its organisational aims. The family would undoubtedly have been left feeling cross, frustrated and worried about Mr L. Unpleasant though that would have been, it most accurately fits with the criteria for a level one injustice. This is because the effect on Mrs M was of short duration, and there were no other adverse effects or ongoing wider impact. So, we will usually consider an apology to be an appropriate remedy for these cases. For this reason, we consider the Trust’s apology is enough to remedy the impact caused by its poor communication.
Hearing aids
48. Mrs M says she had given staff her father’s hearing aids but found they were not given to him. She says he needed them to communicate with staff and they had been specifically brought to the ward to help him stay calm. She says surely this should be part of basic care for all patients. She says Mr L would not have been able to understand what was happening or being said to him, causing him a great deal of frustration. Mrs M says they were extremely angry about this as such a simple thing would have made a big difference to him and his stay in hospital. She says they were very upset and frustrated to find out his hearing aids had sat in an envelope on the sister’s desk.
49. The Trust says there was no evidence in the medical records about issues with Mr L’s hearing and the ward manager was very sorry Mr L’s hearing aids were not used to help him communicate and feel calm. It says, with Mrs M’s permission, they would share this with staff as a way to improve their understanding of how their actions can affect the patient and their loved ones. It also says Mrs M’s experiences was a timely reminder to staff about the importance of making sure they are always fully aware of a patient’s needs and, where necessary, using the hospital ‘passport system’, which outlines any needs or requirements for patients.
50. We do recognise it would have been most frustrating to find out Mr L’s hearing aids had not been used. The level of injustice here is hard to gauge, especially in how it might have impacted Mr L. Although we understand he was not totally deaf, he was ‘hard of hearing’, which is not unusual in an elderly patient. On a hospital ward, where there can sometimes be a lot of background noise, it could understandably have been difficult for Mr L to hear things properly.
51. We can see the injustice this may have caused him, and we recognise his family were undoubtedly worried and frustrated about this. Overall, however, the impact of this particular part of the complaint would again only be level one of our ‘Severity of Injustice Scale’, as there is no evidence of any other adverse effects or ongoing wider impact of this failure. As the Trust has apologised, and appears to have taken learnings from this complaint, we are satisfied this is an adequate and proportionate response in terms of putting things right.
Visiting restrictions
52. Mrs M says the family were not allowed to visit their father while he was in hospital, even though the Trust’s Policy says if a patient has dementia, family can visit. She says they had not been aware of their father’s dementia, but as the Trust said this was the case, then surely they should have been allowed to visit him. She says there were posters up around the ward saying patients with dementia could have a visitor. She says the impact of not being able to visit him while he was in hospital was devastating and she says Mr L would have felt abandoned by the family, which was very distressing for them.
53. The Trust told Mrs M, in its complaint response dated April 2021: ‘You have asked why when your father had dementia, we were not allowing you to see them as your posters say in that situation, visiting is encouraged. At the time of your father's admission, we were only allowing visitors for patients at the end of life.’
54. The Trust’s policy says: ‘In response to increased community and hospital COVID-19 cases nosocomial spread, visiting in adult inpatient areas has ceased with the exception of the aarrangements for compassionate visiting, which remain in place. For compassionate visiting, visitors will be requested to provide evidence of a negative lateral flow COVID-19 swab.’
55. But it also says: ‘For patients with additional care and support needs, one nominated person from the patient’s immediate family or support bubble can undertake extended visiting (extended visiting refers to the carer attending in person and for a period of time agreed by the clinical staff, acting in the best interest of the patient and family/relative). The nominated person should “normally” provide care and support to the patient in the family/patient’s home and/or the patient is likely to be distressed if the family member/carer is not present. This would include but is not limited to for example… an elderly patient with dementia who is becoming distressed/agitated/upset if his wife isn’t present to hold his hand and comfort him in the unfamiliar surroundings.’
56. We asked the Trust about the discrepancy between its policy and its complaint response during our investigation. The Trust said, ‘On further review of this case, it is clear that at no time did we stop compassionate visiting for patients with additional support needs and this included dementia patients. However, the list of exceptions was not exhaustive, and it was down to the clinical team’s discretion. Based on these findings, we acknowledge that incorrect information was provided in the complaint response as this showed the Trust was only allowing visiting for end of life and offer our apologies for the confusion caused.’ The Trust asked us to convey its apologies to Mrs M for the error in its complaint response.
57. In terms of whether it would have been appropriate for the Trust to allow a visit by Mrs M or another family member during this admittance, this was specifically for instances when a patient with dementia was distressed or agitated, and the familiarity of a close family member might have helped to calm the dementia patient. We know in mid-August 2020, when Mrs M was allowed to visit Mr L at Hospital A, this was done to help calm him down, as he had become unsettled, agitated and aggressive. This was an example of how the Trust applied this exception on that occasion.
58. We have reviewed the medical records for Mr L and have found no more episodes of agitation. Instead, the daily records for this period show Mr L was consistently recorded as being ‘settled’, ‘appears to be asleep’, ‘resting in bed’ and ‘no concerns’. So, we are content that although the Trust can use its discretion to set aside COVID-19 visiting restrictions when needing to help calm a dementia patient, in this case, there were no other episodes of agitation or aggression when it might have been appropriate for the Trust to do so.
59. Although the Trust did make a mistake in its complaint response, it has explained and apologised for this. Its decision not to set aside its COVID-19 visiting restrictions was in line with the Trust’s policy. Although this error would have been confusing and frustrating for Mrs M and her family, the level of injustice this caused is no more severe than level one on our ‘Severity of Injustice Scale’. As explained above, level one injustice includes cases where ‘we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact.’
60. For this level of injustice, we usually consider an apology to be appropriate. As the Trust has apologised for its inaccurate complaint response, we are satisfied this is enough to put right its communication error. We hope Mrs M can take some comfort from knowing her father was restful and often sleeping throughout this period, and was not showing any signs of distress at all.
The day of Mr L’s death
61. Mrs M says even when Mr L was felt to be approaching the end of his life, staff still did not tell the family in time for them to see him before he died. She said they have to try and move on with their lives knowing in the final days of his life, his care was taken out of their hands, making it a very worrying and distressing time for them.
62. She says her father must have felt they had abandoned him when he needed them most. She also says when they did arrive on the ward after his death, Mr L had not even been moved to a side room and was still in the COVID-19 bay. Mrs M asks why they were allowed to visit him after he had passed away, but not when he was alive. She says she and her family feel there was no care or compassion towards them at this very difficult time.
63. The Trust has said the nursing team was told of the positive COVID-19 result on the afternoon of the day he died, which meant Mr L had to be moved to a red bay (for COVID-19 positive patients). It said unfortunately, at the time the ward had several poorly patients, including Mr L, and they had to be prioritised. Unfortunately, because of these pressures, staff were unable to contact the family before Mr L deteriorated very quickly and sadly passed away that evening. The Trust said: ‘We do acknowledge that there was a missed opportunity for the medical team to provide regular updates regarding your father’s condition, particularly after he tested positive for COVID-19.’ It apologised for the distress caused by these circumstances.
64. Regarding Mr L not being moved out of the COVID-19 bay after his death, the Trust said the ward sister apologised that on this occasion it was not possible to move Mr L to a side room after he passed away. It said, this is something the team always aims to do to maintain the patient’s dignity and offer the family privacy. The Trust was only able to allow relatives of patients who were considered to be end of life and Mr L was not considered to be end of life at that time. So, staff had not anticipated the need for a side room. Also, the influx of COVID-19 patients at the time meant these rooms were being used to isolate COVID-19 positive patients to reduce the risk of the spread of infection. The Trust said it recognised the distress this had caused, particularly knowing in hindsight Mr L deteriorated very quickly.
65. We know from the Trust this was a particularly busy day on the ward. We have also considered the government’s national and local COVID-19 statistics for this period (coronavirus UK data). We can see at this time, during the ‘second wave’ of COVID-19, this was when COVID-19 admissions were rising steeply, very quickly. For example, at the start of October 2020, there were only two admissions. The daily average then more than doubled and on the day he died later that month, there were 12 COVID-19 positive admissions. This was consistent with the national average at the time which was also rising steeply in October 2020. As we are aware from our experience investigating complaints about COVID-19 more widely, this would also have meant increasing numbers of hospital staff with COVID-19 also being unable to work.
66. We recognise the sense of injustice the family feel at not being able to see their father before his death, as this is very deep and personal. It was very sad, as this meant they did not have the chance to say goodbye to him, as they would have liked to do. The difficulty is that although Mr L was already very unwell, his deterioration on the day he died was very fast, and so the Trust had not anticipated his death at the time. This is unfortunate as had they foreseen it and planned ahead, they could have allowed two visitors and they could have made sure a side room was provided for him. But it is not always possible to know how soon someone is likely to die, and so this does sometimes happen. This can often be heartbreaking for the family, but is something that sadly, is not always avoidable. Although we can see there was not enough time and opportunity to let Mr L’s family know in time to see him and prepare them for his death, we recognise this did cause them injustice.
67. The injustice caused by the Trust’s failure to inform the family in time for them to visit their father before his death is therefore more serious than level one on our ‘Severity of Injustice Scale’. But we do not think it exceeds level two. This is because a level two injustice includes cases that result in a degree of distress, inconvenience or minor pain. This could also include instances where an injustice was more serious but only took place once or was of short duration. In this case, the delay in updating the family about their father’s condition on the day he died was over a matter of hours. Although there was a loss of opportunity to say goodbye to Mr L, this is not so serious an injustice to be level three on our ‘Severity of Injustice Scale’. For a case to be level three, the impact would usually have been experienced over a significant period of time. A case may also be level three if the impact on the person affected was significant but was only experienced for a short period of time.
68. We do not doubt that the feelings of upset and anger would have continued long after the day of Mr L’s death. But it would always be difficult to separate the loss of opportunity to say goodbye, from the natural feelings of loss and grief the family would have no doubt felt. In this case, this was about what happened over a fairly short period. We recognise it is more difficult to measure the impact of something that did not happen rather than something that did happen. But, having weighed this up carefully, we have concluded the degree of distress caused fits more appropriately with level two on our ‘Severity of Injustice Scale’. As the Trust has already given explanations and an apology, we consider this to be enough to remedy this level of injustice. So, there is nothing more we would ask of the Trust in relation to this aspect of the complaint as the injustice has already been put right.
69. We can see Mrs M and her family went through a very difficult and distressing time when they lost Mr L. This was undoubtedly made far more difficult by the impact of the national restrictions to hospital patient visiting during the COVID-19 pandemic. We also know Mr L’s death was a shock for the family, because before his admission, Mr L lived independently in his own flat, using his mobility scooter to get out and about socially. This must have made his sudden deterioration after contracting COVID-19 even more devastating. We do understand why Mrs M brought her complaint to us and would like to assure her that we have taken her complaint seriously. We are grateful to her for bringing this matter to our attention and hope she can see we have considered it very carefully.