Manchester University NHS Foundation Trust

4. Ms G complains that when Mr K was in one of the Trust’s care homes (the Care Home) in 2020:

• the Trust did not make sure Mr K was wearing leg and palm splints and this limited his range of movement • the Trust caused a four-day delay in Mr K receiving Difflam spray prescribed to him • the Trust did not notice Mr K’s weight loss, treat it or find out what had caused it, and Ms G is concerned the Trust may not have run Mr K’s percutaneous endoscopic gastrostomy (PEG) feed • the Trust did not provide appropriate mouth care, which Ms G says caused distress to Mr K and resulted in his tongue becoming fused to his bottom teeth, black scabs forming in his mouth and throat, and his tongue becoming dry, split and cracked • the Trust delayed arranging hospital treatment for Mr K’s aspiration pneumonia until he became critically ill, and • the nurse who handed him over to ambulance staff in May 2020 wrongly said he had had a cough for two days when he had only had a high temperature and Ms G believes they wanted to give the impression he had COVID-19.

5. Ms G believes Mr K would not have died if he had been taken to hospital sooner. She says his death has had a significant impact on her and her family’s mental health. Ms G also does not believe the Trust has completed the actions it planned to improve its service.

6. Ms G would like the Trust to acknowledge there were failings in the care Mr K received. She would like the Care Quality Commission to carry out an unannounced inspection of the Care Home. She feels this will help prevent other residents having a similar experience to her son’s. She also says the staff working there should not be allowed to work in the care sector.

7. Mr K had been under the care of another hospital trust but was discharged in April 2020 due to the COVID-19 pandemic. Ms G is not complaining about that organisation so we have not looked at its actions. We understand it weighed Mr K on 8 April 2020 and his weight was 76.4kg. We refer to this for context as it is relevant to the complaint.

8. Mr K was unable to care for himself independently. He had a brain injury and was unable to communicate when he needed assistance. He had to wear palm and leg splints (used for support and to keep joints in place). Mr K was fed through a PEG tube, directly into his stomach.

9. The Trust admitted Mr K to the Care Home, which provides nursing care to people who are highly dependent. On 8 May, the Trust contacted the out-of-hours GP service responsible for Mr K’s care when it observed he was unwell. It started Mr K on antibiotics because he appeared to have a lower respiratory tract (chest) infection.

10. The Trust prescribed Difflam spray (used to treat painful conditions of the mouth and throat) on 12 May but did not order this until 14 May. It received the medication on 15 May.

11. Around this time, the Trust carried out blood tests which showed Mr K’s sodium levels were high. On 19 May 2020, it contacted the out-of-hours GP service, which advised the Trust that Mr K needed to go to hospital urgently. The Trust called an ambulance, which took Mr K to a hospital which is also part of the Trust.

12. Sadly, Mr K died in hospital shortly after this. Ms G has no concerns about the care at the hospital. She complained to the Trust about the care the Care Home provided. Ms G was unhappy with the response she received in September 2020 so the Trust sent her another response in February 2021.

13. In its responses, the Trust identified several action points to improve its service. Ms G brought her complaint to us as she felt the Trust’s responses were not good enough.

17. Before we decide if we should investigate a complaint in detail, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We appreciate addressing a complaint does not change the situation a complainant or their loved one has experienced.

18. Our ‘Principles of Good Complaint Handling’ say organisations should acknowledge mistakes and apologise where appropriate. They should use all feedback and the lessons learned from complaints to improve their service. Having considered this, our view is the Trust has already done enough to address issues around Mr K’s splints, Difflam spray and oral care.

Leg and palm splints 19. Ms G complained Mr K did not have splints in place when he was transferred to hospital. She is concerned about whether the Trust had been applying the splints because there was no clear documentation about this.

20. Section 10 of NMC’s ‘The Code’ provides guidance on record keeping. It says nurses must keep clear and accurate records relevant to their practice.

21. The Trust said staff were aware Mr K needed to wear palm and leg splints. It said its records show they were in place at times during his stay but this was not documented consistently or within a care plan. We recognise this will leave Ms G with uncertainty about whether her son received the care he should have.

22. The Trust acknowledged it is good practice to have plans of care which make it clear when splints need to be applied and for how long. It said it has developed a document which records patient splints as part of their care plans. It has also referred all patients who wear splints to the community therapy team to have their splint regimes reviewed and updated.

23. As we have explained earlier in this statement, we expect organisations to acknowledge when things have gone wrong and take action to stop them happening again. This is what the Trust has done. While we appreciate this does not change what happened to Mr K, we have decided not to consider this part of the complaint further.

Difflam spray 24. Ms G questioned why there was a four-day delay in providing this medication to Mr K and why the Trust did not try to get it from a local pharmacy. The Trust explained the prescription charts at the Care Home are not legally held at a community pharmacy. The pharmacy at one of its hospitals supplies all its medications.

25. Our ‘Principles of Good Administration’ say organisations should provide effective services. When mistakes happen, they should put things right quickly and effectively. The Trust said its records show it planned to order the medication on 12 May but due to human error, it did not do so. It is clear something went wrong here.

26. We can see the Trust took action when it identified the issue on 14 May. It placed an order on its system and received the medication as part of the next delivery, which arrived the following day. This was in line with our ‘Principles of Good Administration’.

27. The Trust apologised on behalf of the pharmacy team for the delay in getting the Difflam spray and referred to the recommendations Ms G’s complaint had prompted. It explained it had changed its system so that staff no longer write down orders to input at the end of ward rounds and instead have access to a laptop in patient areas. There is also an extra afternoon pharmacy delivery.

28. The Trust appears to have taken appropriate action to address the issues which caused the delay Mr K experienced. We consider it has acted in line with our ‘Principles of Good Complaint Handling’ by acknowledging what happened and apologising for this. This is why we are not taking further action in relation to this.

Oral care 29. The NICE guideline on ‘Oral health for adults in care homes (NG48)’ says managers should ensure care staff give residents daily support to meet their mouth care needs and preferences, as set out in their personal care plan after their assessment.

30. Ms G says the state of her son’s mouth shows he did not receive appropriate mouth care. The Trust said it initially identified in Mr K’s care plan that he needed mouth care at least twice a day and ideally more frequently as he was nil by mouth. It acknowledged there was no evidence in his clinical records that this had happened.

31. The Trust said the inside of Mr K’s mouth showed visible evidence of not being clean enough. It acknowledged that the mouth care its documents show Mr K had received does not appear to have been effective. The Trust apologised for not carrying out mouth care more frequently.

32. After Ms G’s complaint, the Trust made sure all staff completed the national e-Iearning training devised by the national Mouth Care Matters education programme. We understand this was not available when Mr K was at the Trust. We consider this appropriate action in the circumstances and hope it will improve the service the Trust provides.

Weight loss 33. Before we decide if we should investigate a complaint in detail, 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.

34. We also look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. We have done this and have not found any signs something has gone wrong in the way Ms G describes. This means we cannot link the events complained about with the clinical impact she believes they had.

35. The Trust’s ‘Adult Nutrition Screening Policy’ says patients who are admitted to hospital or a bed-based unit should be weighed within 24 hours of admission. It acknowledged this did not happen for Mr K. It also said there were gaps in the information shared between the community nutrition team and the Care Home about Mr K’s weight when he was transferred.

36. Ms G says the Trust did not identify or address Mr K’s weight loss. She has described him as being ‘skeletal’, which we recognise must have been very concerning to see. According to the NHS, for most adults, an ideal body mass index (BMI, a measure that uses your height and weight to work out if your weight is healthy) is in the 18.5 to 24.9 range.

37. Mr K was admitted to the Care Home on 16 April. The records indicate the Trust weighed him on 19 April but there are no entries showing his weight until 20 April. At that point, he weighed 68.2kg, meaning his BMI was 21.

38. On 24 April, Mr K’s BMI had increased to 21.4, as he weighed 69.2kg. On 11 May, the Trust recorded Mr K’s weight as 64.4kg, so his BMI was 20.1. On 13 May, Mr K’s BMI was 20.2 as he weighed 65.6kg. Throughout this time, Mr K’s BMI was within the healthy range.

39. We recognise Ms G may still be concerned her son was not fed as he should have been. The Trust’s records show it gave Mr K his feed. There were occasions where Mr K’s PEG feed had to be stopped because he was vomiting. The Trust got advice from its dietician and medical team when it was needed and took appropriate action.

40. We hope this reassures Ms G and explains why we are not considering this part of the complaint further.

Escalation and handover 41. Ms G says that when Mr K was suffering from aspiration pneumonia, the Trust delayed arranging hospital treatment until he became critically ill. Aspiration pneumonia is an infection from germs (present in body fluid or matter) that have leaked into the lungs from the stomach or mouth.

42. Our adviser said that when the Trust found Mr K had a temperature on the evening of 8 May, it gave him paracetamol and carried out regular observations. Mr K’s temperature settled after this and the Trust also gave him fluids and antibiotics after seeking medical advice. It suspected he had a lower respiratory tract infection at that time.

43. Ms G feels it was clear her son needed to be in hospital sooner. Patient.info explains that a cough is the key feature of aspiration pneumonia. Early symptoms can also include feeling generally unwell, with a high temperature (fever), headache, sickness (vomiting) and muscle aches.

44. We have seen no indication there were signs Mr K needed hospital treatment until 19 May. That was when a doctor said he needed urgent treatment because the results of a blood test showed his blood sodium was very high.

45. We considered Ms G’s concerns about the information given to the ambulance crew. According to the NHS website, a high temperature is usually considered to be 38°C or above. The Trust said the ambulance crew documented Mr K’s temperature as 37.4°C. We have seen no evidence to suggest Trust staff told the ambulance crew Mr K had been coughing.

46. We recognise this does not match Ms G’s account. Based on the information available to us, we are unable to conclude the Trust deliberately misled the ambulance crew or that this affected the care Mr K received. This is why we are not looking into this part of the complaint further.

47. We would like to thank Ms G for asking us to consider her concerns and we offer our condolences for her loss. Overall, we have decided not to investigate Ms G’s complaint further. Where there were issues, the Trust appears to have learned from them and made changes to stop them happening again.

1. The Parliamentary and Health Service Ombudsman has carefully considered Ms G’s complaint about Manchester University NHS Foundation Trust (the Trust). We understand why she has concerns about the care her son, Mr K, received before he died. We are very sorry for her loss.

2. The Trust has already acknowledged there were things it should have done differently. We think it has taken appropriate action to address these issues. Although we recognise this does not change Ms G’s experience, it shows the Trust has learned from what happened. This is why we are not taking further action.

3. We have seen no sign anything went seriously wrong in relation to Ms G’s concerns about Mr K’s weight loss and the escalation of his treatment. We have explained our reasons in this statement, which we hope will reassure her.