The care home
17. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and we have not seen any sign that something has gone wrong.
Deprivation of liberty
18. Mrs A and Mrs K are concerned their father wanted to leave the home but could not. They feel it was wrong for him to be taken to hospital, particularly without contacting his family.
19. In its response to the complaint, the care home said ‘a patient does not have to be under a Deprivation of Liberty in order to be taken to hospital this is done in their best interests and is no deprivation’. Our nursing adviser said this is correct.
20. DoLS should always be viewed of as a ‘last resort’. As reflected in the Mental Capacity Act, DoLS should only be applied when a person, aged 16 or above, lacks the mental capacity to consent to their own treatment and needs to be deprived of their liberty to get care or treatment.
21. The Mental Capacity Act sets out principles that underpin the legal requirements:
• ‘Principle 4: If a person has been assessed as lacking capacity then any action taken, or any decision made for, or on behalf of that person, must be made in his or her best interests • Principle 6: Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.’
22. Our adviser explained Mr B did not need DoLS to allow his treatment and a less restrictive ‘best interests’ decision was made. This is in line with Principles 6 and 4 of the Mental Capacity Act. Our adviser explained the person who has to make the decision is known as the ‘decision-maker’ and normally will be the carer responsible for the day-to-day care (in this instance, the care home nurse who was caring for Mr B).
23. The Mental Capacity Act allows restraint and restrictions to be used but only if they are in a person’s best interests. Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are called the Deprivation of Liberty Safeguards.
24. Mrs A and Mrs K gave evidence to support their view that the care home did not follow the correct process. This has not changed our decision. Mr B was not deprived of his liberty. He did not need to be physically or chemically restrained to allow care to be given and he was reassured when in distress.
Communication
25. We understand Mr B’s family are concerned he had asked to go home and the care home did not act on this or tell them. Mr B was completely dependent on staff for his care and it was thought to be necessary for him to stay in the care home.
26. We have seen entries in the records from 8 February 2021 that show he was ‘talking about going home’ and ‘calling out to his daughter’ to ‘please come and help me’. We can see he missed his family but he was not held against his will. Our adviser explained it was in his best interests to stay at the care home.
27. Mr B did not want to be assessed by the paramedics but the records do not show that he refused to go to hospital. Our adviser explained it was appropriate for staff to offer reassurance, which they did. If there was any escalation, Mr B’s family could be contacted to offer more reassurance. The records do not show this was needed.
28. We appreciate the family feel differently and are unhappy about the care home’s communication before Mr B was taken to hospital.
29. The care home’s response said ‘We would not contact Next of Kin in these emergency time sensitive medical situations for their view or advice, this is a clinical decision based on the findings of the nurses and paramedics, any decision not to send someone to hospital would be focused around a pre-arranged best interest decision and an end of life diagnosis.’
30. Our adviser explained when a best interests decision is made, it is made by the decision-maker who was the nurse. In an emergency, the nurse would follow the advice received from 111 (who the nurse had originally phoned and they advised to get an ambulance) and the paramedics (who are skilled in assessing an acutely unwell patient).
31. In line with the Mental Capacity Act, consent from the family is not needed but they do need to be contacted. Based on the information we have seen, the decision to transfer to hospital was made in Mr B’s best interests and the family were informed. There is no sign of a failing with these actions.
Not accompanied to hospital
32. The family are concerned no care home staff accompanied Mr B to hospital. Our adviser explained there is no requirement to accompany a care home resident during transfer from the home to hospital. Their care is handed over to paramedics.
33. This is in line with section 8 of the NMC Code which says nurses must work cooperatively and advises on sharing care between teams. Sections 8.1, 8.3, 8.5 and 8.6 in particular say nurses must respect the skills, expertise and contributions of colleagues and keep them informed when sharing care. They must work together and share information to identify and reduce risk.
34. We have not identified any failing in relation to this or the other aspects of the complaint about Mr B’s care at the care home. We know the family are concerned about what happened so we hope we have clearly explained our decision.
The Trust
Decision to admit Mr B to hospital
35. Mrs A and Mrs K are concerned the Trust decided to admit Mr B to hospital. Our ED adviser explained the relevant guidance is the GMC ‘Good medical practice’. Point 15 says doctors must provide a good standard of practice and care.
36. This means if they assess, diagnose or treat patients, doctors must:
‘a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs.’
37. The records show this is what happened. The doctor recorded a history of Mr B’s presentation, examined him, arranged investigations and referred him for admission. This was in line with the GMC guidance.
38. The Trust’s records say Mr B had been found on the floor the night before and that staff in his care facility had noted he was non-communicative and had a high temperature.
It recorded that Mr B did normally communicate but that he was not communicative when he was assessed in the ED.
39. The Trust’s observations show Mr B had an increased respiratory rate of 30 (normal breathing rate is 12-20 per minute), he had a slightly raised temperature of 37.5 degrees and his oxygen saturations were slightly low at 94% (normal saturations are above 95%).
40. In addition to Mr B’s altered behaviour and the high temperature the ambulance staff had recorded earlier, the Trust also documented abnormal observations and blood test results. A venous blood gas test (a blood test used to identify any initial signs of serious illness) taken at 7.22am in the ED showed a raised lactate level (lactic acid is produced by the body in serious illnesses such as sepsis).
41. Two markers of infection and/or inflammation were also raised in Mr B’s blood test results. There was a raise in his white cell count at 15 (the normal range is four to ten. White blood cells are released into the blood in infection or inflammation) and his CRP level was raised (C-reactive protein – a substance released into the blood in infection or inflammation). A chest X-ray ordered by the ED doctor was later noted to show evidence of infection in the right lung.
42. These were all signs that Mr B was physically unwell when assessed in the ED. Given the information the ED doctor had, their findings on examination and the abnormal observations and blood test results, the decision to refer Mr B for admission was justifiable and the safe thing to do.
43. Our adviser said it is important to note that it is not uncommon for an initial examination of a patient’s chest not to identify signs of an abnormality. When examining a patient, a doctor relies on the cooperation of the patient in taking deep breaths allowing the lungs to be heard clearly.
44. In confused or uncooperative patients this may not happen, and an abnormality may not be identified. In this situation, and when there are other signs of a possible respiratory problem (such as raised respiratory rate and low oxygen saturations), it is common practice for a chest X-ray to be ordered, which may show an infection or other problem.
45. As we have explained, there is no evidence that it was safe to discharge Mr B at the time he was assessed. This is why we have not seen any sign of a failing in the decision to admit him to hospital.
Placement on COVID-19 ward
46. The family are concerned the Trust inappropriately put Mr B on a COVID-19 ward. They say he had a recent history of COVID-19, and tested negative on a lateral flow test but positive on a PCR test.
47. PCR tests are more sensitive than lateral flow tests. Our physician adviser explained that with Mr B’s recent history of COVID-19, it would have been relatively safe for him to be put with other patients who tested positive because he would have had a degree of immunity. By comparison, it would not have been safe for him to be on a ward with patients who had tested negative.
48. The decision about where to put a patient is made by the hospital bed manager. During the COVID-19 pandemic, Trusts produced local versions of guidance to reflect their circumstances.
49. This situation is not specifically included in the policy supplied, but according to the policy a swab positive patient would be managed in a red (COVID positive) area. Taking this into account, the Trust acted in line with its policy and we have not seen any sign of a failing in this.
Oral care
50. The family are concerned the Trust did not provide oral care to Mr B and say he developed oral thrush and ulcers. The records show he needed assistance in all areas of care and would have needed help managing his oral hygiene. Mouthcare is seen as an essential aspect of care in the Department of Health’s ‘Essence of care’.
51. Before we decide if we should investigate a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have done this and we have decided the Trust has already done enough to address what happened.
52. Section 1.2 of the NMC Code says nurses must make sure they deliver the basics of care effectively. Regular mouthcare is a basic part of care and the Trust’s local guidance is reflected in its oral hygiene documentation. In line with this and the NMC Code, the Trust should have assessed Mr B’s nursing needs on admission to hospital and a mouthcare plan should have been made.
53. The records show Mr B’s mouth was assessed on 13, 15, 16, 17, 18 and 20 February. The action from the assessments was to ‘clean daily’. Mr B’s mouth is documented as being cleaned on 16, 17, 18, 20 and 21 February. There were five days when he did not receive mouth care (not including the day he was discharged).
54. In summary, the Trust did appropriately assess Mr B’s oral hygiene needs but it did not deliver oral care daily. This should have happened in line with its own oral hygiene care plan so there is a sign of a failing.
55. The speech and language therapist’s (SALT) assessment on 15 February says ‘oral hygiene poor – dried blood at back of tongue’. Based on the available evidence, Mr B had not received any mouthcare until 16 February, so we consider the lack of mouthcare did affect him.
56. The Trust told us it has reviewed Mr B’s hospital notes in detail again and it seems staff had not completed the oral care plan daily during part of his admission. It said this was not acceptable and it wanted to sincerely apologise for this. The Trust said it has been speaking with staff in ward huddles and team meetings. The aim of this is to make sure that oral care and clear documentation is maintained, and it will continue to monitor this for completeness.
57. The Trust said a separate meeting has been arranged with new staff on the ward to make sure they understand the documentation used. The Trust recognised it cannot change what happened, but it is confident that with regular monitoring of the care plans and continuous teaching it can make sure Mr B’s experience is not repeated for someone else.
58. Section 16.4 of the NMC standards says nurses should ‘acknowledge and act on all concerns raised to you, investigating, escalating or dealing with those concerns where it is appropriate for you to do so’. The Trust’s response to us shows it has acted in line with this.
59. This acknowledgement and reflection is also in line with our ‘Principles of Good Complaint Handling’. Our nursing adviser agreed teaching and reminding staff about the importance of documentation and then auditing (regular monitoring of the care plans), should address this issue.
60. We appreciate this has only taken place because of our involvement. We take the opportunity to resolve complaints where we consider it is possible to. We are reassured by the additional information the Trust has provided and hope Mrs A and Mrs K will be too.
Food charts
61. The family are concerned the Trust inaccurately recorded Mr B had meals, at a time when he had difficulty swallowing. We can see Mr B was on a puree diet from admission and was referred to SALT. They assessed him on 15 February and decided he was able to have a soft diet and thin fluids.
62. Sections 8.1 and 8.5 of the NMC guidance says nurses must respect the skills, expertise and contributions of their colleagues, referring matters to them when appropriate. They must work with colleagues to preserve the safety of those receiving care.
63. Our nursing adviser said there is no evidence to suggest that the food charts were inaccurate. All the food given to Mr B could have been pureed or was already soft. SALT had assessed that Mr B was safe for this consistency of foods and drinks. This is why we have not identified any signs of a failing in relation to this.
Medication administration
64. The family are concerned the Trust did not administer Mr B’s regular medications. The Trust acknowledged Nifedipine, Venlafaxine and Laxido were not given. This is a sign of a failing. The medications were missed for a relatively short period, two days (14 and 15 February). We asked our physician adviser about whether this had an impact on Mr B.
65. Nifedipine is used to control blood pressure. While this could have had an impact on Mr B, his Early Warning Scores (a scale used to measure the severity of a patient’s illness) were not persistently raised. Similarly, there is no sign that he was more unsettled or delirious when the Venlafaxine had not been given. Missing Laxido is also unlikely to have had an impact as there were occasions when Mr B refused this.
Use of co-amoxiclav
66. The family are also concerned the Trust continued treating Mr B with co-amoxiclav when his CRP levels were increasing from 13 to 17 February. The Trust checked Mr B’s CRP levels on 13 and 16 February, there were no tests in between. Mr B’s Early Warning Score shows he did not deteriorate clinically during this time.
67. It is unlikely (even if there had been further tests) that the CRP would have prompted further action. This is because the NICE guidance on antimicrobial therapy for pneumonia does not say that CRP should be acted upon. In line with GMC ‘Good medical practice’, the Trust would be expected to assess the patient and use clinical judgement appropriately.
Use of Tazocin and Sando-K
68. The family are concerned Tazocin was not appropriate given Mr B’s low potassium levels. Hypokalaemia is defined as a serum potassium concentration of less than 3.5 mmol/L. Mr B’s potassium level was recorded as 4.1 on 13 February and 3.5 on 18 February. It was 3.3 on 19 February.
69. The BNF does not say Tazocin is contraindicated (can cause complications) in patients with low potassium levels. This is why we have not seen any signs of a failing in the Trust’s decision to give this medication.
70. The family are also concerned the Trust took too long to prescribe Sando-K (a potassium supplement). Our adviser explained there would have been no physiological impact to Mr B from his low potassium levels. He was given potassium supplements soon after it was found that the levels were low. This is why we have not seen any sign of a failing here.
71. In summary, we identified a potential failing in relation to some aspects of the complaint about the Trust. We are satisfied the Trust has accepted these. While this does not change Mr B or his family’s experience, we hope it will reassure them