Delayed surgery
14. Before we decide if we should do a detailed investigation of 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.
15. From Mrs E’s medical records, we understand she suffered from peripheral neuropathy (damaged nerves in the arms and legs), this contributed to the fall and broken hip. She also had chronic obstructive pulmonary disease (COPD), asthma, heart disease and high blood pressure. These are all significant medical conditions on their own. We also understand Mrs E had a recent admission to the Trust before 11 August 2020 for a lower respiratory tract infection.
16. The NICE guideline discusses the timing of surgery for hip fractures. It says surgery should be done on the day of, or the day after, admission. Medical staff should identify and treat other conditions immediately so surgery is not delayed by chest infections, for example, existing chest conditions are worsened or various heart conditions.
17. Our adviser told us the orthopaedic team and the orthogeriatric team (both teams specialise in looking after older people, the second team specialise in older people with fragile fractures) felt Mrs E was not well enough for surgery because of her chest infection, although they did not clearly document when they made this decision on 12 August 2020. A note from 11.30am that day says Mrs E would not have surgery that day and that she needed a chest X-ray. We think it is likely this means staff were concerned about her chest that morning. Our adviser said it was reasonable to delay surgery because of a chest infection. This is in line with the NICE guidance.
18. The medical records show the Trust planned to operate on Mrs E on 13 August 2020, because its theatre lists were full on 12 August. That would have been a day later than the guidance recommends. But, even if the Trust had planned to operate on 12 August, it is not likely this would have happened because Mrs E became unwell with a chest infection that day. This means we do not think the surgery could have happened sooner.
19. We do not think it was wrong to delay surgery until the Trust thought Mrs E was well enough. We hope this gives Mr I reassurance.
Consent, risks and TEP
20. At the time of Mrs E’s admission, staff recorded that she was not confused and had capacity to understand what she was being told. Our adviser said the Trust completed an abbreviated mental test. This is a test used to quickly assess a patient for the possibility of dementia. Mrs E’s score was satisfactory.
21. Our adviser noted that although different professionals saw Mrs E during her admission, none raised any concern that she had impaired or changing capacity to make decisions about her care.
22. We saw nothing in the records to suggest staff should be concerned about whether Mrs E could understand discussions about risks of treatment or the TEP. Although Mr I referred to his mother’s clinical frailty, frailty does not mean someone cannot understand relevant information and make decisions about their care.
23. Under the Mental Capacity Act 2005, staff must assume people have the capacity to make their own decisions unless there is evidence they do not. We consider the evidence does not show Mrs E lacked capacity to understand what she consented to.
24. Point 27d of the GMC decision-making and consent guidance says clinicians should accommodate a patient’s wishes if they would like anyone else to be involved in discussions and/or help them make decisions.
25. Our adviser explained that if the patient has capacity to consent, then their family do not have to be present at the time of any conversation. We can see no evidence in the records that Mrs E wanted someone with her while these conversations took place. This means we do not think Mrs E should have had someone with her during the discussions about her treatment.
26. We understand Mr I has concerns about his mother’s ability to properly understand the information she was given, particularly about the risks of surgery. We appreciate that as Mrs E died, this part of the complaint is particularly upsetting. We hope it gives Mr I some reassurance as we do not think the Trust failed to do more.
COVID-19 and visiting restrictions
27. NHS England and NHS Improvement visitor guidance says visiting was suspended at the time of Mrs E’s admission. In exceptional circumstances one visitor, an immediate family member or carer, was allowed to visit in the following circumstances:
• the patient they wished to visit is getting end of life care • they were the birthing partner accompanying a woman in labour • they were a parent or appropriate adult visiting their child • they were supporting someone with a mental health issue like dementia or a learning disability or autism, where not being present would cause the patient to be distressed.
28. Mr I feels strongly that more effort should and could have been made to allow family to visit Mrs E given how poorly she was and that she was likely at the end of her life.
29. We appreciate this part of the complaint is deeply upsetting for Mr I as he feels he, and his family, missed out on the opportunity to see Mrs E before she died.
30. We understand Mrs E had a clinical frailty score (CFS) of six. This is used to help staff decide the level of fitness or frailty of an older adult. A score of six indicates someone who is moderately frail. People in this level may need help with outside activities and housekeeping. Inside, they often have problems with stairs and need help with bathing and may need minimal assistance with dressing.
31. End of life is the time leading up to when a person dies. Mrs E’s medical records show that she was poorly before the operation, but they do not suggest she was at the end of life stage.
32. This means Mrs E did not meet any of the requirements in the visitor guidance for family to have been allowed to visit. Mrs E’s death was unexpected and the Trust acted in line with the policy in place at the time. We cannot say the Trust did anything wrong when not allowing a visit before surgery.
Notification of death
33. The Trust’s Care After Death policy explains the patient’s next of kin or family should be informed of the patient’s death and supported.
34. Mr I complains he was informed of his mother’s death by a text message that he got from his stepfather.
35. Mrs E’s medical records show her husband was next of kin, and the Trust contacted him when Mrs E deteriorated and sadly died. The records also show that Mrs E’s husband and Mr I went to the ward after her death.
36. Mrs E deteriorated rapidly while in recovery and her death was unexpected. The Trust acted in line with its policy and informed Mrs E’s next of kin. It is not expected to do more than that, as it would be usual for the next of kin to tell other family members.
37. We realise Mr I found it really upsetting to be told in the way he was, and we are sorry to hear of the impact this had on him.