15. Before we decide if we should do a detailed investigation of a complaint, 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. We have done this and have not seen any signs that something went wrong in Mrs A’s complaint about SPFT and UHSFT.
SPFT The unit where he was cared for
16. Mrs A complains SPFT was not the appropriate facility to care for Mr A, as it did not know how to deal with his specific type of dementia.
17. SPFT’s website describes the unit that looked after Mr A as, ‘a specialist dementia intensive care unit designed specifically to care for people with dementia to meet their clinical needs.'
18. At the time of his admission Mr A was showing behavioural symptoms associated with his dementia. As time went on, his behaviour became more complex with his refusal to eat, drink or take medication. As his needs changed and progressed, the consultant decided to transfer Mr A to another dementia unit at the other hospital.
19. Our psychiatrist adviser explained there are no specific centres to care for and treat people with frontotemporal dementia. Given the description on SPFT’s website, we have seen nothing to suggest the unit was not the appropriate place for Mr A or that its staff were unable to manage his dementia.
Eating, drinking and managing Mr A’s weight loss
20. Mrs A says staff at the unit were unable to manage Mr A’s physical health needs and this caused him to lose a lot of weight during his admission.
21. The Alzheimer’s Society says it is common for patients with dementia to have a poor appetite and lose interest in food. It says eating and drinking can be made more difficult if a person’s routine and diet have changed. This can lead to weight loss.
22. Mr A had been detained under the Mental Health Act. He had been admitted to a mental health unit and was out of his normal routine. Mr A wanted to go home and at times, refused to eat and drink unless staff discharged him home. He lacked capacity to consent to his admission and possibly did not understand the need for him to be in hospital.
23. Our psychiatrist adviser explained frontotemporal dementia can cause impulsive behaviours and a lack of judgment in decision making. Mr A also had specific obsessional behaviour patterns around eating particular types of food at certain times. This is shown in Mrs A’s letter about Mr A’s eating habits. Mr A was not in his normal routine, and this inevitably affected his eating and drinking.
24. The evidence in Mr A’s medical records suggest he was accepting some food and drink between 9 and 29 April, but not as regularly as he would in his normal environment.
25. SPFT’s food and nutrition policy says when a patient is not eating or drinking regularly, staff must make sure nutrition screening is completed at appropriate times, regularly check that nutrition care plans are started and reviewed, be aware of the roles of other professionals and make timely referrals for specialist assessment and advice. It should also prescribe nutritional supplements.
26. The evidence in Mr A’s medical records shows staff were aware he was not eating and drinking as he normally would at home. They were also aware he was losing weight because of this. In line with its policy, we can see staff completed regular malnutrition screening tools (MUST) and kept food and fluid charts updated.
27. In line with its policy, staff also had a discussion with a diabetic nurse specialist, who was not overly concerned but advised staff to monitor Mr A’s blood sugar levels. The information in Mr A’s records suggest he often refused to have this checked. Staff also contacted a senior dietitian, who developed a detailed plan of his diet.
28. In line with its policy, staff also started Mr A on chocolate forticream, fortijuice and fortisip compact. These are all nutritional food that would give Mr A the energy and calories he needed, while he was not eating all his meals.
29. We can see doctors also tried to give Mr A olanzapine medication, which can help to increase appetite. This was stopped when an ECG (a test that measures the electrical activity of the heart) reading suggested some difficulties which could have been a side effect of the medication.
30. NICE guidance NG97 says healthcare professionals should encourage and support people living with dementia to eat and drink regularly. In line with this, we can see staff left snacks in Mr A’s room to encourage him to eat and Mrs A brought in specific food he liked to eat at home.
31. Mr A’s dementia meant he found it difficult to adjust to his new environment and routine. Mr A was eating and drinking on admission, but as time went on and his symptoms and behaviour got worse and he became more agitated, he was refusing to eat and drink. On 26 April, his body mass index (BMI) was still over 30, which was within the normal range for him.
32. We can appreciate why Mrs A has concerns about the way staff were managing Mr A’s physical health needs. There is no doubt he was losing weight because of irregularity with his food and fluid intake. We have seen staff were aware of this, monitored it and took appropriate steps to manage this in line with its food and nutrition policy and NICE guidance.
33. In summary, the Trust’s management of Mr A’s eating, drinking and weight loss was in line with the relevant guidance. Mr A had a complex condition with the progression of his dementia, delirium and then COVID-19. We have seen nothing to suggest the Trust’s management of Mr A’s physical health needs contributed to his death.
Mr A’s medication
34. Mrs A says the medication SPFT provided to Mr A at the unit was not appropriate and this affected his mental and physical health needs.
35. Mr A was very unwell when he was admitted to the unit. He had been aggressive towards Mrs A and their daughter and there were significant risks of harm if he stayed at home. This led to Mr A being detained under the Mental Health Act and his behaviour had to be managed at the unit.
36. NICE guidance NG97 supports the use of antipsychotic medication in dementia patients, when there are significant behavioural or psychological symptoms which cause significant distress to the patient and put them at risk of harm to themselves or others.
37. We can see Mr A was on risperidone, an antipsychotic medication licenced to use for agitation and aggression in dementia. He was also on lorazepam and clonazepam, a diazepam group of medicines used for calming agitation. The Trust’s administration of these medications was in line with NICE guidance NG97.
38. Our psychiatrist adviser said Mr A’s medical notes are detailed and the consultant clearly documented the reasons for giving Mr A the medication. Our psychiatrist adviser also said the consultant regularly reviewed the medication, to make sure it was still appropriate to give to Mr A. This was in line with GMC’s standards on good medical practice.
39. We can see why Mrs A has concerns about the medication SPFT was giving Mr A. We can appreciate why she feels this may have affected his overall mental and physical health. The Trust’s administration of medication was in line with the relevant guidance. As explained above, Mr A had a complex condition with the progression of his dementia, delirium and then COVID-19. We have seen nothing to suggest the Trust’s management of Mr A’s physical and mental health needs contributed to his death.
UHSFT
Discharge on 2 May
40. Mrs A says UHSFT discharged Mr A to the hospital several times when he was not medically fit for discharge. She says he was already very unwell and the moves to and from hospital contributed to his death.
41. On 1 May, we can see staff at the hospital suspected Mr A was suffering from heart problems and chest pain. To rule out a serious condition, they arranged for him to be taken to UHSFT.
42. NICE guidance CG95 says health care professionals should refer people to hospital if they suspect acute coronary syndrome and the patient has chest pain. The hospital should do a physical examination and take an ECG and blood tests.
43. We can see UHSFT did a physical examination of Mr A. His physiological observations, ECG and blood tests were all normal. As there was no evidence Mr A was suffering from acute coronary syndrome, UHSFT discharged him back to the care of the hospital. This was in line with NICE guidance CG95.
44. Our geriatrician adviser said there was no acute medical need for UHSFT to keep Mr A in hospital. Once all his tests had come back clear, he was medically fit for discharge back to the hospital.
Discharge on 7 May
45. On 6 May, we can see staff at the hospital were concerned about Mr A. He had not been eating or drinking for several days and had a productive cough. To rule out anything more serious, they arranged for him to be taken to UHSFT.
46. On examination, UHSFT found Mr A had high white blood cells, suggesting the likelihood of a bacterial infection. It also found worsening sodium levels (hypernatremia) suggesting Mr A was dehydrated.
47. Our geriatrician adviser explained there are no specific guidelines for the treatment of dehydration. But there are standards in several medical texts that support fluid replacement to rehydrate the patient. In line with this, we can see UHSFT treated Mr A with intravenous fluids (given through the veins). In line with NICE guidance NG120, UHSFT prescribed Mr A with antibiotics for the infection.
48. During this admission, UHSFT offered Mr A regular drinks to rehydrate him. But, Mr A was refusing to drink anything. He was also removing his cannula and refusing to take his medication. Despite these difficulties, we can see the UHSFT did try its best to rehydrate Mr A.
49. UHSFT repeated blood tests on 7 May, that showed Mr A’s sodium levels had improved with treatment. As his condition had improved from the last day, he was medically fit for discharge back to the hospital, to continue with the course of antibiotics. Our geriatrician adviser said there was no acute medical need for UHSFT to keep Mr A in hospital.
Discharge on 13 May
50. On 11 May, Mr A’s blood test results showed increasing sodium levels again. Staff transferred him back to UHSFT for treatment.
51. Mr A had still not been eating or drinking and the acute medical issue was again dehydration due to poor oral intake. As above, UHSFT treated Mr A with intravenous fluids to rehydrate him. Once his blood test results were normal and his sodium levels had improved, Mr A was medically fit for discharge back to the hospital.
52. Our geriatrician adviser explained that in view of Mr A’s psychiatric behavioural problems, it would have been difficult to keep him on an acute medical ward. When he was medically fit for discharge, UHSFT discharged Mr A back to the hospital, where he was more familiar with the surroundings and staff. We appreciate that by the time of his fourth admission to UHSFT, he had already been back and forth several times. Considering this, UHSFT made a decision to keep Mr A in hospital until it was able to plan a safe discharge home. There was no sign for UHSFT to keep Mr A in hospital before this.
53. Any hospital moves for an older person with physical or cognitive disabilities can be damaging to their health. But, on balance, taking into account the needs Mr A had, the hospital moves are unlikely to have had a significant impact on his life expectancy.
54. Our geriatrician adviser explained the main issue here was Mr A’s unwillingness to eat, drink or take medication as a result of his frontotemporal dementia. Looking at his overall mental and physical health issues, Mr A’s condition deteriorated over time. We have seen no signs to show this was due to any failings by either organisation. For this reason, we do not think we need to investigate further or make any recommendations.
55. We are sorry to hear about the circumstances of Mrs A’s complaint and offer our sincere condolences for her loss. We can see this was a difficult and upsetting time and we appreciate her sharing details of her experience with us.
56. We hope this statement gives reassurance that we have considered the evidence carefully and clearly explains the reasons why we will not be taking any further action.