Sandwell and West Birmingham Hospitals NHS Trust

6. Ms A complains on behalf of her mother about the nursing care she had at the Trust’s stroke and rehabilitation ward from August to December 2022. She complains about:

• the transfer to the ward on 26 August saying nursing staff put Mrs R in a bed far away from the nursing station and did not provide a timely handover of care • communication – she says the nursing staff were not able to update her on Mrs R’s condition and directed her to a medical and physiotherapy team instead • nursing staff attitude – she says the nursing staff were defensive and rude towards the family and not aware of Mrs R’s care plan • hygiene standards – she says the nursing staff did not keep a clean environment, Mrs R’s hands and the bed rails were stained with faeces, staff did not rinse her nightdress before putting it in a laundry bag, staff switched Mrs R’s table with a different patient • responsiveness – she says the nursing staff did not act when Mrs R became drowsy and struggled to communicate until she raised this issue herself • general care – she says the nursing staff would not make sure Mrs R had dentures in during mealtime, did not provide oral care and did not arrange podiatry care when needed • nursing staff not allowing Mrs R dignity – she says they left her in a chair with her underwear exposed.

7. Ms A complains about the Trust’s complaint handling. She says when she complained, it took too long to respond. She thinks the nursing staff will not improve despite the Trust’s promises.

8. Ms A says these events made her feel her mother was an unpopular patient and this added to the overall feeling of poor care with no dignity. She says the poor care led to Mrs R’s worsening condition and she had two falls at the hospital. She says this caused her distress and made her question the Trust’s care. She says the staff switching tables led to Mrs R using another patient’s things. She also says the Trust’s complaint handling only made her frustration worse.

9. Ms A wants the Trust to make improvements.

10. Mrs R attended the Trust’s emergency department on 20 August 2022. The Trust arranged investigations and diagnosed her with subdural haemorrhage (a serious condition where blood collects between the skull and the surface of the brain). It admitted Mrs R for observation.

11. On 23 August, Mrs R’s condition deteriorated and she had a stroke (a life-threatening medical condition that happens when the blood supply to part of the brain is cut off). We understand her condition was critical.

12. On 26 August, the Trust transferred Mrs R to a stroke and rehabilitation ward. Ms A complains about what then happened.

13. Mrs R had a fall on 3 and 5 October. Ms A is taking legal action against the Trust about this and for Mrs R’s injuries from the second fall.

14. In December the Trust discharged Mrs R home with end-of-life care. She sadly died in April 2023.

Bed location, communication, awareness of care plan and arranging podiatry care

17. Before we decide if we should investigate, we look at whether there is an ongoing legal claim, or if it would be reasonable for someone to consider this. We think there is a potential overlap with these issues because the court may look at these as part of the ongoing legal proceedings.

18. Ms A is pursuing a clinical negligence claim against the Trust for the two falls Mrs R had and her injuries. Ms A was unable to give us any details of the stage the legal proceedings are at. We understand this means the claim is still in its early stages.

19. Usually, where there is an ongoing clinical negligence claim we would not look at the complaint. Once the court case has finished someone could ask us to consider any issues the court did not consider. This is because the court may make findings or provide an outcome so we cannot look at the same issues at the same time.

20. Ms A told us her complaint about the nursing care and the falls are unrelated. But, Ms A also said she thinks the overall poor nursing care led to Mrs R’s worsening condition and to the two falls. This suggests that there may be a link between the complaint she has asked us to consider and the legal action she is taking.

21. We think there are some parts of the complaint that may be linked with the legal action. These are:

• transfer - location of Mrs R’s bed • communication – nursing staff were unable to update the family • attitude – staff were not aware of the care plan • general care – staff did not arrange podiatry care.

22. This is because Ms A thinks these issues may have contributed to the falls. This means these issues may be part of what the court would look at.

23. Staff knew that Mrs R had a history of falls at home. We are also aware that after the second fall, staff moved Mrs R to a high visibility bed. This suggests the location of Mrs R’s bed may be looked at by the court.

24. We understand Ms A’s complaint about the staff not being aware of the care plan led them to not being able to update the family. We think this can be linked to her concerns about the care leading to Mrs R’s worsening condition and increased risk of falls. This suggests the courts may investigate this as well.

25. With the podiatry care, we understand this happened sometime in October 2022, after the two falls. Ms A says this had not been noticed until Mrs R developed an ischemic toe (blocked blood flow to a toe). If Mrs R had already started having problems with her toe in early October, it is possible that this contributed to the fall.

26. We recognise these links do not necessarily mean the court will reach a decision on or include these parts of the complaint in its conclusions. But , if we investigated there would be a risk that our investigation may prejudice the court’s decision and vice versa.

27. Ms A only wants service improvements for what she brought to us. As explained above, we cannot look at complaints where someone is taking legal action. We think these issues link too closely with what the court may consider. If the court does not consider these issues, or if it does and Ms A is not satisfied that the Trust has taken action to improve after this, she can ask us to reconsider her complaint.

28. We also recognise it would be unfair to ask the Trust to balance a legal claim and our investigation at the same time. We ask Ms A to come back to us when the legal proceedings have ended.

Attitude and responsiveness of staff, patient dignity and switching tables

29. Before we decide if we should investigate further, we look at what we would be able to achieve. We think it is unlikely that we could add anything here. This is because we can see the Trust explained what happened where possible and apologised where it did not get things right.

30. Ms A complained about staff behaviour. She said they were confrontational, abrupt and defensive. For example, she said staff implied she was bullying Mrs R. Ms A said staff left Mrs R in a chair with her underwear exposed.

31. She said staff switched Mrs R’s table with one belonging to another patient. She also said staff did not do anything when Mrs R became drowsy until Ms A raised concerns about it and the new medication Mrs R was taking.

32. Our Principles say that when mistakes happen, organisations should acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.

33. The Trust said it reminded its staff to express themselves in a clear and calm way. It said the staff apologised and explained it was not their intention to upset Ms A.

34. The Trust also apologised it had not kept Mrs R’s dignity and agreed this was unacceptable. It said it could not find who swapped the table but assured Ms A it would not have been intentional. It apologised it happened. It also assured us it had not got other complaints about mixing up patients’ belongings since. Lastly, it said staff did act on Ms A’s concerns about Mrs R’s drowsiness.

35. We are sorry to hear how these events led to Ms A’s overall sense of poor care and a lack of dignity. We understand her worries about the risk of cross infection (when the tables were swapped) and having to raise her concerns about medication to staff.

36. We think it is unlikely we would be able to achieve more from investigating these parts of the complaint. This is because the Trust has already recognised that staff could have communicated better and that it did not keep Mrs R’s dignity. We are also reassured that it has spoken with staff about this. It also explained it was unable to find how the table was swapped. Mrs R’s belongings did not go missing. We can also see the Trust has apologised for its mistakes and the impact these had.

37. Regarding the medication-related drowsiness, we recognise that staff acted when Ms A raised concerns. We understand staff alerted a doctor on her request. The doctor reviewed Mrs R and adjusted the dosage. We understand Mrs R was not drowsy the next day.

38. We appreciate how these events would have been upsetting for Ms A. We think the Trust’s apology is enough here. This is because we can see there was no wider impact beyond the distress and upset Ms A experienced.

Timely handover of care, oral care and dentures and hygiene standards

39. We look at what the Trust has done so far to put right the impact of what happened. We think the Trust has put things right by making service improvements and this is what Ms A wanted.

40. Our Principles say, ‘when mistakes happen, NHS organisations should… put things right quickly and effectively’.

41. Ms A told us when her mother was transferred on 26 August 2022, staff did not handover her care in a timely way. She also said staff did not make sure Mrs R had dentures in during mealtimes or provide oral care.

42. She said staff did not keep a clean environment for Mrs R. This was because she found Mrs R with faeces on her hands and the bedrail. She said Mrs R’s soiled night dress was simply placed in a bag.

43. We are very sorry to hear how these events led to Ms A feeling like Mrs R was an unpopular patient and the distress this caused her.

44. The Trust apologised for the poor care it provided and promised improvements. It said it gave staff feedback about the delay in the handover of care and that it is working on a welcome process and information leaflet.

45. It also said it gave staff feedback about making sure dentures were in for mealtimes and the importance of oral care. It said the ward was part of a project called ‘Mealtime Matters’ and it was auditing its improvements. Lastly, it said it gave the relevant staff feedback about hygiene standards. It assured us it has had no other complaints since about the hygiene standards.

46. We have seen evidence of the ‘Mealtime Matters’ project. This project encourages staff to stop non-essential clinical work during mealtimes. All staff are encouraged to help and families who wish to support feeding their loved ones will also be welcomed onto the ward at mealtimes. The overall aim is that improving nutrition and hydration will help with quicker recovery.

47. We have no reason to believe the Trust did not feedback to the staff as it said it did. It explained the leaflet is currently on hold because the ward is having a restructure. The stroke section of the ward will be transferred to a different hospital. We accept this explanation.

48. Overall, we have seen the Trust accepted its mistakes, apologised and explained what it has done, or will do, to make sure there are improvements. We think this is in line with our Principles.

Complaint handling and service improvements

49. Before we decide if we should investigate further, 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 sign that something has gone wrong.

50. Ms A complains about how the Trust handled her complaint. She says it took too long to respond.

51. The Complaints Regulations 2009 say the NHS body must respond within six months from when it received the complaint.

52. We understand Ms A first tried to resolve her complaint informally by speaking to senior staff. She complained in writing on 7 October 2022. The Trust acknowledged the complaint on 13 October. It promised a response by 21 November.

53. We note the complaint was about the overall care from August to October 2022, including the falls.

54. When the Trust responded on 13 March 2023, it apologised for the long delay. Ms A raised further concerns on 18 April and the Trust responded on 21 June. We also note the Trust sent the patient fall incident report on 19 April.

55. We recognise the Trust replied almost three and a half months later than it said it would. We understand the Trust updated Ms A on its delays and told her on 13 January that the report was completed and with the risk team. Despite this, the Trust replied in full almost two months later.

56. Overall, the Trust took five months to respond to Ms A’s complaint. It took almost six months to give her the falls report. We recognise the Trust did not do what it said it would but, we do not think this service falls below the expected standard to be a failing. This is because it still dealt with the complaint within the six-month deadline set by the Complaints Regulations.

57. The Trust responded in around two months to the concerns Ms A raised in April. This is in line with the Complaints Regulations.

58. We appreciate Ms A may find our decision disappointing. We also appreciate that Mrs R died in April and it would have been very difficult for Ms A to get the report around that time.

59. Ms A also told us she does not think the nursing staff will improve despite the Trust’s promises.

60. Our Principles say, ‘when mistakes happen, NHS organisations should… put things right quickly and effectively’.

61. In its March 2023 response the Trust said it provided the relevant staff with feedback:

• on the delay in the handover of care and it is working on a welcome process and information leaflet (point two) • on its commitment and standard of care and it is holding daily team huddles and regular audits (point four) • to make sure a patient has dentures in for a mealtime and the ward is piloting a project called ‘Mealtime Matters’ and auditing its improvements (point six) • on hygiene standards and the overall importance of checking belongings if things are moved around (points eight to 11) • on their communication, it also holds daily ward rounds, team handovers and weekly team meetings to make sure the care plans are communicated between staff (point 12).

In its June 2023 response the Trust advised it has:

• provided staff with feedback relating to the relevant areas of care (point one) • provided staff with feedback on how vital it is that they express themselves clearly and calmly (point seven) • started the ‘Mealtime Matters’ project, there are daily patient safety meetings and nutrition and hydration is being monitored by the ward nursing leadership team and discussed with wider teams (point eight).

62. We have not looked at the improvements relating to the falls report because legal action is being taken on this.

63. We asked the Trust to provide us with evidence that it actioned the promises it made to Ms A. In relation to its March 2023 response, it:

• said the information leaflet is on hold because of the restructure but there have been no other complaints about admission and the welcome process (point two) • said morning safety huddles continue to be led by the clinical lead or ward sister, it explained this happens alongside handover and patients that are at risk of any kind are highlighted, it provided us with evidence of monthly audits (point four) • provided us with a report on ‘Mealtime Matters’ presented to the Trust’s executive quality group on 7 February 2023 (point six) • assured us the feedback was given and there have been no other complaints about hygiene standards or mixing up patients’ belongings (points eight to 11) • said daily ward rounds by the medial teams are in place and recorded in patient’s medical records, verbal handover happens twice a day at 7am and 7pm, weekly meetings are held and notes are recorded in patient’s records and during the ward sister’s quality rounds patients and their families are asked if they feel up to date with information and given support (point 12).

64. In relation to its June 2023 response, the Trust told us:

• If there are any incidents, complaints or concerns, these will be shared and discussed at a safety huddle, at handover and at weekly meetings. It said conversations with family members and ward leadership members are clearly recorded in patients’ electronic notes so all members of the team are informed of communications (point one) • no further complaints or concerns have been raised about this member of staff. It said visible leadership on the wards has supported staff communication with patients and families (point seven) • ward sisters do quality rounds including monitoring nutrition and hydration - this includes spot checks of oral care assessments and food and fluid charts. It said a recent visit from the integrated care board (ICB) showed evidence of quality rounds being completed (point eight). The ICB is an NHS organisation that is responsible for developing a plan for meeting the health needs of the population in the local area.

65. With the exception of a welcome process and information leaflet, we have seen the Trust has acted in line with what it promised Ms A. We have no reason to believe these improvements were not made. We accept the Trust’s explanation for why the leaflet is on hold. We hope Ms A finds it reassuring that the Trust has taken the actions it promised it would.

1. We have carefully considered Ms A’s complaint about Sandwell and West Birmingham Hospitals NHS Trust (the Trust). We are sorry to hear how difficult these events were for Ms A, especially as her mother, Mrs R, deteriorated during her hospital stay. We appreciate how these events led to her overall feeling of poor care.

2. We think Ms A’s issues about the bed location, communication, awareness of a care plan and arranging podiatry (foot) care may have an overlap with the legal claim she is making. As it is likely these may be looked at during legal proceedings, by law we cannot investigate them at this stage.

3. Regarding the attitude of staff, patient dignity and switching tables, we think it is unlikely that we would be able to achieve more by further investigation. This is because we can see the Trust explained what happened where it could and apologised.

4. We think the Trust has already done enough to put right the impact of what happened with the handover of care, oral care and dentures and hygiene standards issues. This is because we can see the Trust provided an explanation, apologised where it had not got things right and made improvements.

5. We have not seen signs of anything going seriously wrong with the Trust’s complaint handling. We recognise the Trust did not reply as quickly as it promised but overall, the timescale was still in line with relevant guidelines. We have seen the Trust kept to the promises it made to Ms A during the complaints process.