Geriatric ward
16. Miss I says her father was admitted to the emergency department (ED) in early December 2021 and then transferred to a general ward. She says the geriatric ward was not made aware that he was in the ED.
17. She says he should have been sent to the specialist geriatric ward for vital age-appropriate tests.
18. In its response, the Trust said it could see from the admission information that it was suggested for Mr I to be admitted to a geriatric ward. But, there is no request for this on its system. It apologised for this and fed this back to staff for learning.
19. The records show Mr I was assessed by a consultant two days later who considered his presentation, the history given by Mr I’s wife and the results of the CT scan. Staff felt that Mr I was developing dementia, but they also thought COVID-19 encephalitis (brain inflammation caused by the COVID-19 infection) was a possibility because he had COVID-19 in October.
20. The records show the management plan included transfer to the geriatricians. Mr I was not transferred to the geriatric team and the reasons for this are not clear.
21. NICE guidance for ‘Transition between inpatient hospital settings and community or care home settings for adults with social care needs’ says:
‘1.4 During hospital stay Provide care for older people with complex needs in a specialist, geriatrician led unit or on a specialist geriatrician led ward.’
22. Our physician adviser says Mr I’s needs were complex because he had increasing confusion and occasionally aggressive behaviour, worsening mobility and falls. Because of this, it was appropriate to assign him to be cared for by the geriatricians.
23. The same NICE guidance says a patient like Mr I should have a comprehensive geriatric assessment which is:
‘an interdisciplinary diagnostic process to determine the medical, psychological, and functional capability of someone who is frail and old. The aim is to develop a coordinated, integrated plan for treatment and long-term support.’
24. Our physician adviser says the nursing staff working on geriatric wards are particularly experienced in dealing with patients with worsening dementia, delirium or associated aggressive behaviour. Mr I should have been put on a geriatric ward where staff are trained to deal with people with these complex needs.
25. We find the Trust did not act in line with the relevant guidelines when it admitted Mr I to a general ward rather than a geriatric ward.
26. Our physician adviser says although Mr I was not on a geriatric ward, he was assessed by psychiatry, physiotherapy and occupational therapists along with the medical team looking after him. This gave the comprehensive geriatric assessment required by the NICE guidance.
27. The evidence shows Mr I should have been admitted to a geriatric ward but he still had the needed geriatric assessment to develop a treatment plan. We cannot say that Mr I had a lower standard of treatment or that his health would have been different if he had been put on a different ward.
28. We recognise Miss I is concerned about this. We hope she is reassured that although it was a failing for Mr I not to be put on a geriatric ward, this does not seem to have affected the care he received. We explore this care in more detail below.
Tests and investigations
29. Miss I says staff did not do the right tests and investigations and her father’s oesophageal cancer was missed. She says he lost a lot of weight while he was an inpatient.
30. In its response, the Trust said Mr I had a chest X-ray and a CT scan of his head. His X-ray did not show any sign of a tumour and there was no sign that he needed more scans. His weight had not changed at this time and he was clinically stable.
31. The Trust also explained that on Mr I’s second admission in March 2022, he had loss of appetite, weight loss and difficulty swallowing. Because of these new findings, there was a need for more scans and he had a CT scan of his thorax (the area between the neck and the abdomen) which found the cancer.
32. The records show that during Mr I’s first admission, he did not report or display any of the symptoms in the NICE guidance below to prompt investigation for oesophageal cancer. The nursing notes show there were no concerns over his eating habits.
33. NICE guidance for ‘Suspected cancer: recognition and referral’ says:
‘1.2.1 Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for oesophageal cancer in people: • with dysphagia [swallowing difficulties] or • aged 55 and over with weight loss and any of the following: • upper abdominal pain • reflux [heartburn] • dyspepsia [indigestion].
1.2.3 Consider non urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with: • treatment resistant dyspepsia or • upper abdominal pain with low haemoglobin levels or • raised platelet count with any of the following: • nausea • vomiting • weight loss • reflux • dyspepsia • upper abdominal pain, or • nausea or vomiting with any of the following: • weight loss • reflux • dyspepsia • upper abdominal pain.’
34. The records show Mr I’s weight was 55kg on 19 December 2021, it increased to 61.54kg on 9 January 2022 and had reduced slightly to 59.5kg on 23 January 2022.
35. The records show that on admission in December Mr I’s haemoglobin levels were 120 g/L. His haemoglobin level was recorded as 107 g/L on 9 December and his folic acid levels were low and a replacement had been prescribed.
36. Our physician adviser says the normal haemoglobin level for males is greater than 130 g/L which means Mr I was anaemic on admission.
37. Our geriatrician adviser says the type of anaemia that Mr I had was not typical of an iron-deficiency anaemia. His measured mean cell volume level (MCV) was not at a level that would trigger a ferritin check, as per NICE guidance for anaemia that says:
‘If results of the FBC [full blood count] show a low haemoglobin and low mean cell volume (MCV) check the ferritin level — check the ferritin level in all people with an MCV less than 95 femtolitres.
• An MCV less than 95 femtolitres has a sensitivity of 97.6% for iron deficiency anaemia.
• In people with anaemia and an MCV of more than 95 femtolitres, there is a low probability of iron deficiency.’
38. Our geriatrician adviser says Mr I’s MCV levels were always above 95, so the treating team did not need to do more investigations to look for iron-deficiency or causes of iron-deficiency anaemia.
39. Our physician adviser said if the Trust had investigated Mr I’s anaemia further, it is possible that his cancer would have been found earlier. As we have explained, there was no need to investigate the anaemia further and there is no evidence that staff should have found his cancer sooner.
40. Our physician adviser also said that even if the Trust had found Mr I’s cancer sooner, it is sadly likely to not have affected his survival. He was elderly with significant health problems which would have meant major surgery to cure oesophageal cancer would very likely not have been an option.
41. The records also show Mr I was very frail and needed assistance to wash and dress and had been suffering from (a likely diagnosis of) newly recognised dementia with behavioural problems and regular falls. Our physician adviser said this meant it would have been very unlikely that he would have been seen as suitable for palliative chemotherapy (cancer treatment). They also said that even if his cancer had been detected earlier, the medical decision would have been for no active treatment but best supportive and end-of-life care.
42. We find the Trust acted in line with the relevant guidelines when investigating Mr I’s condition. Mr I did not have any of the typical red flag symptoms of oesophageal cancer and we cannot say the Trust missed an opportunity to diagnose him sooner. We hope this gives Miss I and her family some reassurance about the Trust’s investigations.
Communication with the family
43. Miss I says the doctors did not communicate with her mother and never answered the phone when the family tried to get an update on Mr I’s health.
44. She also says the communication around his discharge was poor.
45. In the final response letter, the Trust apologised that Mr I’s family were not kept up to date with his progress.
46. The Trust also said it had addressed this with the ward staff as the minimum expectation is for the teams to keep relatives updated with their loved ones’ care while they are on the ward.
47. The medical records show there are times when staff noted ‘discussion with wife’ but the content or context of the discussions is not documented. We cannot say what information staff gave to Mr I’s family from December 2021 to January 2022, but it is clear from what they told us that it did not meet their needs or expectations.
48. The Trust has apologised to the family that they were not kept fully up to date but we could not see that any other improvements have been made.
49. Our Principles say that to put things right organisations should provide an apology, explanation and accept responsibility. We say organisations should take corrective action that may include changing procedures, policies or guidance to prevent the same thing happening again, or training or supervising staff.
50. We asked the Trust if any further work had been done as a result of the complaint.
51. The Trust said since Mr I’s admission, it had moved to holding patient records electronically. This move allows for clear documentation to be held in a patient’s notes, reflecting conversations that have taken place between a patient and their family members.
52. The Trust also explained that the ward where Mr I was being cared for now holds lunch time ward huddles most days to discuss each patient on the ward with the nursing staff. This prompts where family discussions could be appropriate. The ward manager and matron have raised awareness to the ward’s nursing staff around the importance of communicating with patients and their family members.
53. We understand it was distressing for Mr I’s family to not be aware of or be given updates on his condition, especially when they were unable to visit him due to the COVID-19 pandemic.
54. The Trust’s improvements are in line with what Miss I has asked for as outcomes to her complaint. We think the Trust acted in line with our Principles and it has done enough to put right the impact of the lack of communication. We are not making further recommendations.
Concerns about discharge
55. Miss I says staff did not consider her mother’s concerns about her father being discharged as medically fit to a nursing home.
56. In its response, the Trust said all queries were addressed by staff appropriately at the time and the correct advice was given. It apologised that Miss I’s mother felt this way and offered reassurance that her concerns were taken seriously.
57. We have reviewed Mr I’s medical records and there are documented conversations between staff members and Mr I’s wife on the 3, 16 and 21 December 2021.
58. The records show Mr I was first considered for in-patient rehabilitation and his wife was noted to be supportive of this plan.
59. By 16 December, the rehabilitation team assessed this option but declined it due to his cognitive issues. It is documented that Mrs I told the occupational therapist she did not feel like she could manage with him at home.
60. A ‘discharge to assess’ bed was planned for when he left hospital which Mrs I is noted to have agreed with. This is needed when a patient is able to leave the hospital but is not necessarily well enough to return to where they were living before. On 21 December, the physiotherapist repeated to Mrs I why he was not going for rehabilitation and it is documented that she agreed with the ‘discharge to assess’ bed.
61. We reviewed NICE guidance on ‘Transition between inpatient hospital settings and community or care home settings for adults with social care needs’ which says:
‘1.1 Overarching principles of care and support during transition
Personcentred care 1.1.1 See everyone receiving care as an individual and an equal partner who can make choices about their own care. They should be treated with dignity and respect throughout their transition.
1.1.2 Identify and support people at risk of less favourable treatment or with less access to services for example, people with communication difficulties or who misuse drugs or alcohol. Support may include help to access advocacy.
1.1.3 Involve families and carers in discussions about the care being given or proposed if the person gives their consent. If there is doubt about the person's capacity to consent, the principles of the Mental Capacity Act must be followed.
Communication and information sharing 1.1.4 Ensure that the person, their carers and all health and social care practitioners involved in someone's move between hospital and home are in regular contact with each other. This is to ensure the transition is coordinated and all arrangements are in place.’
62. We recognise, in hindsight, that Mr I had oesophageal cancer when he was discharged but this had not yet been diagnosed. As we have explored, we have not found that the Trust missed an opportunity to diagnose Mr I’s cancer.
63. We find the Trust acted in line with the NICE guidance as it involved Mr I’s family in the discussions about the care it gave. The Trust also kept in regular contact with Mr I’s family and told them about the plans for discharge, any changes being made and the reasons why.
COVID-19 testing
64. Miss I says during Mr I’s admission he was exposed to COVID-19 twice because there were outbreaks on the ward where he was staying. She says this meant he had no visitors at this time including the Christmas period.
65. The Trust said it was unfortunate there was a COVID-19 outbreak on the ward over the Christmas period and it decided to have stricter visiting restrictions than on other wards.
66. It said it had a COVID-19 testing policy in place since soon after the start of the pandemic. It said patients were tested on admission, at day three, day six and weekly then weekly.
67. The Trust apologised that Mr I’s family was not able to visit him but has not accepted any fault.
68. The Trust’s policy on COVID-19 infection prevention says:
‘Testing for COVID 19:
The criteria for patient testing are as follows:
•All patients at emergency admission with no history of Covid or with new symptoms of COVID •Those who test negative upon admission, a further single retest should be conducted at day 3. If negative at day 3 a further test should be conducted at day 6 •Continue with weekly testing for negative inpatients.’
69. The records show Mr I was tested on admission, re-tested on day three but not tested on day six. He was also not consistently tested weekly. The Trust did not keep to its policy.
70. We are unable to confirm whether other inpatients were tested in line with the guidance. It seems likely that if the Trust was not testing Mr I in line with its guidance, it was also not testing other patients in line with the guidance.
71. We cannot say with any certainty that the lack of COVID-19 testing for inpatients led to the COVID-19 outbreak on the ward. At this point in the pandemic COVID-19 cases were again on the increase. Nationally hospitals were introducing different levels of visiting restrictions to manage this. Even where regular testing was happening and strict infection control was in place, unfortunately the spreading of COVID-19 could not be completely prevented. But, we recognise poor testing protocols would have deprived staff of the best opportunity to manage any outbreaks.
72. We recognise the impact of these COVID-19 outbreaks was that Mr I’s family were unable to visit him in hospital, which was especially difficult over the Christmas period.
73. We find that the Trust should have tested Mr I for COVID-19 in line with its guidance. As this was not done, there was an increased risk of COVID-19 spreading, leading to tighter visiting restrictions. We cannot say that Mr I’s family would definitely have been able to visit if he had been tested correctly.