Hygiene needs 13. Section 3.6 of the Department of Health continence guidance recognises some people with urinary incontinence (not being able to control passing urine) will present or be identified for the first time during a hospital admission. Hospital nurses must be trained to carry out the initial management. A key principle is that pads should only be issued after an initial assessment.
14. Sections 6.1 and 6.2 of the NMC standards reflect this too. They expect nurses to observe and assess level of urinary and bowel continence to decide on the need for support and intervention assisting (help) with toileting. This looks at maintaining dignity and privacy and managing the use of appropriate aids. Nurses select and use appropriate continence products.
15. This means there should be evidence that the Trust assessed Mrs J’s need for assistance with personal hygiene and whether she had needs for continence care. If it provided appropriate continence products, there should be evidence of this too.
16. When Mrs J was admitted to hospital, the Trust noted she used incontinence pads but did not detail whether this was for urinary or faecal incontinence or both. The guidance and our nursing adviser say there should have been a follow up assessment for continence needs.
17. Mrs R told us her grandmother was not incontinent and did not use continence pads at home. This means either this was a documentation error, or a pad had been provided by either the ambulance crew or in the emergency department. We are unable to say which is the case. This is why we cannot say if there was a failing here.
18. We have seen evidence that the Trust assessed Mrs J and decided she was continent (able to control when she went to the toilet). This was in line with the guidance. The Trust should have assessed how to maintain this and address the need for help. As it did not identify if she needed assistance when she was unwell, this was not in line with NMC standards. We consider this a failing.
19. There are entries in Mrs J’s records that say she was able to walk to the toilet. Others say she was sometimes incontinent and sometimes needed assistance with access to a commode (chair that is fitted with a toilet). The Trust recalculated Mrs J’s Waterlow score (used to assess ulcer risk) approximately weekly. It had recorded ‘0’ for continence, suggesting she was completely continent, during March.
20. The Trust’s ‘Daily Nutrition and Hydration Chart’ includes a check for whether the patient has passed urine. The chart dated 27 March, the day Mrs J’s family say she was in a soiled bed, does not have any entry for whether she passed urine or was incontinent.
21. The nursing entry from that day does not provide any further information or refer to Mrs J having an episode of incontinence. The day before, an entry said she had become very breathless but was walking to the toilet.
22. Mrs R has given us a convincing account of what she saw, reflected in an email she sent to the Trust on the day of the incident. We have no reason to doubt this account. Mrs J may have been in a state of acute deterioration which included the need for more help.
23. Based on what we have seen, the Trust did not act in line with the NMC standards.
24. This meant Mrs J’s hygiene needs and dignity were not maintained in the way they should have been. We are very sorry to hear Mrs J was left feeling she would be unable to return to hospital. This was clearly upsetting for her and added to the distress her family experienced.
25. We are making recommendations so the Trust can consider making nursing or comfort rounds and to improve its record keeping.
Discharge 26. The NHS Long Term Plan said all hospitals with a major A&E department would provide an acute frailty service for at least 70 hours a week. They would work towards achieving clinical frailty assessments within 30 minutes of arrival.
27. The Silver Book says older people should be routinely assessed. The presence of one or more frailty syndromes should trigger a more detailed comprehensive geriatric assessment within two hours (or 14 hours overnight). In line with the later version, the Trust should have been working towards identifying frailty in older people, to aid effective discharge planning.
28. Our nursing adviser said the Trust should probably have identified Mrs J as a frail person due to her change in mobility (due to her breathlessness). It should have identified her specific needs coming from this, ideally through a Comprehensive Geriatric Assessment. This would include any medical, functional, psychological and social needs and lead to a multidisciplinary care plan (created by healthcare professionals from different areas of medicine) to be followed through to discharge planning.
29. NICE guideline NG27 and QS136 say there should be evidence that the Trust carried out an assessment of Mrs J’s discharge needs, taking account of her social and emotional wellbeing, as well as the practicalities of daily living. In her case, it would have included her ability to manage the stairs. A discharge plan should then have been identified and communicated to the GP and relevant services.
30. Our nursing adviser explained the multidisciplinary team would usually send a ‘Discharge to Assess’ (D2A) referral to social services and the hospital therapist would make sure the patient’s functional needs were met. Sadly, this did not happen for Mrs J.
31. The Trust noted a brief social history on 7 March which mentioned Mrs J lived in a house and managed the stairs. We have seen no other evidence of frailty screening, a comprehensive assessment or any nursing or therapy discharge assessments or planning documentation. We consider this a failing.
32. Although Mrs J was reviewed by physiotherapists on 28 March, they did not assess her ability to manage the stairs. We consider this a failing too.
33. Having found failings, we considered what the impact was. Mrs R told us the consequences were ‘astronomical’, leading to an ‘agonising and traumatic’ ten days for her family. She said they had to fight for basics to support Mrs J with her daily needs and attempting to get upstairs ‘almost killed her’.
34. We appreciate it must have been distressing for Mrs J not to be able to go upstairs in her home. She had to sleep on the sofa, for example. Mrs J’s daughter was unable to work and had to manage her own health needs while she was caring for her. All of this added to what was already a challenging time for her family.
35. Multidisciplinary discharge planning, in line with NICE guidance, would have resulted in a thorough assessment of Mrs J’s needs. An occupational therapist would have looked at her functional needs which might have meant providing equipment downstairs and Mrs J would have had a care package in place, if needed.
36. The Trust should be screening for frail patients to make sure they have the assessments they need and are seen by the relevant teams during their admission. We are making recommendations so the Trust can address this. It may wish to review its internal discharge policy and guidance to increase awareness of the multidisciplinary team.
Oxygen therapy 37. In line with NICE Quality Standard 10, because Mrs J had COPD (chronic obstructive pulmonary disease) she should have been seen by the respiratory team while in hospital. They should have provided individual written advice on management of her condition, including the use of home oxygen.
38. Our nursing adviser explained that in hospital the prescription for home oxygen is usually made by the respiratory team. It is then provided at home by the community service, with an ongoing prescription from the GP.
39. The records should show a patient had been seen by the respiratory team and received written information about oxygen treatment and a prescription for community treatment.
40. The Trust’s discharge summary from 4 April 2022 refers to Mrs J’s respiratory problems as the primary medical condition. It says she had bronchiectasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection) and chronic obstructive lung disease and that respiratory nurses advised on her long-term oxygen therapy. This is in line with NICE guidance.
41. The Trust prescribed oxygen while Mrs J was in hospital and it kept records of its administration. It prescribed oxygen by a nasal cannula (at rate of 0–4 litres/minute, four times a day) when it discharged her on 31 March. This is the correct procedure as it makes sure that oxygen is supplied in the community.
42. We have seen no evidence that the Trust had a care plan in place for Mrs J’s respiratory needs. A note from 31 March, the day the Trust discharged Mrs J, says the respiratory nurse specialist saw her before discharge and provided information verbally.
43. The specialist nurse recorded they explained the long-term oxygen to the patient and made appropriate arrangements for oxygen to be supplied in the community. But, the note does not say whether the information was given in writing. NICE guidance says information must be given in writing. We consider this a failing.
44. We understand Mrs R’s concern that her grandmother did not know how to use the therapy.
45. It is possible Mrs J got home and could not remember how to use the oxygen therapy and did not have any written information to refer to. Our nursing adviser explained a handout would usually be given to the patient and a copy would be included in their notes.
46. Our respiratory physician adviser helped us consider the potential impact of reduced oxygen on Mrs J’s physical health. They referred to the British National Formulary (BNF), that provides information about the use of medicines and guidance from the BTS.
47. The BNF treatment summary about oxygen therapy says oxygen saturation for most acutely ill patients should be 94–98%. Mrs J’s oxygen saturation was 88% on air at home. This means she was chronically hypoxic, where the body becomes used to low oxygen levels. She had a flare-up of bronchiectasis and also had COVID-19. She would have been more oxygen-dependent than usual due to the illness.
48. According to BNF and BTS guidance, long-term oxygen therapy should typically be considered for patients with PO2 (blood oxygen level) of less than 7.3. The Trust measured Mrs J’s blood gas on air on 28 March. Her PO2 of 6.45 meant she met the threshold for supplying long-term oxygen therapy. This means we have no concerns about the prescription.
49. Mrs J’s oxygen level was not much below the BNF blood gas threshold. Mrs J’s blood oxygen level of 28% from the same day was 10.15. On 31 March, it was recorded as 7.72.
50. Long-term oxygen therapy is a preventative measure for the long-term (to prevent heart failure), not the short term. Long-term use typically involves using oxygen 15 hours a day. The BTS guidance says use up to 24 hours per day may be of added benefit. A lack of oxygen therapy is not known to cause flare-ups of bronchiectasis or COPD. Instead, this is often due to an infection.
51. There are no short-term studies to tell us about what happens if oxygen is not given in this situation, but Mrs J’s readmission was only ten days after discharge. There is no evidence that the use of oxygen therapy at home contributed to this. And, Mrs R told us the oxygen therapy was consistently on.
52. Our respiratory physician adviser explained Mrs J went into hospital after having low oxygen levels at home. Although Mrs J went from type 1 respiratory failure (low oxygen) to type 2 respiratory failure (low oxygen and retaining carbon dioxide), this reflects she was getting worse. It is not a sign that something had gone wrong with the use of the oxygen therapy. We hope this provides some reassurance to her family.
53. The Trust has provided evidence that it uses an appropriate home oxygen document and a patient letter it can adjust. It was not able to confirm that it gave this to Mrs J or not, but it has recognised the need to record this by scanning the document in future. We are not making recommendations in relation to this.
DNAR 54. GMC guidance on care towards the end of life says doctors must work on the presumption that every adult patient has the capacity to make decisions about their care and treatment. A patient’s age, disability, appearance, behaviour, medical condition, beliefs, apparent inability to communicate or decisions should not lead to an assumption that they lack capacity.
55. If a patient lacks capacity, the doctor must consult with any legal proxy (a person who can make decisions for someone who does not have capacity) and others close to the patient about the DNAR decision and the reasons for it. If it is not practicable or appropriate to do so, these discussions should take place at the earliest opportunity after. They should include a sensitive and careful explanation that the intention is to spare the patient treatment that will be of no benefit. It is not to withhold any other care or treatment the patient will need.
56. The Trust did not clearly document if Mrs J had capacity. Our adviser said it may be the Trust assessed Mrs J as having capacity so did not consider it needed to formally record this.
57. We appreciate Mrs R’s concerns about her grandmother’s involvement in the discussion. She was very clear with us that her grandmother did not have capacity to make a decision.
58. The records refer to Mrs J being alert and involved in the discussion about DNAR with a consultant. We recognise the documentation is not as detailed as it could be. The Trust may wish to reflect on this.
59. Based on the available information, our adviser said the Trust acted in line with best practice by having a conversation about its decision with Mrs J’s relatives within an hour. The Trust’s decision that Mrs J was not a suitable candidate for CPR was in line with what they would expect to see. She was frail and would have been unlikely to recover from resuscitation.
60. We appreciate how strongly Mrs R feels about the Trust’s decision. She feels the Trust did not address her concerns around the DNAR. The Trust’s response explained an ED doctor and a member of the medical team assessed Mrs J. A consultant discussed the DNAR form with her and then with her daughter.
61. This is consistent with what we have seen. The records say Mrs J had agreed to the DNAR and the Trust told her daughter this. We recognise Mrs R feels it was wrong for the Trust not to involve the family sooner.
62. We hope our explanation about this reassures her. We have seen that even if the Trust had considered Mrs J did not have capacity, this would not have changed anything in terms of the decision it made. This is why we have not found a failing in relation to this.
63. We have looked at each aspect of Mrs R’s complaint separately. Although she has not specifically raised this herself, a common underlying issue across the care we looked at seems to be the record keeping.
64. The GMC ‘Good medical practice’ and the NMC Code say doctors and nurses must keep accurate records. They must include information about assessments, discussions, decisions made and steps taken to deal with any problems. Medical records are made to support safe and effective care so it is important for us to note issues around them.