Assessments 13. Ms A complains the Trust did not do appropriate nursing assessments of her father during his admission, based on his condition at the time.
14. The NEWS guidance explains clinicians should regularly assess a patient’s overall condition based on six areas - respiration rate, oxygen saturation (how much oxygen is in your blood), systolic blood pressure (the pressure when your heart pushes blood around the body), pulse rate, level of consciousness and new confusion and finally their temperature.
15. These areas are then scored (given a NEWS score) either low, medium or high depending on the severity, this in turn affects how often a patient should be reviewed. For:
• patients scoring zero the minimum frequency of assessment should be every 12 hours • patients scoring one to four the minimum frequency should be every four to six hours • patients scoring five to six the minimum frequency should be every hour • patients scoring seven or above there should be continuous monitoring.
16. The NICE guidance explains for patients with COVID-19 who need extra oxygen to meet their required oxygen saturation levels, clinicians should treat patients with corticosteroids (steroids).
17. Mr A had COVID-19 pneumonia during his admission and was put on high-flow oxygen treatment through a mask. We have reviewed Mr A’s clinical records during his admission to see if the Trust did appropriate assessments during this time.
18. The records show Mr A’s NEWS score was between two and 11, meaning he needed differing levels of observations throughout. We can see he was reviewed every day during the admission and each time his NEWS score increased, the Trust arranged for him to be reviewed again in line with the timescales given in the NEWS guidance above.
19. The records show his treatment was appropriately escalated to a senior clinician for review and we can see the Trust spoke with Mr A’s family to agree a routine for observations, set at two hourly. Our physician adviser confirms the Trust escalated Mr A’s care at the correct time.
20. We can also see the Trust reviewed Mr A at each point when his condition deteriorated throughout the admission. The Trust started him on dexamethasone steroids which is in line with the NICE guidance and discussed his condition with doctors within the intensive care unit, who decided he was not suitable for critical care at the time. At the end of his admission, Mr A was receiving the maximum treatment possible, but his condition continued to deteriorate despite the Trust’s intervention.
21. Overall, we consider the Trust did appropriate assessments during the admission and escalated his care when necessary. We have seen no failing in this part of the complaint. We understand how important this issue is for Ms A. We hope our findings provide her with some reassurance.
Continence 22. Ms A complains the Trust failed to meet her father’s continence needs during his admission.
23. The Trust’s guidance explains intentional rounding is a structured process where nurses on the ward carry out regular checks with individual patients at set intervals. During these checks, nursing staff carry out scheduled tasks or observations with the patient including addressing pain, positioning and toilet needs, assessing and attending to the patient’s comfort and checking the environment for any risks to the patient’s comfort or safety.
24. The clinical records show the Trust carried out intentional rounding on Mr A throughout his admission and he needed continence care by helping him to use the toilet and a skin barrier cream to prevent skin breakdown.
25. From reviewing the evidence provided by the Trust it is not clear what assistance, if any, it gave to Mr A to meet these continence needs. Our nursing adviser explains there is only one note of the Trust recording Mr A’s urine output by use of a urine bottle and nothing more in the clinical records to say what level of continence care the Trust gave to Mr A.
26. Based on the evidence available we cannot say, even on balance, that the Trust gave appropriate continence care to Mr A. We think it failed in its overall continence care and did not act in line with its intentional rounding guidance.
27. Ms A says the failure to provide appropriate continence care caused her father pain and discomfort. Having found a failing, we have considered if this had any impact on Mr A.
28. There are no records to detail the continence care given so it is not clear what impact if any, the failing had on Mr A. Our nursing adviser explains the failure to provide appropriate continence care would cause a poor experience of care, the distress of feeling uncomfortable and the risk of skin breakdown. Ms A says her father experienced pain and discomfort due to poor continence care and we have no reason to dispute this.
29. We think it is more likely than not that the failing to provide appropriate continence care caused Mr A pain and discomfort during his admission. We recognise knowing this caused Ms A distress and upset and we recommend the Trust apologises to her and acknowledges the impact this had on her. We also recommend the Trust creates an action plan to show how it plans to learn from this complaint to prevent the same things from happening again.
Falls assessment 30. Ms A complains the Trust did not properly assess her father’s falls risk and make a plan.
31. The Trust’s falls guidance explains all patients admitted should be assessed for the risks of falling using the risk assessment tool. This is split into three parts, to be completed within 24 hours of admission. Parts one and two should be completed for all patients and this includes a history of previous falls and any potential falls risks. Part three should be completed daily to evaluate the patient’s falls risk that day.
32. The falls guidance goes onto explain nurses should make sure the patient is familiar with the ward environment, a nurse call bell is accessible to the patient and they know how to use it and bed rails should be fitted if necessary.
33. If patients are incontinent, nurses should consider moving them closer to the toilet facilities. If they have an altered mental state such as confusion or issues with cognition (understanding), they should consider the use of bed/chair sensors or move to an area of the ward that increases observation and consider one to one nursing care.
34. The clinical records show the Trust did a falls risk assessment on Mr A on the day of his admission. It found risks in part two of the assessment, meaning a daily risk assessment was needed. We can see no evidence of the Trust doing a daily falls risk assessment after the admission, until the day Mr A died. This is against the Trust’s falls guidance and our clinical advice. This is a failing.
35. We have considered whether this had any impact on Mr A. Ms A says this failing caused her father to get out of bed to reach his commode which was at the other side of the room. She says his oxygen supply came out and he died and this was avoidable.
36. It is likely that by failing to do daily falls risks assessments, Mr A was potentially at a greater risk of falling and we understand he did fall on the way to his commode.
37. We have considered what measures the Trust had in place before his fall. The records show during the last observations before his death Mr A had bed rails in place and constant access to the nursing call bell, which Ms A confirmed he knew how to use. Mr A had no reported issues with his cognition and capacity and did not need constant one to one nursing care.
38. The records also explain doctors had told Mr A to keep his oxygen mask in place and stay in bed. This meant he was receiving personal nursing care to use a bedpan. This is all in line with the Trust’s falls guidance. We do not think there is anything more the Trust could have done to stop Mr A from removing his oxygen mask and getting out of bed to use his commode.
39. We got clinical advice to establish whether Mr A’s death was avoidable. Our physician adviser explains Mr A was very unwell towards the end of the admission and he was already on the maximum level of treatment possible. But despite this, his condition continued to deteriorate. Our physician adviser thinks Mr A was dying at this time and sadly there was no way to prevent this.
40. Taking everything into consideration including Mr A’s overall condition, his cognition and the measures taken by the Trust to prevent a fall, we have not seen evidence to say his sad death was avoidable.
41. We recognise that knowing Mr A did not receive the correct care caused Ms A distress and upset and we recommend the Trust apologises and acknowledges the impact this had on her. We also recommend the Trust creates an action plan to show how it plans to learn from this complaint to prevent the same things from happening again.
42. Ms A has also asked for a financial payment as an outcome. We have considered this carefully in line with our guidance. We have decided the issues came from a one-off failing with a low impact so we do not feel that a payment is appropriate.