Lack of opportunity to recover
17. 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 has gone wrong.
18. Mrs T complains the Trust did not provide her mother with the opportunity to recover from her fall on 29 May 2022. She told us this was because the Trust left her unattended and neglected and did not offer physiotherapy.
19. We are sorry to hear about Mrs T’s experience. It must be difficult to witness a family member being unwell and in pain. We appreciate Mrs T would want to know the Trust did its best for her mother when she was vulnerable.
20. To address Mrs T’s concerns we reviewed Mrs O’s relevant medical records and discussed what guidance is relevant with our adviser. They told us NICE quality standard on hip fracture in adults is most relevant.
21. This states people who have had an operation for hip fracture should be offered rehabilitation at least once a day to help them recover. Rehabilitation should be started by the day after their operation (unless there is a medical or surgical reason not to). It should include support with sitting and standing and keeping an upright posture to improve movement and strength and help with their recovery.
22. The medical records show Mrs O stayed in bed for much of the time during her first inpatient admission. We reviewed the times where Mrs O was offered physiotherapy by the Trust during her admission.
23. At 8.30pm on 29 May 2022, the Trust admitted Mrs O to the orthopaedic ward . It operated on her left hip on 30 May.
24. On 31 May, the Trust planned for full weight bearing physiotherapy. The physiotherapist (PT) reviewed Mrs O and did three rounds of yankauer suction (a process of removing excess mucus from the back of the throat and upper airway).
25. Between 1 and 7 June, the PT reviewed Mrs O daily. They reported limited engagement and poor transfers, confusion and fatigue on 1, 2 and between 5 and 7 June. They reported Mrs O appeared bright and chatty on 4 June.
26. On 7 and 9 June, the PT documented concern with whether Mrs O had much rehabilitation potential due to her dementia and non-weight bearing in one arm.
27. The PT reviewed Mrs O on 15, 20 and 30 June. They noted she was incontinent, unaware and was falling asleep in the chair on 20 June. They did three rounds of yankauer suction to the back of the mouth on 30 June because Mrs O had a choking incident.
28. We asked our adviser if the post-surgery physiotherapy was in line with relevant guidelines. We explained Mrs T’s concerns that her mother was not given the opportunity to recover from her fall. Our adviser explained that in their experience as a geriatrician, they felt the staff made a good attempt at post-surgery physiotherapy.
29. Our adviser noted physiotherapy should be offered at least once a day to adults who have had an operation for hip fracture. Our review of the records show the PT team visited Mrs O eight times in the ten days after her surgery on 31 May 2022. Mrs O was regularly noted to be asleep and confused.
30. Our adviser explained PTs are only able to facilitate patient recovery through the patient’s cooperation and this is where the patient will see the most benefit. If the patient does not cooperate, there will be minimal benefit to physiotherapy. Our adviser stated that when dementia patients specifically lose their mobility, they will likely not get it back.
31. In this case, the evidence suggests physiotherapy was difficult because of Mrs O’s ability to engage. Mrs O was noted to be drowsy and confused on five occasions. The evidence shows the Trust offered physiotherapy the day after Mrs O’s surgery but noted it to be inappropriate in her circumstances. This is in line with the NICE quality standard on hip fracture in adults.
32. The Trust attempted physiotherapy on 1 and 2 June, between 4 and 7 June and again on 9 June. It reviewed Mrs O on 15, 20, and 30 June. Staff transferred Mrs O and documented she was able to sit to stand with a rotunda (a transfer device) during physiotherapy.
33. These actions are in line with the NICE quality standard on hip fracture in adults. The evidence shows the PTs attempted to safely move Mrs O even at times where she was particularly confused on 6, 7, 15 and 20 June.
34. In summary, there are no signs of failings in this part of the complaint. Our review of all the evidence shows the Trust offered physiotherapy in line with the NICE quality standard on hip fractures in adults.
35. We hope Mrs T and her family are reassured that the Trust followed the relevant guidelines.
Failure to provide dementia medication
36. Mrs T complains the Trust denied her mother her dementia medication for six weeks between late May and mid July 2022 because of a swallowing problem. She complains this was despite the medication being available in liquid form. She says the Trust made no effort to make the liquid medication available during Mrs O’s first admission.
37. We are sorry to hear about the decline Mrs T says her mother experienced. To address this part of the complaint, we discussed what guidance is relevant with our adviser.
38. BNF guidelines say galantamine can be available as a modified release (MR) capsule, which must be swallowed whole or as an oral solution (liquid).
39. Our review of Mrs O’s medical records found the Trust gave galantamine orally on 30 and 31 May and 3 June 2022. It asked for a Speech and Language Therapy (SALT) review on 31 May and kept Mrs O nil by mouth until 4 June.
40. On 2 June, the SALT team recommended a level four pureed diet, level two mildly thick fluids and non-tablet medications. It kept Mrs O on this between 4 June and 4 July.
41. On 4 June, the pharmacy noted there was no galantamine modified release capsules available. Between 5 and 20 June, the Trust did not provide galantamine to Mrs O.
42. On 8 June, the Trust recorded Mrs O had a choking episode in the afternoon and needed suction. On 9 June it documented there was an accepted risk of aspiration (when something swallowed enters the airway or lungs). Mrs O aspirated a small amount of liquid paracetamol and pureed porridge on 28 and 30 June and needed suction.
43. The Trust gave galantamine orally on 21 June, between 24 and 27 June, and between 30 June and 4 July. The records show Mrs O refused galantamine between 22, 24 and 28 June and 2 July.
44. The Trust discharged Mrs O to a care home for respite on 4 July but readmitted her on 8 July. On 12 July, the pharmacist advised to consider switching galantamine to 12mg twice daily in liquid as appropriate.
45. The Trust did not supply galantamine 24mg between 8 and 13 July. It noted it was out of stock. The Trust switched to galantamine 4mg in 1ml oral solution twice daily between 14 July and 20 July.
46. The GPhC’s principles state pharmacists have a duty to provide medicines that are safe and fit for purpose. In this case, as the 24mg capsules were not safe, we think the pharmacy should have found galantamine in liquid form as early as 5 June, after it had found Mrs O could not take the capsules. It did not do this until 13 July. This is an indication of failing.
47. In its complaint response the Trust explained it was able to find and order galantamine in liquid form during Mrs O’s second admission. Its investigation said it would have been possible to do this while Mrs O was cared for on the orthopaedic ward. It accepted the information provided by the pharmacy at the time was incorrect. It shared the error with staff in the pharmacy department.
48. Our Principles say where a public organisation has failed to get it right and this has led to injustice or hardship, it should take steps to put things right. This means, if possible, returning complainants to the position they were in before any failing took place. In many cases, a quick explanation and an apology is enough and an appropriate response.
49. We note Mrs T’s concerns that the lack of her mother’s dementia medication proved fatal and her dementia took over. To address whether the Trust had done enough to put this right, we discussed the potential impact of not having galantamine with our adviser. We calculated Mrs O went without galantamine for 31 days in total during her admissions. Mrs O refused the medication on five of those days.
50. Before answering our question, our adviser provided some background information on galantamine in treating dementia. Our adviser explained galantamine is one of four drugs used in Alzheimer’s disease. They explained the idea is to reduce the deterioration of dementia over a period of years.
51. A patient with a mild to moderate (above ten) score on the mini-mental state examination (MMSE) will be a candidate for a trial of galantamine or other similar medications. Patients will expect to deteriorate around 1.5 points per year on the MMSE without treatment. This is indicated by Study B. Patients will expect to deteriorate more gradually with treatment.
52. Our adviser said if a patient is not on galantamine for a period, they may sometimes have short-term acute confusion. The long-term effects include a slow deterioration of cognition (understanding) that is not as slow as if they were still on the medication. They explained it is important to note galantamine is not a short-term medication, but clinicians will usually try to keep a patient on it if possible.
53. NICE guidelines have shown there is a statistically significant benefit of galantamine which increases with time.
54. But, the evidence shows Mrs O was struggling to swallow and choked on other liquids (including paracetamol) at times. In this case, it is important to note Mrs O’s circumstances and the decision to risk feeding from 4 June onwards. Our adviser pointed out a patient cannot go indefinitely without oral medication and nutrition.
55. Our adviser explained that in Mrs O’s circumstances the impact of not being on galantamine for 31 days was minimal. NICE guidelines state the benefits of galantamine increases over time and it is therefore a long-term medication. Study A concluded this benefit (slowing the progression of Alzheimer’s disease) is estimated to last around 36 months.
56. The records show Mrs O had delirium (short-term worsening of confusion) and was noted to be drowsy and more confused than normal. The PT recorded Mrs O’s confusion eight times between 31 May and 20 June. Our adviser explained Mrs O’s confusion was more likely a consequence of several factors and not just because of the lack of galantamine. This includes the hip fracture, surgery, related pain, chest and water infections and a change in usual living circumstances.
57. Our adviser told us even when hospitals admit healthy dementia patients (for example, if their partner is admitted and they cannot be left at home alone), the change in circumstances alone can make them confused. Sadly, this likely contributed to Mrs O’s confusion and delirium during her time at the Trust.
58. We understand Mrs T might see her mother’s confusion as a result of the lack of galantamine and we sympathise with this. It must be difficult to see her mother, who she has explained was full of life before this, to be in a vulnerable and confused state.
59. We recognise there was an emotional impact on Mrs O. We do not minimise this. We have thought about what the Trust has already done to put this right and if it needs to do more.
60. The evidence we have seen shows Mrs O’s confusion was due to everything happening to her medically, including the pain and infections. Mrs O had a chest infection from 7 June and was prescribed antibiotics to treat a water infection from 14 June.
61. We also need to consider the evidence that suggests Mrs O was at risk of aspiration and choking. The Trust suctioned her on 31 May, and 28 and 30 June. We do not know if Mrs O would have been able to take galantamine in liquid form consistently during this time.
62. In this case, we have not seen enough evidence to link the confusion and deterioration Mrs O experienced with not having galantamine for 31 days. We consider the Trust’s actions are in line with our Principles and properly address the impact of what happened. This is because the evidence shows the impact would be minimal and we cannot say it was only the lack of galantamine that caused Mrs O’s confusion.
63. Mrs T told us one of her desired outcomes would be a financial payment. Our severity of injustice (SOI) scale puts Mrs T’s injustice at level one (the SOI is part of our guidance on financial remedy).
64. A level one injustice typically comes from a single failing, where the effect on the individual is of short duration and where there are no other negative effects or ongoing wider impact. This is the case for Mrs T’s complaint. We would not recommend a financial payment for a level one injustice and generally consider an apology to be enough.
65. In summary, we think the Trust has done enough to put right the impact of what went wrong. The evidence shows that many factors contributed to Mrs O’s confusion. As per the guidelines and discussion with our adviser, the impact of not being on galantamine for a short period was minimal. We understand this might be disappointing to Mrs T and her family, but hope they are reassured by our explanation.
Communication
66. Mrs T complains the Trust communicated poorly with the family.
67. Mrs T told us she felt the Trust did not make any effort to communicate with her mother. She told us the family continually found itself chasing the Trust, instead of focusing on Mrs O and her recovery. They felt ignored. Mrs T told us no discussions were had about any options available with the SALT team and they were not told about Mrs O’s pneumonia.
68. To address the concerns about the Trust’s communication, we reviewed the relevant medical records and complaint file. We noted times where the Trust documented its communication with Mrs O’s family.
69. On 30 May, the Trust discussed a DNAR (do not attempt resuscitation decision) with Mrs O’s daughter (Mrs T’s sister). It explained that attempting CPR may not be favourable.
70. On 4 June, the consultant discussed trialling SALT’s recommend diet and fluids with Mrs T. They noted Mrs T advised she had been present at Mrs O’s last meal and felt she did fine with puree.
71. The consultant documented Mrs T’s concerns that the syringe of medicine squirting down Mrs O’s throat set her coughing off. They explained the options available and advised they had reached a decision to reattempt staged diets and fluids and accept the risks involved. They explained they could revisit the options if they felt feeding was unsafe.
72. On 9 June, the OT telephoned Mrs T’s sister for the first interview. They documented Mrs O lived with her and was independent before. They documented Mrs O’s current mobility needs, incontinence and that they felt she was not safe for home with a full care package. The OT documented her agreement that Mrs O needed to step down from acute care for social assessment.
73. On 10 June, the Trust documented that Mrs T’s sister visited Mrs O and helped her with lunch. It explained there could be an infection in the chest and it would get an up-to-date chest X-ray and treat. It also explained the infection could be from aspirating. The Trust noted it explained if it became clear that Mrs O was really struggling to swallow safely, it may need to revisit feeding options.
74. On 24 June, the OT received a message from Mrs O’s discharge coordinator. The message advised Mrs O’s daughter had told the team she wanted Mrs O to come home. The OT contacted her and documented that she was happy for Mrs O to go to short-term care.
75. On 29 June, the Trust documented Mrs O’s daughter fed her a level four diet at lunch time.
76. On 30 June, the Trust documented Mrs O choked. It noted a further discussion about Mrs O’s feeding plan with her daughter. It explained the frequent choking episodes could lead to aspiration pneumonia and some deterioration of healthy teeth. It explained there was no long-term alternative and noted Mrs O’s daughter was fully aware and agreed to continue to risk feed.
77. At 11am on 4 July, the Trust noted Mrs O’s family were aware of the discharge plan. At 4pm, it rang the family and made them aware it had discharged Mrs O.
78. The GMC’s Good medical practice states clinicians must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. Clinicians must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including: • their condition, its likely progression and the options of treatment, including associated risks and uncertainties • the progress of their care, and your role and responsibilities in the team.
79. The Trust’s communication with Mrs O’s family is an indication of a failing. Over Mrs O’s inpatient stay between 29 May and 4 July, the evidence shows the Trust directly communicated with the family just six times. This includes a discussion about Mrs O’s suitability for rehabilitation on 9 June and about a DNAR on 30 May.
80. We note Mrs T told us no discussions were held about the options available with SALT and the Trust did not tell the family about Mrs O’s pneumonia. While reviewing the records, we found three discussions about Mrs O’s risk feeding on 4, 10 and 30 June. We noted that on 30 June, the Trust documented its explanation to Mrs O’s daughter about the link between choking episodes and aspiration pneumonia.
81. We would consider this to be in line with GMC’s Good medical practice on sharing the information patients will need to make decisions about their care. In this circumstance, the Trust shared its discussions on risk feeding and the potential consequences of this (aspiration pneumonia) with Mrs O’s family.
82. But, in its complaint response the Trust acknowledged it had not properly explained the clinical circumstances to the family. It provided an apology for this. It noted it had fed back to the consultant and senior nursing teams about explaining and documenting the severity of the type of injury Mrs O had.
83. We can understand that not being fully aware of the clinical circumstances may influence a patient’s and their families understanding of recovery. This is likely to add to any distress felt if the patient deteriorates unexpectedly.
84. From our review of Mrs O’s records, it seems she was unwell and struggled to rehabilitate after major trauma. This must have been difficult for both Mrs O to go through and for her family to see and we wish to repeat how sorry we are to hear about Mrs O’s death.
85. In this case, the Trust acknowledged and apologised for not properly explaining the full clinical circumstances to the family. It agreed to feedback the importance of explaining and documenting the severity of the injury to the relevant teams.
86. We consider the Trust’s response to this issue to be in line with our Principles. This is because the evidence shows discussions were held about Mrs O’s risk feeding, the risk of aspiration pneumonia and suitability for rehabilitation. We do think the Trust could have acted more in line with GMC Good medical practice in fully explaining the clinical circumstances of Mrs O’s injury to her family.
87. Mrs T told us two of her desired outcomes would be service improvements and an acknowledgement of any mistakes. We can see the Trust has done this through its complaint response and in providing feedback to the medical teams involved. We do not think a financial payment is appropriate on this point.
88. Based on this, we think the Trust has done enough to put right this part of the complaint.
89. We wish to thank Mrs T for bringing her complaint to our attention.