Neck Fractures 12. Mrs A complains that on 31 December 2020 after a fall at home, Mr A attended the ED and the Trust failed to detect two fractured bones in Mr A’s neck. Mrs A says that after Mr A’s discharge he had neck pain, and she believes the Trust failed to detect two fractures in his neck that were later discovered after a fall on 14 January 2021. Mrs A says the Trust should have completed a neck scan, as well as the CT head scan.
13. The Trust says there is no evidence to support this and it is impossible to say that the fractures were old.
14. NICE guidelines say to do a CT cervical spine scan within one hour for people who have a head injury. This would be the kind of scan Mrs A is suggesting above. NICE has criteria for the circumstances that this would be needed. One of these is if the patient is over the age of 65.
15. Mr A fell at home on a tiled floor in his bathroom. This caused him to have a severe nosebleed that would not stop so he called an ambulance. Paramedics assessed him and took him to the ED for a head Xray and head CT scan. He was diagnosed with a broken nose.
16. The records show that what happened was discussed with him and he was examined. The nurse who assessed Mr A documented that he did not complain of any neck pain and the ED doctor, who later assessed him, recorded that Mr A had no other symptoms other than his sore nose and there was no neck tenderness. They also noted Mr A was alert, orientated and not confused.
17. Our ED adviser explained there was no clinical suspicion of a neck injury at this time so there was no suggestion that a CT cervical spine scan was needed. They explained that while Mr A had a head injury and the guidance says that patients over 65 should have a cervical spine scan within an hour, his injuries and symptoms indicated he needed a head X-ray and head CT scan, as this was where his pain and nosebleed were.
18. Our adviser also explained a CT scan carries risk due to the elevated levels of radiation used and it is known that exposure to radiation during CT scans can increase the chances of developing cancer, although this risk is thought to be very small. In this case Mr A had head injuries so a head CT scan was done. They also said, CT scans are a limited resource in the NHS and will only be done where clinically necessary.
19. We can see the Trust acted within the guidelines when it decided to just do a head CT scan on Mr A.
20. To reassure Mrs A we did ask our radiology adviser to look at the head CT scan images. They explained that although the Trust’s intention was to scan only Mr A’s head, the head CT scan also captured part of the cervical spine.
21. Our radiology advisor said this scan did not show any neck fractures. So it seems likely that the neck fractures must have happened later, and not during the fall on 31 December 2020.
22. We have seen no signs that anything went wrong and we do not uphold this part of the complaint. We understand how distressing this was and why Mrs A and her family were concerned. We hope our findings have reassured Mrs A that the neck fractures were not missed in December 2020.
Fall Risk 23. Mrs A complains that after Mr A’s admission on 13 January 2021, the Trust did not follow the correct procedure for falls risk and he fell on 17 and 19 January. She says after the second fall the Trust found a bleed on his brain. She thinks that if it had taken correct prevention action, the falls would not have happened.
24. On this admission Mr A was unwell with delirium (confusion). He also had sepsis and needed to wear a hard collar for his neck fractures. He had a pre-existing cognitive (comprehension and understanding) decline that was suspected to be vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain that causes problems with reasoning, planning, judgment and memory). He also had pre-existing severe chronic obstructive pulmonary disease (COPD is a lung disease) and had a heart valve replacement.
25. The Trust’s slips, trips and falls policy says NICE guidelines on falls in older people says that all inpatients must have a falls risk factor assessment form and bed rails risk assessment form completed within six hours of admission. After assessment, the falls care plan and interventions such as a bed rail care plan must be completed by both nursing and medical staff.
26. NICE guidelines on falls in older people says older people who have had a fall, or report ongoing falls in the past year, should be offered a multifactorial falls risk assessment. It goes on to say they should then have a falls care bundle, a falls risk symbol, a bed rail risk assessment and bed rail care plan and the Trust should start a confusion care pathway.
27. The Trust did not complete these on admission and a multifactorial risk assessment was also not completed. This is not in line with the guidelines and is a failing.
28. The Trust has acknowledged that it failed to assess Mr A in line with its policy. Mr A was not assessed until six days after he was admitted.
29. We went on to consider the impact of this failing. Mr A fell twice before he was assessed. After the second fall he developed a bleed on the brain (a subarachnoid haemorrhage). Mrs A feels that these failings added to cutting her husband’s life short.
30. Our nursing adviser has explained that a risk assessment is intended to identify risk factors that could be treated or managed during the hospital stay, but this may not have stopped Mr A from falling as they are only preventative measures.
31. Although there was no assessment, there were frequent and regular entries in the notes about Mr A’s history of falls and his confusion, non-compliance with care and his collar - so staff were aware that he was at risk and he was referred to the physiotherapists and occupational therapists. They created an approach to Mr A’s mobility as recommended by the NICE guidance.
32. So, although the assessment was not completed, we cannot say Mr A would not have fallen. We have seen evidence that staff were aware of the risk and started some of the interventions needed.
33. When Mr A fell a CT brain scan was done within eight hours which diagnosed the subarachnoid haemorrhage. Mr A was then referred to and discussed by the neurosurgical specialists, neuroobservations were carried out and apixaban (a blood-thinner) was stopped. This is in line with NICE guidelines on head injury.
34. Our physician adviser explained a subarachnoid haemorrhage is considered a milder form of traumatic brain injury that has a low death rate, needing a shorter length of stay compared with other types of brain injury. They said it is unlikely this was a significant factor in Mr A’s continued deterioration and death several months later.
35. We cannot say that the failure to assess Mr A’s risk of falls and put full prevention actions in place led to a much reduced life expectancy for Mr A. The failing did cause Mrs A anguish, anger and worry that his fall could have been prevented.
36. Our Principles say we would expect organisations to acknowledge mistakes and apologise for the impact these had. We would also expect an organisation to take action to learn and improve from its mistakes. When things go wrong, we expect organisations to put things right. This includes considering offering all forms of remedy such as an apology, explanation, and action to put things right.
37. The Trust has already acknowledged that Mr A was not correctly assessed within six hours in line with its policy and it has apologised. The Trust has provided extra training to staff and closure monitoring to make sure they are following the policy.
38. We are satisfied that the action the Trust has already taken is enough to address the impact of the failing. We do not uphold this part of the complaint.
39. We hope it gives Mrs A some peace of mind in knowing that the failing is unlikely to have affected what went on to happen. Although it was clearly very distressing for them both at the time. We hope Mrs A is reassured from her meeting with the Trust and our investigation that the Trust has taken the complaint seriously and taken action to learn and improve.
Discharge 40. Mrs A complains that on 17 February 2021 Mr A was incorrectly discharged. She says he was sent home in a taxi and should have been sent home in an ambulance. She also says he was sent home in hospital clothes and socks with no shoes which was inappropriate. She says he was discharged home while still experiencing delirium and the police had to be called because he was a danger to himself.
41. The Trust has accepted he was sent home in hospital clothes, socks and no shoes. It said the family should have been asked to bring in his own clothes and shoes. It apologised for this and for sending Mr A home in a taxi.
42. It explained Mr A was due to go home in an ambulance, but the ambulances became very busy and the hospital was under a lot of pressure because of the pandemic. It said the policy is now not to send patients home in taxis and it has not happened since. It said it sent him home in hospital clothes as his own were soaked in urine.
43. We are unable to confirm discharge advice at this point in the pandemic. But, generally discharge should be in line with NICE guidelines. NICE says discharge should include person-centred care, communication and information sharing. It says discharge planning should begin at the point of admission and include a hospital-based multidisciplinary team. It says during the hospital stay this planning should include recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge.
44. The NICE guidance also says clinicians should make sure of continuity of care for people being transferred from hospital, particularly older people who may be confused or who have dementia. They should also make sure that any pressure to make beds available does not result in unplanned and uncoordinated hospital discharges.
45. The Trust followed this guidance before Mr A was discharged. There is evidence of a discharge plan and multidisciplinary approach to the discharge by doctors, nurses, physiotherapists and occupational therapists.
46. The failing we have seen is that the plan does not seem to have been kept to when making the final decision to send Mr A home in a taxi. This was not part of the planned discharge and happened due to the unavailability of an ambulance. The Trust said, ‘the balance and the pressure on the nurses at the time is we’ve got more and more patients downstairs waiting to come in, and the nurses have got to try and make beds for them.’ NICE guidance is specific about this not affecting a safe coordinated discharge. This was a failing.
47. Our nursing adviser said sending a patient who is confused home in a taxi with his medications is not in line with the NMC Code and is not safe practice. Sending a confused patient home in a taxi with an unknown person is not continuity of care in line with NICE guidelines.
48. The NMC Code says you should only delegate tasks and duties that are within the other person’s scope of competence, making sure they fully understand your instructions. Our adviser explained by sending Mr A home with a taxi driver, his care was being delegated to a member of the public which is not in line with the Code.
49. The NMC Code also says to treat people as individuals and uphold their dignity. To achieve this you must treat people with kindness, respect and compassion. Discharging Mr A in a taxi in pyjamas was not dignified and in line with the Code.
50. Mrs A also complains that on 17 March her husband was discharged again but was not well enough for this and had a poor support plan in place. She says he should not have been sent home and the fact he returned to hospital the same day shows this.
51. The Trust said six days before he was discharged on 17 March, Mr A repeatedly said he wanted to go home and the hospital thought the home setting would be best for him. It said there was a high expectation that he would settle at home but admitted that this time the discharge failed.
52. The records we have seen show that during this admission there was a multidisciplinary approach to care and the discharge plan was kept to in line with the NICE guidelines. There seems to have been a clear awareness about the struggles the family faced caring for Mr A, but the records suggest they were happy at the point of discharge. It also seems to have been Mr A’s wish and he was medically fit for discharge and not needing any specific care that he had to be in hospital for.
53. The occupational therapists confirmed he was fit for discharge from 15 March and a plan was in place. The discharge to assess referral was completed detailing the support he needed. The Trust got confirmation the equipment needed at home had been delivered. It seems Mrs A was advised his delirium was unlikely to resolve, but he might be less agitated at home. He was safely discharged with the paramedics this time.
54. The discharge was safe as it was expected that it would be beneficial for Mr A to be at home in familiar surroundings which would decrease his delirium. Supporting services were in place and he was transported home with the support of paramedics. This time his delirium did not improve at home and in fact he became more distressed and had to be readmitted the same day. The Trust did get discharge wrong at this time.
55. Mrs A says the failure to discharge Mr A correctly in February caused her immense anguish and anger. Mrs A feels these failings cut her husband’s life short. We can see from what she told us and what went wrong that this was the case.
56. Our Principles say we would expect organisations to acknowledge mistakes and apologise for the impact these had. We would also expect organisations to take action to learn and improve from its mistakes. It also states when things go wrong, we expect organisations to ‘put things right.’ This includes considering offering ‘all forms of remedy’ such as an ‘apology, explanation and remedial action’ to put things right.
57. By bringing this complaint to us, Mrs A said she wanted an acknowledgment of failings, for the Trust to make improvements to its service and to make a payment to her.
58. We can see evidence that the Trust has already formally acknowledged and apologised for the poor service in February 2021 and new measures are now in place. The poor service has already been put right in line with our Principles. The Trust has changed its policy and given reassurances that since Mrs A’s complaint it has stopped using taxis to send patients home. It also explained that what happened was due to the exceptional circumstances of the pandemic and the fact that no ambulances were available.
59. We think the Trust has already done enough to put things right. We are not asking the Trust to do anything more and we do not uphold the complaint.
60. It is clear Mrs A and her family have all had an extremely difficult, upsetting and distressing experience. We are sorry to hear how this has affected them all. We do not want to underestimate how difficult it must have been to re-live these events and explain the complaint to us. We are grateful for the time and effort Mrs A has taken to do this.