Nursing care
20. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done this we decided the Trust has already done enough to put right the impact of what happened.
21. Mrs A says when Mr A went into hospital, he had a small bedsore on his buttocks that she and Mr A’s carers told staff about. She says because staff did not get Mr A out of bed or move him around enough, his bedsore got worse. We are sorry to hear this caused Mr A pain and discomfort and Mrs A was upset by this.
22. In its complaint response the Trust said staff provided Mr A with regular repositioning while in bed. It said out of the 13 days Mr A was in hospital, there were four days when Mr A got out of bed and sat in a chair.
23. The Trust also said therapists assessed Mr A and he could not sit up on the edge of the bed. It said to get Mr A out of bed, therapists would need to have used a hoist transfer. The Trust said the therapist was unable to remember why they did not hoist Mr A into a supportive chair and they did not write the reasons. It also said after a detailed assessment, therapists should provide recommendations to nurses on the method of transferring patients to a chair and it acknowledged these recommendations were not made.
24. The Trust said therapists continued to have difficulty getting Mr A to the edge of his bed over the next few days due to his agitation. It said by the end of April Mr A had improved and was walking on the ward. In a later response the Trust said Mr A did not get out of bed for two days at the end of the month.
25. Mrs A says staff did not read the booklet explaining Mr A’s condition (dementia) and did not show due care to a dementia patient when trying to bathe him. She says staff should not have tried to force him to be bathed and should have shown more patience with him. Mrs A says this caused Mr A to lash out and caused him injuries. We are sorry to hear that Mr A got cuts to his arm/hand during this incident and we understand this caused Mrs A further distress.
26. In its complaint response, the Trust acknowledged the injury to Mr A’s hand. It said it is difficult to say if staff read the ‘This is me’ booklet as expected. It said nursing staff noticed a change in behaviour when Mr A’s own (private) carers were helping him and this was helpful as staff learned about his care needs. The Trust said this is not an excuse for not attending to or understanding Mr A’s needs.
27. The Trust also said the care of the elderly team review patients with dementia. It said staff failed to refer Mr A to this service which could have provided staff with a greater understanding and the family with a better service.
28. Mrs A says that if staff had read the documents properly, they would have taken more care and Mr A would not have lashed out when being washed, ending in the injury. We understand why she is concerned about this and recognise this was really distressing for her. It is clear, and the Trust has accepted, that staff should have taken note of the document which would have provided important information about Mr A. But, we cannot say that reading the booklet would have prevented Mr A from lashing out and we cannot say the injuries could have been avoided. This is not to dismiss Mrs A’s concerns. Staff should have reviewed the document and taken every care to prevent Mr A’s distress.
29. Mrs A is also concerned that her husband’s bed sores got worse. The Trust said they did not get worse during the admission. We cannot say for certain whether more movement would have increased the amount of time Mr A spent out of bed or if there would have been any improvement to his bedsores. We are not excusing what happened and most importantly the Trust has accepted it should have done better. We recognise the things that went wrong have left Mrs A uncertain about whether her husband’s experience could have been different.
30. While we cannot say the actions of the Trust caused Mr A’s bedsores to get worse or caused the injury to his hand/arm, we can see the issues the Trust has accepted caused Mrs A distress and upset.
31. Our Principles say it is good practice for organisations to be customer focused, specifically, ‘Apologising for and explaining the maladministration [fault] and poor service.’
32. The Trust acknowledged the events were very distressing and apologised that the family felt staff lacked empathy, they did not meet their expectations and for the family’s experience at the Trust.
33. Our Principles also say organisations should seek continuous improvement, including ‘Using the lessons learned from complaints to ensure that maladministration or poor service is not repeated.’
34. The Trust acknowledged there are learning and training needs for staff when caring for patients with dementia. It said it has started taking steps to improve staff knowledge around this, providing specialist support and services to enable staff to develop their skills.
35. In its complaint response, the Trust outlined an action plan to address the issues raised by Mrs A and those identified through its investigation. It said: • make sure all therapists are aware of the importance of getting patients out of bed and if that is not possible to document the reasons • to remind therapy staff to continue to communicate with their nursing colleagues to check that advice is given on getting patients up • make sure all nursing staff are up to date with training including attending COE (Care of the Elderly) training day • to arrange bitesize training with dementia specialist nurse.
36. We asked the Trust to update us on the progress of this action plan. It provided evidence that shows the therapist team leader held a meeting with the therapists on 14 July 2023 to address the first two actions. It also provided evidence that nursing staff attended dementia and care of the elderly training on 6 and 7 July 2023.
37. We think the Trust has already taken steps to improve its services for future patients to prevent the same things happening again. This is in line with our Principles and we are pleased to see this is because Mrs A has taken to the time to make her complaint.
38. For these reasons, we will not investigate this issue further.
Positioning of Mr A
39. Mrs A says when she and staff thought Mr A had pain in his neck, staff put him flat on his back and secured his head in head blocks. She said after a CT scan of Mr A’s neck, staff told her Mr A would have to stay in head blocks until he had an MRI scan the next morning. Mrs A says this was longer than necessary and we are sorry to hear it caused Mr A distress. We understand it was also distressing for Mrs A to see her husband like this.
40. In its complaint response the Trust said after discussions with a therapist and the family, there were concerns about the possibility of a fracture of the bones in Mr A’s neck.
41. The Trust said it is usual practice to place a patient on a trauma mattress with head blocks when waiting for scans for possible fractures in the neck. The Trust acknowledged that the family raised concerns about Mr A being flat with the blocks on for a prolonged period. It said because of this, it brought the CT scan forward.
42. The Trust went on to say the CT scan did not show any fractures in Mr A’s neck. It said staff suggested Mr A should also have an MRI scan and for him to stay in the blocks for the ward team to review this the next morning.
43. NICE guidance says a person is at high risk if they are over 65 years of age. The guidance says to carry out full in-line spinal immobilisation if a person is high risk and to do a CT scan. It says immobilisation should be done by stabilising the head with measures including head blocks and tape.
44. An entry at 5.26pm in Mr A’s clinical notes details a consultant review. This note says staff explained to Mrs A that they would need to put Mr A on a trauma mattress and in head blocks. It says Mr A needed a CT scan. The note says, ‘Explained plan to wife who was at bedside, explained risk of missing C-spine fracture and difficulty to assess and confidently clear C-spine.’ Our adviser says ‘clear C-Spine’ means confirming there is no fracture.
45. The note goes on to say, ‘if report shows no fracture, can remove everything but may be until midnight or later before we get report. If any fractures, will have to discuss with [another hospital] and keep blocks on.’ It says Mrs A was happy with this plan.
46. Mr A fell into the high-risk category because he was over 65 years of age at the time of the events. Our adviser said once staff thought Mr A may have a neck injury, they acted in line with NICE guidance when they immobilised him by putting him on a trauma mattress, in head blocks and then requesting a CT scan.
47. The clinical records show the Trust did a CT scan shortly after it was requested (5.55pm) and a radiologist provided a report. The image report shows no obvious fracture or dislocation, but it did show some degeneration of three sections of the C-spine and some ligament or calcification (hardening) at the edges of the bone. In their report, the radiologist recommended an MRI scan of Mr A’s neck.
48. Our adviser said core hours for senior ward consultants are between 8am and 4pm or 9am and 5pm, so this was outside of normal hours and it is unlikely there would have been a consultant there at that time.
49. Our adviser said in the absence of a consultant, an on-call team should follow the recommendations from the CT report. The notes show that at 8.25pm the on-call doctor told staff to keep Mr A in head blocks until the MRI scan was done the next day and this was for Mr A’s safety. Our adviser said this is in line with NICE guidance as his neck had not been cleared. They said MRI scanners are only normally in operation in core hours so it is understandable that this would be the next morning.
50. An entry in the notes from the next day shows a doctor reviewed Mr A and set an action for a senior doctor to review if he needed an MRI scan. A note was added to this at 12.12pm to say there was a conversation with another doctor. Our adviser said this was likely to be a senior consultant as planned. The conversation shows this doctor said given there was no fracture on the CT scan and based on Mr A’s history and presentation, he did not need an MRI. The notes show staff could take Mr A out of head blocks and mobilise him.
51. The notes are not clear on when staff removed Mr A’s head blocks. Mrs A says she called the ward at 7.30am and staff told her the head blocks were off. She says a doctor called her daughter at 9am and confirmed this. She also says Mr A’s carers attended at 9.30am and did not report the head blocks being on so she believes they were off at this time.
52. Our adviser said morning handovers are at around 7am. They said it would be normal for junior doctors to do ward rounds after handover to review cases, then contact senior consultants if needed.
53. GMC guidance says doctors must provide effective treatments based on the best available evidence and should consult colleagues when appropriate. Our adviser said the morning doctor acted in line with this guidance when they considered the best treatment for Mr A, spoke with a senior clinician and then directed for Mr A to be mobilised.
54. Our adviser said as the headblocks were removed sometime before 9.30am, this was in good time and in line with GMC guidance.
55. For these reasons, we think staff acted in line with GMC and NICE guidance when they kept Mr A immobilised in head blocks overnight.
56. We are sorry to hear it was distressing for Mr A to be in head blocks and for his family to see him this way. We are reassured that staff were acting in his best interests and the head blocks were kept in place as a precaution to protect him. Removing them before staff were confident his neck was clear would have been more dangerous and could have caused him more harm. We are grateful to Mrs A for telling us about her experience and we appreciate this was a difficult time for her. We hope she is reassured by what we have seen.