18. We have considered each of the issues Mrs T has raised with us. Where issues are similar in nature, or closely related, we will address them collectively.
Mr H’s mobility
19. Mrs T tells us her father was living independently before he was admitted to hospital. She says because no effort was made by clinical staff to get her father out of bed and rehabilitate him, he became bedbound and was unable to look after himself once discharged. She says this contributed to his deterioration and limited his chances of making a recovery.
20. The Trust says its physiotherapists regularly reviewed Mr H throughout his stay at both hospitals A and B and made appropriate attempts to improve his mobility.
21. Sections 1.3 and 8.6 of the CSP guidance say members should fulfil their duty of care to service users by constantly evaluating their plans to ensure they are effective and relevant to the patient’s changing circumstances.
22. We can see the Trust’s physiotherapy team visited Mr H at least 16 times between 26 January and 18 February. This is the period between his first admission to hospital A and his discharge home from hospital B.
23. The records show physiotherapists attempted to mobilise Mr H into sitting and standing positions during this period. We can also see ‘transfer practice’ (the safe movement of a person from one place or surface to another) with the assistance of a walking fame, was attempted.
24. Physiotherapists noted, however, that Mr H’s physical ability was limited due to the significant confusion he was suffering from at the time. This made it difficult for him to understand and safely follow instructions.
25. Physiotherapy treatment ended on 16 February (two days before his discharge home from hospital B) as physiotherapists were unable to make further progress with his rehabilitation.
26. We are satisfied the Trust’s physiotherapy team made all the appropriate efforts to improve Mr H’s mobility while he was a patient at both hospital A and hospital B.
27. Regular visits took place where physiotherapists reassessed and attempted to rehabilitate Mr H in line with CSP guidance and there is no evidence to indicate those attempts were poorly managed or carried out incorrectly.
Staff updates
28. Mrs T says family were unable to visit Mr H in hospital A due to COVID-19 restrictions. She says she and her mother called the hospital daily but were given very little information in return between 26 January and 9 February. Mrs T says they were anxious about Mr H’s condition, so it was important for staff to keep them updated.
29. The Trust says at the time of Mr H’s admission there was a national suspension on hospital visiting due to the COVID-19 pandemic. It says prior to the pandemic, patient visiting times provided opportunity for relatives to meet staff and ask questions about a patient’s care.
30. The Trust says its staff found the lack of face-to-face contact with relatives ‘extremely difficult’. It says its nursing staff did their best to telephone family members and provide updates, but this was challenging.
31. Our Principles say public bodies should communicate effectively, using clear language that people can understand which is appropriate to them and their circumstances.
32. We can see clinical staff spoke with Mrs T or Mr H’s wife, Mrs H, once or sometimes twice a day throughout the period in question. The consistency of updates they received appears to be in line with our Principles.
33. We appreciate Mrs T is mainly concerned with the level of information they were given. For example, she says they were often given the same information by different nurses and were unable to get more detail when they asked.
34. The medical records note nursing staff contacted family members to give them updates, but those records do not specify what was discussed.
35. Had records been more detailed it would have helped us to better understand what was discussed. This being said, we would not necessarily expect nurses, who provided a majority of these updates, to have set out notes on what was discussed. This is because those nursing entries already included a great deal of observational information around Mr H’s condition, which likely formed the basis any update they gave.
36. We must recognise that during the COVID-19 pandemic, the pressures faced by the NHS organisations had a huge impact on the service they provided. We appreciate the Trust was not able to contact Mr H’s family in the way it wanted.
37. We also acknowledge Mrs T, Mrs H and their wider family were anxious to receive information about Mr H and were frustrated not to receive the level of information they wanted.
38. We are satisfied staff, overall, acted in line with our principles in the updates they provided to Mrs T and her family.
Sedation
39. Mrs T says her father was ‘given something’ to calm him down as he was reported to have been aggressive after being moved to ward 11 on 28 January.
40. She says she was later told her father was just trying to get out of bed and ‘presumably he wanted to use the toilet as he was still doing at home before being admitted.’ Mrs T is concerned her father was inappropriately sedated and this caused him to become immobile and less able to recover from his illness.
41. The Trust says it prescribed haloperidol as Mr H was agitated and delirious while on ward 11. It says this prescription was made following input from its mental health team and subsequent dosages between 29 January and 9 February (when Mr H transferred to hospital B) were administered in line with NICE delirium guidance.
42. NICE delirium guidance, section 1.7 recommends haloperidol if ‘a person with delirium is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term haloperidol (usually for 1 week or less). Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms’.
43. BNF haloperidol guidance confirms a maximum dosage of 5 milligrams (mg) per day.
44. Mr H’s medical records document he was very agitated on 29 January so 500 microgrammes (or 0.5mg) of haloperidol was given to calm him. We can see 500 microgrammes of haloperidol was also given when Mr H was distressed or agitated on 30 January, 3 February, 6 February, 7 February and 8 February.
45. The dosage of haloperidol given to Mr H was far below the daily recommended maximum dosage. We can also see this drug was used to calm Mr H when he was distressed or agitated.
46. We see doctors’ use of haloperidol is in line with both NICE delirium guidance and BNF haloperidol guidance. There is also no evidence to indicate this drug inhibited Mr H’s recovery.
A reduction in gabapentin
47. Mrs T is concerned the Trust decided to reduce her father’s gabapentin dosage (gabapentin is an anticonvulsant medication) from nine tablets to two. She says her father was taking this drug to treat pain caused by sciatica (an irritated nerve in the lower back which causes pain). Mrs T says her father would likely have suffered unnecessary pain due to the reduction in this medication.
48. The Trust says gabapentin can ‘promote drowsiness and delirium’ and for this reason it reduced this medication in the hope it would alleviate Mr H’s symptoms.
49. Both Mrs T and the Trust agree gabapentin was reduced from nine tablets (before admission) to two tablets (following admission).
50. GMC guidance sets out how a doctor can provide good care. Under part 16, it says doctors must provide effective treatment based on the available evidence.
51. BNF gabapentin guidance lists ‘common or very common’ side effects which include confusion, dizziness, drowsiness, memory loss, unusual walking pattern, movement disorders and nausea.
52. Mr H arrived at hospital A with worsening confusion and falls. Our physician adviser says it was therefore in line with guidance for doctors to reduce the dose of gabapentin in case this drug was contributing to his symptoms.
53. We have also reviewed the records and cannot see clinicians noted Mr H was in pain, or that he reported being in pain except for an inflammation he suffered in his elbow, which was treated separately.
54. We are satisfied Mr H did not suffer any pain as a result of a reduction in his gabapentin. We also see doctors acted in line with applicable guidance by reducing his dosage of gabapentin in case it was hindering his recovery.
The source of infection was never found or treated before discharge
55. Mrs T says the Trust did not treat her father’s infection before discharging him from hospital A on 9 February.
56. The Trust says Mr H appeared to be suffering from a chest infection and urine samples also suggested a UTI. It says doctors prescribed antibiotics to cover both potential sources of infection and Mr H appeared to respond to this treatment.
57. DHSC discharge guidance lists the criteria for patients to remain in an acute hospital bed. If a patient does not fulfil any of the criteria, it says they should be discharged.
58. Part 1.4.7 of NICE delirium guidance is also helpful here. It says doctors should treat delirium by looking for and treating any underlying infection.
59. Our Physician adviser says common sites of infection in older people are the chest and urinary tract. We can see the Trust arranged a chest X-ray and a urine test to check for infection, and those tests indicated infection may be present. In response, doctors prescribed co-amoxiclav (an antibiotic) which is commonly used to treat suspected chest and urine infections.
60. We are satisfied this antibiotic was administered in line with NICE delirium guidance.
61. We can also see the Trust discharged Mr H in line with DHSC discharge guidance. This is because Mr H did not meet any of the criteria set out in this guidance to reside in an acute hospital on 9 February. We therefore see the transfer to hospital B on 9 February is in line with guidance.
Mr H did not receive adequate food or drink between 26 January and 18 February
62. Mrs T says her father appeared to have lost a considerable amount of weight when she spoke to him via ‘Facetime’ on 16 February. She says when he came out of hospital on 18 February, he was unable to hold cutlery or feed himself. She says this clearly indicated he was unable to look after himself and did not receive enough sustenance during his admission.
63. The Trust says Mr H scored low on a Malnutrition Universal Screening Tool (MUST) risk assessment on 29 January. MUST risk assessments are important as they identify patients who are malnourished or at risk of malnutrition. They can also be used to develop care plans to ensure patients receive appropriate care, based on their individual circumstances.
64. The Trust says it did not carry out a further MUST assessment for the rest of Mr H’s admission at both hospital A and hospital B. It acknowledges this is not in line with its internal policy which says MUST assessments should be reviewed every seven days, or if the patient’s condition changes.
65. The Trust says its nursing staff did document Mr H’s records daily and they assisted him with his food and drink intake. It says he was managing to eat small to medium portions of food each day.
66. NICE nutrition guidance at 1.2.2 says all hospital inpatients should receive MUST assessments weekly. We can see the Trust’s internal policy mirrors this national guidance.
67. NMC guidance says nurses must use ‘evidence based, best practice approaches’ and use ‘contemporary nutritional assessment tools’ for meeting a patient’s food and drink needs.
68. A review of the records shows MUST assessment were not repeated after 29 January. This represents a failure as it is not in line with NICE nutrition guidance or NMC guidance.
69. We will now consider the Trust’s food and drink charts in more detail to see whether Mr H received appropriate sustenance during his admission period.
70. Nursing evaluations show Mr H needed encouragement and assistance to eat and drink. Despite this, the records do not consistently document he received such support.
71. Food charts are also missing, so we cannot see what Mr H ate daily throughout the period in question. What charts we can see show Mr H was eating small to moderate amounts of food. In terms of drink, these are much clearer, but they show he had poor fluid intake.
72. It is also important to note that on all fluid charts the volume Mr H consumed does not appear to have been calculated. Calculating fluids is vitally important as the volume of fluids consumed must be balanced alongside the volume of fluids expelled from the body (in urine for example). There is the potential for a patient to become dehydrated if this balance is not accurately calculated and recorded.
73. Alongside this, there are no documented interventions aimed at addressing Mr H’s poor food and drink intake described above. Such interventions could include offering snacks between meals, asking family what Mr H’s likes and dislikes were, providing food and fluids on a red tray and in a red jug (this would alert nursing staff that he required assistance), ensuring his mouth was not sore and making sure he had the time needed to eat meals.
74. We asked the Trust if it had additional records to fill the gaps in our evidence. It told us it did not have further records it could provide.
75. We are not persuaded Mr H received appropriate levels of food and drink between 26 January and 18 February.
76. This is due to poor food and fluid intake (in the records we have seen) alongside a lack of MUST assessments, fluid calculations or clearly documented intervention planning. The Trust’s actions are not line with both NICE guidance and NMC guidance and we therefore see this as a failing. We are also concerned about the gaps in Mr H’s food and drink charts.
77. We will consider what impact this had upon Mrs T later in our report where we will also consider what remedy will put things right.
A ‘spot’ on Mr H’s lung was not thoroughly investigated
78. Mrs T says X-rays taken on 26 January and 2 February found a ‘spot’ on her father’s lung. She is concerned this showed the early stages of pneumonia and had doctors taken appropriate action at that stage, he may not have died from this condition on 1 April.
79. The Trust says the X-rays did not indicate pneumonia and Mr H did not show signs he was suffering from this condition during his admission.
80. RCR’s guidance under ‘reporting standards’ says a radiology report should be ‘actionable’ and prompt ‘any appropriate care’ for the patient.
81. Section 15 of GMC guidance says doctors must adequately assess a patient’s condition and promptly arrange suitable advice, investigations or treatment where necessary.
82. We have reviewed the 26 January and 2 February X-rays alongside their reports. We can see doctors were considering whether ‘interstitial’ lung disease or chronic obstructive pulmonary disease (COPD) was present. Interstitial lung disease refers to a large group of disorders which cause progressive scarring in the lungs. COPD is the name for a group of lung conditions which cause breathing difficulties.
83. Our radiologist adviser says there is no evidence to indicate doctors incorrectly interpreted those X-rays. They also noted Mr H’s medical team referred him to a respiratory specialist for further tests and investigation.
84. There is nothing to suggest Mr H was suffering from pneumonia at the time those X-rays were taken.
85. We therefore see the Trust acted in line with RCR guidance in the way it interpreted and reported on those X-rays. We can also see it acted in line with GMC guidance in the referral it made to a respiratory specialist.
Impact upon Mrs T
86. We found failings in the level of food and drink given to Mr H during his admission (see paragraphs 62 to 77).
87. We understand Mrs T was very worried about her father’s wellbeing and this was heightened when she noticed how much weight he had lost upon being discharged home.
88. It is not possible for us to comment on Mr H’s possible weight loss in relation to his food and drink intake because he was not weighed during his admission.
89. The records do not offer enough insight into whether a lack of food and drink impacted upon Mr H’s ability to recover. This is because Mr H was suffering from delirium and was very ill, which can cause disinterest in eating and drinking. It is therefore not possible, even on balance of probabilities, for us to robustly say a lack of food and drink inhibited his recovery.
90. This being said, the Trust should have had adequate interventions in place aimed at addressing Mr H’s poor food and drink intake. We are not convinced it did.
91. We must also acknowledge there are some gaps in Mr H’s food and drink records. We do not see those gaps present a barrier to us reaching a decision about the level of food and drink he received. We appreciate those gaps will no doubt be concerning to Mrs H and will likely cause some additional distress.
92. We cannot see a lack of food and drink impacted upon Mr H’s chances of recovery, but we acknowledge it likely had an emotional impact upon Mrs T. She was clearly concerned about her father’s food and drink intake, and this likely caused some worry and upset.
93. Mrs T wants the Trust to acknowledge its errors, provide her with an apology and put in place service improvements.
94. Based on the information we have seen, we agree such remedy is appropriate to put right the failings we identified.