Chaperone
20. To decide whether we should conduct a detailed investigation into a complaint, we look at what outcome the complainant is seeking to resolve their complaint. Our Service Model Guidance (our Guidance) says we can resolve a complaint without conducting a detailed investigation, if we can deliver the outcome we consider resolves the complaint at an earlier point in our complaint handling process.
21. Mrs S says the Trust’s staff should have allowed her husband, Mr S, to accompany her into the examination room on 13 February 2023. She says, had staff allowed this, he would have supported her and she would not have suffered the fall.
22. In the Trust’s response it said it was not protocol at the time to allow extra people into clinic and examination rooms. The main reason for this was for infection control purposes following the Covid-19 pandemic. Whilst those restrictions had been eased at the time of Mrs S’s appointment, it says there were continued benefits to having fewer people in attendance during examinations.
23. The HEE principles says being person-centred is about focusing care on the individual needs of a person. There are six principles of good person-centred, community focused health and care. One of these principles require that carers be identified, supported, and involved.
24. Our Radiology adviser says the HEE principles apply in this instance. He says people with additional needs who request the support of a relative/carer should have this taken into consideration. He says Mr S could, and should, have acted as Mrs S’s chaperone as she had requested.
25. Our ED adviser told us the Trust’s own website also says every patient has a right to a chaperone being present whilst undergoing an examination.
26. We cannot confidently say whether Mrs S would have suffered a fall had her husband been there to support her. Although, we understand she would have felt reassured of his presence and would have waited for him to further assist her into the wheelchair before trying to get up.
27. Following further discussions with the Trust, it now accepts Mr S could have been in the room and this would have given Mrs S the support she wanted.
28. The Trust has confirmed it added a note to Mrs S’s radiology records, and other Trust electronic systems, on 28 March 2024. This note will ensure Trust staff are aware that Mr S can accompany her as a chaperone to any appointments that she may attend going forward.
29. The Trust also confirmed its Head of Ultrasound held a staff meeting on 9 April 2024 about the use of chaperones. Following this meeting, it has agreed to produce a further document, to be aligned with its current chaperone policy and departmental guidelines. This document will allow Trust staff to assess patients on an individual basis and take into consideration several factors, such as the patient’s physical ability and emotional condition before making a decision around the use of a chaperone. The Trust hopes this will prevent other patients and their loved ones having the same experience as Mrs S and her husband.
30. We consider the Trust has provided the outcome Mrs S wanted to achieve and that is appropriate to address the impact on her. Therefore, we consider this part of the complaint resolved.
Support given from staff
31. Mrs S says the Trust’s staff should have been closer to help and support her to get up from the couch following the examination.
32. The Trust say Mrs S had been able to mobilise herself from the wheelchair onto the examination couch with minimal assistance prior to the examination. This meant staff believed there was no significant risk of falling.
33. Our Radiology adviser says the position Mrs S was in on the examination couch, as well as the injury she had to her calf, could have affected her being able to mobilise safely from the examination couch.
34. He says it is not always appropriate to automatically give additional assistance when it is not needed as this could invade a patient's personal space. In this instance, it would be considered appropriate for staff to have asked Mrs S whether staff support was needed prior to informing her she could get up from the examination couch. The staff member then would have been in a better position to give the support required.
35. Our ED adviser says Mr S brought Mrs S to the ultrasound appointment in a wheelchair. He had asked to accompany her into the examination room stating she was unsteady on her feet. Mrs S was in attendance at the ultrasound department because she had previously suffered a fall at home. Therefore, staff should have made sure she made it safely to her wheelchair as it was clear she had mobility issues.
36. Following further discussions with the Trust it has taken learning from this complaint. The Trust will ensure staff who are accompanying and supporting a patient ask the individual for the level of help they require, in line with standard practice.
37. Mrs S says she fell because staff did not give her the assistance she needed to safely reach her wheelchair from the examination couch. Had staff been closer, or had her husband been allowed to accompany her, she says the fall would not have happened.
38. The Trust say staff were in the process of taking the wheelchair back to Mrs S when she fell. It says it is also possible that Mrs S may still have fallen as its staff are trained to guide patients to the floor rather than ‘catch’ them.
39. The RCN guidelines recommend that updated training in client handling is required when starting a new role and before commencing tasks and duties that require manual handling activities. These guidelines also recommend refresher training also be provided.
40. The Trust has confirmed the staff member attending to Mrs S was up to date with their manual handling training. It confirms it has a policy in place for the Trust’s new starters to undergo manual handling training during their induction and is refreshed every three years in keeping with its policy. The Trust confirms its training programme fulfils the RCN moving and handling guidelines.
41. We consider the Trust has provided the outcome Mrs S wanted to achieve and that is appropriate to address the impact on her. Therefore, we can consider this part of the complaint resolved.
Incident reporting
42. The NHSE strategy says healthcare staff are encouraged where possible to record all patient safety incidents on their organisation’s local risk management systems (LRMS). These reports will then be routinely uploaded to NHSE systems to support national learning.
43. Our Radiology adviser says a patient fall should be reported as soon as is reasonably practicable after a fall event and a full report completed. Staff completed the incident report on 14 February 2023 at 12.19pm, within 24 hours of Mrs S’s fall.
44. Our ED adviser says the incident report is comprehensive, details injuries, assessments, plans for patient, and offers a solution to prevent reoccurrence.
45. The incident report shows it was updated on 3 May 2023. The Trust say it updated the incident report to include the name and contact details of the practitioner. In addition to this, it confirmed it added the details of the investigation it undertook and the learning it had identified to prevent future reoccurrence. This allows the investigation report to be formally closed at that stage.
46. Having considered the available evidence, we do not consider the Trust did anything wrong in its reporting of Mrs S’s fall. Therefore, we will not be taking any further action on this part of the complaint.
Post-fall care
47. Mrs S says she had her blood pressure checked after the fall and had a plaster put on the cut on her knee. She says Trust staff then wheeled her outside to wait for her husband to drive the car round. She says staff did not enquire about her wellbeing or suggest she be further examined by a doctor despite her being unable to walk and suffering with continued pain and discomfort.
48. The Trust say it cleaned and covered Mrs S’s knee with a dressing and took a set of observations including blood pressure, heart rate and oxygen saturations. The Trust did not provide evidence of the post-fall care and observations it undertook on Mrs S.
49. NICE quality standards exist for inpatients who fall in hospital. These standards say hospitals should ensure its staff are given clear guidance on all aspects of essential care after a fall. Staff should understand the importance of observations after a fall.
50. There are no current guidelines or standards that exist for outpatients who suffer a fall in hospital.
51. Our ED adviser says the NICE quality standards for inpatient falls recommends local protocols be put in place for outpatients who suffer a fall in hospitals.
52. Our ED adviser says the staff involved in supporting Mrs S following her fall were not adequately trained and qualified to decide on the right course of action. He says staff should have referred her to its ED for further assessment, care, and treatment.
53. The Trust has highlighted the importance of having an outpatient falls protocol in place. It currently has a policy for slips, trips, and falls, but agrees this has an inpatient focus. The Trust has agreed to incorporate within this policy some guidance for outpatients. This will ensure there are clear steps for staff to follow should a similar incident like this happen again in the future. This will be incorporated into its policy by the end of June 2024.
54. We consider the Trust has provided the outcome Mrs S wanted to achieve and that is appropriate to address the impact on her. Therefore, we can consider this part of the complaint resolved.
55. We are sorry Mrs S experienced the fall she did in the Trust’s ultrasound department. We know what a huge impact it had on her and her husband’s daily life. We understand they never wanted to escalate things to this level.
56. We are pleased Mrs S and her husband are happy with the outcome achieved and that the Trust’s proposed actions does remedy the complaint for them.
57. We hope we have clearly explained the reasons behind our decision. We would like to thank Mrs S and her husband for taking the time to bring this complaint to us. We wish them both all the best for the future.