Inadequate nutrition and delayed referral to a dietician
16. Miss T complains about how the Trust managed her father’s nutritional needs during his hospital admission. She says it did not provide him with enough nutrition and it delayed referring him to a dietician.
17. The Trust’s guidelines on adult nutrition and hydration, detail the standards of assessment and care that is expected to be given to all patients. The aim of the policy is to ensure that all patients receive appropriate nutrition, adequate fluids, and reduce clinical complications due to malnutrition.
18. Malnutrition is when a lack of nutrients such as energy, protein, vitamins, and minerals cause measurable adverse effects on body composition, function, or clinical outcome. Malnutrition can cause patients to be vulnerable to infection, delay healing of wounds, impair heart and lung function, decrease muscle strength, and depression. All of these can lead to increased morbidity and mortality.
19. The Trust’s guidance says that all inpatients should be nutritionally screened using the Malnutrition Universal Screening Tool (MUST) within 24 hours to assess their nutritional status, by a member of staff trained to do so. MUST is a screening tool used to identify adults who are malnourished or at risk of malnutrition. A patient’s body mass index (BMI), weight loss, and health are taken into account to get a MUST score and an overall risk of malnutrition. A score of two or more is considered high risk and needs to be treated.
20. The guidance goes on to say that patients should have their MUST completed weekly, and if they are found to be at risk of malnutrition (scoring 2+ on MUST assessment), they should be referred to a dietitian.
21. The clinical records show that the Trust admitted Mr T on 25 June 2022 following a fall and injury to his head. Mr T was nil by mouth (NBM) from 26 June although we cannot see any clear documentation to say why. Our adviser explained it appears the Trust placed Mr T NBM due to his levels of consciousness.
22. We cannot see any evidence in the records that the Trust completed a MUST screening for Mr T within 24 hours of his admission in line with its own policy on nutrition. When it did complete a MUST, it was four days after his admission on 29 June, and it did not document a score as it was unable to weigh Mr T because of his drowsiness.
23. BAPEN gives advice about the MUST tool and says that if height, weight, or BMI cannot be obtained then other actions such as measuring mid-upper arm circumference (MUAC) or using clinical impression of a person’s weight or nutritional intake can be used to support an overall impression of a patient’s nutritional risk.
24. Our adviser agreed that other measurements can be considered in situations like this. For example, the Trust could have measured his MUAC. However, we cannot see it considered other options to get an accurate MUST score. A score of two or more would have prompted the Trust to refer him to a dietician. The Trust missed an opportunity here to assess his risk of malnutrition, gain a score, and refer him for input from a dietician.
25. On 26 June, the Trust did note in the management plan that a dietician referral should be completed. However, we cannot see any evidence in the records that the Trust actioned this referral and in its complaint response it confirmed that it did not action the referral at this time. The speech and language therapy (SALT) team raised concerns on 29 June about the original dietician referral not being actioned. SALT suggested the medical team should consider alternative nutrition for Mr T. It does not appear that the Trust actioned these concerns as Mr T was not reviewed by a dietician at that point either.
26. We can see that Mr T was finally reviewed by a dietician on 4 July following a verbal referral when they attended the ward he was on. They documented that he had been NBM since his admission, so for 10 days, and there was no clear indication why he was NBM. The dietician noted that he was now at high risk of refeeding syndrome because he had been starved of food for a long period and he had not received adequate nutritional intake. The Trust planned to allow him to have sips of water and to monitor his progress with this.
27. As MUST scores should be completed weekly, the Trust screened Mr T again on 5 and 9 July. On 5 July it weighed him but did not document a score. On 9 July it weighed him, documented that he had lost 2.4kg between 5 and 9 July, and calculated his MUST score as 0 which is low risk. However, by this point he had been NBM for over 10 days.
28. BAPEN advises that if a patient has had no nutritional intake for five days, their MUST score should be two which indicates high risk. Our adviser explained that the score of 0 is therefore inaccurate as Mr T had little to no nutrition since 26 June. The inaccurate screenings appear to show an inaccurate view of his malnutrition risk although we can acknowledge he was already seeing a dietitian by this point.
29. The Trust did not complete a MUST screening within 24 hours in line with its own policy. Even when it did complete a screening four days after his admission on 29 June, it did not look for alternative ways to score him in line with BAPEN guidance and this represents two missed opportunities to refer him to see a dietician to assess his nutritional intake and provide input at an earlier opportunity.
30. Based on what we have seen, we consider the Trust’s actions around MUST screening did not meet the standards set out in its own policy or BAPEN guidance, and therefore this is a failing. We think this then led to a missed opportunity for the Trust to refer Mr T to a dietician and have input 10 days sooner than he did, which is also a failing. We will consider the impact this had on Mr T and therefore, Miss T after we have considered how the Trust managed his nutrition.
Nutrition and Nasogastric enteral tube (NG) feeding
31. Miss T complains the Trust did not attempt an alternative way to feed her father.
32. NICE guidelines on nutrition support for adults says nutrition support should be considered in people at risk of malnutrition, defined as those who have eaten little or nothing for more than five days and / or are likely to eat little or nothing for five days or longer. It says healthcare professionals should consider NG feeding in people who are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract.
33. The guidance also says in a hospital setting, people unable to swallow safely or take sufficient energy and nutrients orally should have an initial two-to-four-week trial of NG feeding. Healthcare professionals with relevant skills and training in the diagnosis, assessment and management of swallowing disorders should assess the prognosis and options for future nutrition support. NG feeding is a method of getting special nutrition and medication directly to the stomach through a tube.
34. On 2 July, a member of the chest physiotherapy team reviewed Mr T on the ward. They shared their concerns about his nutritional status and him being NBM for seven days with other staff members caring for him. However, it does not appear the Trust considered alternative feeding options until 4 July which is when he was seen by a dietician.
35. There is an entry in the records on this date to suggest that the Trust considered using NG feeding to give Mr T the nutrition he needed. This is nine days after his admission and since he had been placed on NBM. On 5 July, a dietician noted that NG feeding was the only appropriate option to trial and should be tried even if Mr T had not tolerated it well previously.
36. On 7 July, the Trust held a multidisciplinary team (MDT) meeting. An MDT meeting is a team of health professionals that make collaborative decisions about a patients care. The Trust had concerns about whether the ward staff had the skills to support this during night shifts. It considered moving him onto another ward to support the NG feeding, however, it also had concerns that he would not tolerate NG feeding as he had not done so with a previous attempt at another hospital.
37. Therefore, it decided against NG feeding but to try and feed Mr T little and often. By this point Mr T had gone 13 days without sufficient nutrition and the Trust noted this in the clinical records.
38. Our adviser explained there is an inadequate consideration of alternative plans for nutrition and hydration in a timely manner when the Trust kept Mr T NBM for 10 days. They said it could have considered NG feeding much earlier in Mr T’s admission in line with NICE guidance on nutrition support and to keep him NBM for over 10 days without considering alternative nutrition, fell below the standard of care expected in these guidelines.
39. Therefore, we cannot see the Trust followed NICE guidance on nutrition support for adults as it did not appear to consider nutrition support sooner for Mr T or that he was at risk of malnutrition as he had not eaten for more than five days. This is a failing.
40. NICE guidelines on decision making and mental capacity says when a person lacks capacity to make a particular decision at the time the decision needs to be made, all actions and decisions taken by practitioners must be in the person’s best interests. This also includes consulting with the person’s family.
41. Our adviser explained that Mr T had care and support needs due to his dementia, limited communication, confusion, and ability to receive adequate nutrition and as a result, he would have been unable to influence the decision to place him NBM for over 10 days.
42. We cannot see any evidence in the clinical records to suggest that his family were involved with any decisions regarding his feeding, in line with NICE guidelines on decision making above. If his family had been involved with the decision making, they would have been able to advocate for him and would have also been aware of his nutritional status at an earlier opportunity. Therefore, the Trust actions fell short of NICE guidelines on decision making and this is a failing.
Impact
43. We have gone on to consider how the failings around the lack of nutrition and the delayed dietitian referral impacted Mr T and in turn, his family. Miss T is concerned that her father’s lack of nutrition put him at risk of refeeding syndrome and contributed to his discomfort and pain before he sadly died.
44. She feels the Trust’s actions around nutrition impacted her father’s outcome and she may have had more time with him. This causes her and her family a great deal of distress, upset, pain, and confusion. She also told us that the family were not aware her father was not getting the nutrition he needed at the time, and they only found out following the medical examiner’s report after his death.
45. We can clearly see this experience has been very distressing for them and recognise their concerns have impacted them in the way they have described.
46. Our adviser explained that after 10 days of no nutrition, a patient’s nutritional status will deteriorate, and the body moves into a physiological state where energy stores are mobilised to release energy, such as fat stores are broken down and muscles become depleted.
47. After more than five days of little to no nutrition, patients become ‘at risk’ of refeeding syndrome, which occurs where starved or malnourished patients develop electrolyte and fluids shifts (which in extreme cases can be fatal), the longer the patient goes without nutrition, the greater the risk of developing refeeding syndrome. Our adviser said 10 days of no nutrition would place Mr T at high risk of malnutrition.
48. They explained that feelings of hunger and appetite regulation are a complex mechanism, and sensations of hunger may become supressed after several days of not eating. It is also known that in patients with dementia, appetite and hunger sensations may also be altered and patients may not feel hunger.
49. It is therefore difficult to comment on whether Mr T would have experienced pain due to being NBM. However, our adviser explained it would be fair to say this would have affected his comfort. Earlier dietetic referral and escalation of Mr T’s NBM status, may have avoided or reduced his refeeding risk.
50. Our adviser said it is difficult to say for certain if Mr T’s outcome would have been different if the Trust had given him improved nutritional care. However, we do have to acknowledge that there are links between malnutrition and poor clinical outcomes as stated above. Therefore, nutrition is a risk factor in a patient’s care that can be managed to reduce the risks.
51. Although we cannot say for certain that Mr T’s outcome may have been different if he had received adequate nutrition, we can say that the family will never know if they could have had more time with him or if his condition would have improved. We can also recognise how the lack of nutrition would have affected his comfort. We are sorry that the family have concerns about his care and we can recognise how these concerns have caused them the distress they told us about.
52. We can also see that if the family had been more involved in discussions about Mr T’s nutrition, they would have been able to advocate for him and would have been aware of his nutritional status at an earlier opportunity. Rather than finding out from the medical examiner. We can see how finding out this information would have caused them the confusion, distress, and upset they told us about.
53. Our Principles say that organisations should identify and acknowledge when something has gone wrong and apologise for it. We are pleased to see the Trust has apologised for the family’s’ experience and taken the complaint seriously. It has acknowledged there is some learning to do around communication and has implemented some service improvements by using a morning board during the ward round. This action is in line with our Principles.
54. However, we do not think it has fully acknowledged what happened or reflected on the impact these failings had on Miss T, or the missed opportunity for a better outcome for her father.
55. Overall, based on what we have seen, we consider the Trust’s actions fell short of guidance from NICE, BAPEN, and its own nutrition policy. This is because it did not complete a MUST screening within 24 hours of Mr T’s admission, did not consider alternative nutrition until he had been NBM for 10 days, and did not involve his family in decisions about his nutrition. Therefore, we uphold this complaint and make recommendations at the end of our report.
56. From what Miss T told us, she has clearly been through an upsetting and distressing time with her concerns about how the Trust managed her father’s care and we are sorry for this. We hope our report helps to answer her concerns.