Atrial Fibrillation 20. Dr U complains that the Trust did not take her mother’s history of atrial fibrillation into consideration and provide essential treatment for this.
21. In line with the GMC’s Good Medical Practice guidelines, doctors must adequately assess a patient’s condition, taking account of their history. They must also provide treatment where necessary. Mrs N had a history of atrial fibrillation, and the doctors should have documented an assessment of this and provided treatment if required.
22. Our consideration of this matter has been limited by the Trust’s poor record keeping. It has lost all records of the doctors’ input into Mrs N’s care for September, October and November 2021. We have considered the impact this had later in our report.
23. Despite the lost records, we know that Mrs N was already taking medication for atrial fibrillation before she was admitted to hospital. The records we have seen show she was taking rivaroxaban, which is one of many blood thinning medications used to reduce the chances of strokes in atrial fibrillation. This was an appropriate treatment as outlined in the NICE guideline NG196 (atrial fibrillation).
24. Mrs N had suffered an ischaemic stroke, which is where a blood vessel in the brain becomes blocked. When this happens, NICE Guideline NG128 (Stroke and TIA in over 16s) recommends prescribing aspirin for the first two weeks and then commencing anticoagulant medication following this. Mrs N’s prescription charts reflect this happened and this was in line with NG128.
25. Once the correct treatment for Mrs N’s ischaemic stroke had been implemented, the doctors should then have provided treatment for atrial fibrillation in line with NG196. This meant she should have been prescribed an anticoagulant medication after the initial 2-week period of treatment with aspirin. The guidance lists apixaban as a suitable option.
26. Mrs N’s prescription charts indicate she was prescribed apixaban to manage her atrial fibrillation on 11 October, which was slightly later than the two-week period outlined in the guidance. Our physician adviser explained there may have been a robust clinical rationale for this delay; however, due to the lost records we cannot conclude that this was the case. She was also prescribed bisoprolol, which is a beta blocker, from 16 September. This is also recommended by NICE Guideline NG196.
27. Overall, the records reflect that the clinicians were aware Mrs N had atrial fibrillation from admission. Her rivaroxaban prescription was stopped on admission to hospital, which was in line with NICE Guideline NG128. The physicians prescribed aspirin from 17 September and prescribed apixaban from 11 October. There was a delay of 11 days in changing her medication from aspirin to apixaban in September/October. This was not in line with the NICE Guideline NG196 and was a failing.
28. Once Mrs N was prescribed apixaban, her prescription charts reflect she continued to receive appropriate treatment for her atrial fibrillation, in line with NG128 and NG196, until she died on 26 December.
29. Our physician adviser explained that because the delay in changing Mrs N’s medication was relatively short-term in nature, and she was prescribed aspirin to prevent clots during this time, on the balance of probabilities there was more likely than not no clinical impact to this error. We note that the blood clot in her leg was identified before the delay in prescribing apixaban occurred. Had she been prescribed apixaban at the right time, this would have happened on 30 September, which was after the blood clot had already developed.
30. We recognise, however, that knowing Mrs N’s care was delayed will cause distress to Dr U and impact on her confidence in the care the Trust provided to her mother. This is an injustice to her that the Trust has not yet put right. We address this in the recommendations outlined at the end of this report. Communication 31. Dr U complains that the Trust failed to obtain any medical history for her mother from either the family or her mother’s GP.
32. It is not possible to establish whether or not the Trust obtained an appropriate medical history for Mrs N because it has lost all of the clinicians’ notes for her care from 16 September to 30 November. Without contemporaneous records of what happened at that time, we cannot reach a robust conclusion on this issue. This is an injustice to Dr U, and we address this in more detail later in our report.
Blood clot 33. Dr U complains the Trust did not manage her mother’s risk of blood clots adequately and delayed identifying a blood clot in her mother’s femoral artery. She adds that it also delayed implementing appropriate treatment for the clot in her mother’s leg.
34. Mrs N was at increased risk of developing a blood clot because of her lifelong history of atrial fibrillation. Our physician adviser explained that, broadly speaking, blood clots in blood vessels are classified as arterial or venous. The prevention of arterial blood clots and venous blood clots require different preventative and management strategies.
35. Mrs N was already on the recommended treatment for preventing arterial blood clots before she was admitted to hospital. After her stroke, the Trust stopped this medication, in line with NICE guideline NG128, and prescribed aspirin instead. A new medication, apixaban, was prescribed from 11 October. This was an appropriate strategy to manage the risk of arterial blood clots, though there was a delay of 11 days in implementing this medication.
36. Venous blood clots are managed differently, and this is outlined in NICE guideline NG89 (venous thromboembolism (VTE) in over 16s). In line with this guidance the Trust should have:
• assessed the risk of VTE and bleeding as soon as possible after admission to hospital • balanced the risk of bleeding with the risk of VTE.
37. Guidance from the Department of Health states all patients with reduced mobility should be considered for further VTE risk assessment. Mrs N was documented as being ‘bed bound’ on admission to the ward on 16 September, and so a risk assessment was required. This guidance also recommends that if this further risk assessment indicates the patient is at risk of developing a venous blood clot, preventative measures are indicated as set out in NICE guideline NG89.
38. NICE Guideline NG89 recommends using intermittent pneumatic compression (IPC) for the management of VTE risk in people who present with an acute stroke. IPC reduces the risk of blood clots using an inflatable device to improve circulation in the deep veins of the legs.
39. The Trust completed a risk assessment on 16 September which identified Mrs N had multiple risk factors for developing a VTE. Pharmacological interventions were not indicated due to the risk of bleeding following her stroke and IPC was prescribed instead. This commenced on 18 September and was in line with NG89 which states that IPC should commence within three days of admission to hospital.
40. The IPC continued until 30 September. This was not in line with NG89, which recommends continuing IPC for 30 days, or until the person becomes mobile again or is discharged from hospital. Mrs N remained immobilised and was not discharged from hospital when this treatment was stopped. Unfortunately, there are no clinician’s notes for this period, so we cannot know whether there was a documented clinical rationale for this. Between 30 September and 11 October, the only intervention provided was the aspirin prescription that had commenced upon admission.
41. Dr U states that her family never witnessed the IPC being in situ when they visited prior to 30 September. It is possible that the IPC sleeves were removed prior to visiting, or to facilitate personal care. It is also possible that the sleeves were not placed on Mrs N’s legs consistently during this time. We cannot know which is more likely than not, but we recognise how concerning this is for Dr U and her family.
42. According to the guidance from the Department of Health, patients should be reassessed for their VTE risk whenever the clinical picture changes. There is no record of this happening in Mrs N’s medical records between 16 September and 7 December. On 7 December a VTE risk assessment noted her risk factors for VTE. Her prescription chart shows she was taking apixaban, which is recommended for the prevention both arterial and venous clot prevention.
43. The evidence shows that the Trust:
• initially implemented the appropriate interventions for the prevention of both arterial and venous blood clots in September • did not provide IPC for long enough, as recommended by NG89 • delayed in prescribing anticoagulant medication that could prevent arterial blood clots from 30 September to 11 October • did not review Mrs N’s VTE risk as recommended by the Department of Health.
44. These omissions in Mrs N’s care amount to service failure.
45. We do not think these failings caused Mrs N to develop the blood clot in her leg. This is because the blood clot was documented before these errors happened. However, we do think that knowing Mrs N’s care was not in line with national guidance will be distressing for Dr U and could adversely affect her confidence in the Trust’s services. This is an injustice to her.
46. With regards to whether the Trust delayed in identifying and treating Mrs N’s blood clot, the Trust has lost all clinicians’ notes for September, October and November. This has seriously limited in our consideration of this issue.
47. Despite the lost records, we asked our vascular adviser what should have happened when Mrs N’s leg became ischaemic and whether there is sufficient information to say whether or not this happened on the balance of probabilities.
48. Our vascular adviser explained that in line with the NICE Clinical Knowledge Summary for peripheral arterial disease, the suspicion or diagnosis of acute limb ischaemia requires an urgent referral to vascular surgery for an assessment.
49. They also explained that in line with the European Society for Vascular Surgery’s 2020 Clinical Practice Guidelines, this assessment should have included a consideration of whether the limb could be managed medically, was threatened (can be saved if urgently revascularised), or was non-salvageable (permanent tissue damage already sustained).
50. If a limb is found to be non-salvageable then no further investigations are indicated. If the limb is threatened, then a CT angiography is indicated as it provides the best anatomical information to guide clinicians in revascularising the limb.
51. According to the NICE Clinical Knowledge Summary for peripheral arterial disease, interventions to treat acute limb ischaemia include treatments to remove the blood blot and surgery. There are a number of options that can be considered, such as medications or using a catheter inserted into a blood vessel to break up the blood clot. This guidance recommends amputation for limbs that are not salvageable.
52. Our vascular adviser explained that there is information within Mrs N’s medical records that indicates a referral to the vascular team was made, a CT angiogram took place, and the clinicians discussed the medications that could treat the blood clot. This happened at approximately the first instance Mrs N’s leg was identified as feeling cold and darkening in colour.
53. According to our vascular adviser, this indicates there had been a vascular assessment and that options for revascularisation of the limb were considered. On balance, this shows it is more likely than not the Trust undertook the investigations recommended by the NICE Clinical Knowledge Summary for peripheral arterial disease and that this happened soon after concerns were raised by the nursing team.
54. Unfortunately, due to the lost records we cannot know the details of the assessment that took place, nor the pattern of arterial disease. This means we cannot say whether this assessment was accurate, and our vascular adviser was unable to comment on the likely success of revascularisation. Because of this, we cannot say, even on the balance of probabilities, whether the conclusion that Mrs N’s limb could not be saved was correct. We have considered the impact of these lost records later in our report.
55. Our vascular adviser explained that even if the identification, assessment, and treatment of Mrs N’s ischaemic leg had been optimal, the outcome for her would likely have been very limited. They explained that, sadly, in older adults with multiple health conditions acute limb ischaemia often carries a high risk of death, even when revascularisation of the limb is successful. Limb ischaemia can also be part of the process of dying in older adults, rather than a condition to treat and manage. Any surgical interventions for a patient of Mrs N’s age and medical history, even if carried out under local anaesthetic, would also have carried a high risk of death. In patients who are at high risk of death, palliative care is appropriate (Bjork et al. 2020). Our vascular adviser explained this means the most likely interventions the Trust could have offered would have been anticoagulation medications and palliative care, especially if her leg could not be saved. The records indicate this happened within days of concerns about her leg being raised.
56. In summary the Trust:
• initially implemented the appropriate interventions for the prevention of both arterial and venous blood clots • did not provide IPC for long enough and delayed in prescribing appropriate anticoagulant medication between 30 September to 11 October • used the right interventions to investigate the blood clot, but the lost medical records have prevented us from considering how accurate this assessment was • treated Mrs N’s ischaemic leg using the interventions that were more likely than not most appropriate for a patient of her age and clinical status.
57. Whilst there were failings in the preventative care provided, these did not cause the blood clot in Mrs N’s femoral artery. We recognise that knowing there were failings in her care will be distressing for her family.
58. The Trust has not yet acknowledged what went wrong, nor has it taken steps to put things right. We have outlined recommendations later in this report.
Food, fluid and oral care 59. Dr U complains the Trust failed to adequately manage her mother’s hydration and food intake, and she developed oral thrush due to poor mouth care.
60. Our nursing adviser explained that the Trust should have provided care that aligned with NICE Guideline CG32 (Nutrition support for adults) and NICE Guideline CG138 (Patient experience in adult NHS services). The guidance for nutrition support covers both nutrition and oral fluid intake.
61. In line with NICE guideline CG32, all hospital inpatients should be screened for malnutrition on admission to hospital and this should be repeated weekly. This guidance recommends using the Malnutrition Universal Screening Tool (MUST).
62. The nurses completed a MUST screen on 16 September and Mrs N scored one due to her BMI being 18.5. This indicated she was at medium risk of malnutrition. The Trust’s standardised form outlines the nursing interventions required for those at medium risk of malnutrition and the nurses should have:
• weighed Mrs N weekly • commenced a food chart • started a red tray system (a nationally used system for people who need support eating and drinking) • given nutritional supplements in between meals • reassessed her risk of malnutrition within one week.
63. The nursing notes from 17 to 23 September indicate Mrs N was eating and drinking well and that the staff had implemented the red tray system. There were no documented concerns about Mrs N’s nutrition during that time.
64. On 23 September the nursing team reviewed Mrs N using the MUST tool. The nurse noted a 4kg loss of weight and her MUST score was three. This indicated she was at high risk of malnutrition. The Trust’s standardised form for the MUST tool recommends continuing the steps for medium risk patients, but also referring the patient for dietetic support and informing medical staff of the risk if a patient is high risk.
65. There is a reference to the nursing team referring Mrs N to the dietetics team on 24 September; however, there is no record of an assessment from a dietician. We cannot know whether this is because an assessment did not take place, or because the Trust has lost the clinical records. We consider the impact of the lost medical records later in our report.
66. When the nursing team reassessed Mrs N on 30 September they did not complete a MUST screen, nor document any other assessment of her malnutrition risk. This was not in line with NICE guideline CG32.
67. The nursing notes from 8 to 24 October have been lost by the Trust.
68. On 25 October the nurses reassessed Mrs N’s nursing care needs again but did not complete a MUST screen. Mrs N’s care plan for eating and drinking changed from her care plan dated 23 September to indicate that she needed less support with eating and drinking. Our nursing adviser explained that care plans should be evidence-based, meaning these changes should have been guided by a MUST screen. This did not happen, and this was not in line NICE guideline CG32.
69. The nursing records from 30 October to 20 November have been lost by the Trust.
70. On 20 November the Trust completed a nursing care plan for Mrs N’s eating and drinking needs that indicated she had high nutrition needs. However, there is no record of a MUST screen or any other assessment of her malnutrition risk at that time. It is unclear whether this is because of the lost records or because this did not happen.
71. Mrs N’s nursing care plans dated 4 and 11 December do not include a MUST screen and there was no care plan completed for her nutrition needs. This was not in line with NICE guideline CG32.
72. In summary, we have found that Mrs N was appropriately assessed for her eating and drinking needs upon admission to hospital on 16 September. Following this, the Trust reviewed her eating and drinking needs again on 23 September but failed to implement the required interventions to manage her high risk of malnutrition. Further, it also failed to document any review of her malnutrition risk after 23 September. This fell so far short of NICE guideline CG32 that it was a failing.
73. With regards to Mrs N’s mouthcare, our nursing adviser explained that the Trust should have ensured that her personal care needs were regularly reviewed, in line with NICE guideline CG138. The care provided should also have reflected Health Education England’s guidance (Mouthcare Matters), which states that:
• every adult hospitalised for more than 24 hours should have a mouth care risk assessment completed to identify high risk patients • low risk patients should have their mouth reassessed every 7 days • mouth care should be recorded on a daily basis.
74. Mrs N’s nursing assessment dated 16 September indicated she needed help with mouth care. The Trust completed a mouth care screen on 17 September, which assessed Mrs N as being completely dependent on others for mouth care. The screening form is clear that all those dependent on others for mouthcare should have a mouthcare assessment. Health Education England’s guidance also says that all adults should have a mouth care assessment within 24 hours of admission to hospital. The mouthcare assessment was not completed and this was a failing.
75. Despite the failure to complete the mouth care assessment, the nursing staff did implement a daily recording sheet for mouth care. The Mouthcare Matters guidance states tooth brushing should be carried out twice daily. The Trust’s mouthcare screen documented that Mrs N was completely dependent on others for her oral hygiene, meaning the nursing team should have been supporting her to brush her teeth twice per day.
76. Between 17 and 22 September, there were no documented instances of the staff supporting Mrs N to brush her teeth, aside from at 10pm on 22 September. In the evening of 21 September, they documented that she refused to let staff do this. This means her teeth were likely not brushed for a period of five days, which was not in line with the Mouthcare Matters guidance.
77. Between 23 and 25 September, tooth brushing was not completed and the records indicate that staff were not offering tooth brushing at the frequency required by the Mouthcare Matters guidance. Her teeth were documented as being brushed twice between 26 September and 8 October. There are some instances where it was documented she refused, but in the main there were periods of several days where no toothbrushing was documented as being offered and when it was, it was not frequent enough. There were also dates when no mouthcare was recorded at all.
78. Between 9 and 16 October, no tooth brushing was documented, which was not in line with the Mouthcare Matters guidance.
79. Between 17 September and 14 October, no denture care was recorded by the nursing team, despite documenting she had a lower denture in the mouthcare screen on admission. Denture care was documented for the first time during her admission on 15 October. This falls far short of the Mouthcare Matters guidance and NICE Guideline CG138.
80. On 17 October Mrs N’s teeth were documented as having been brushed twice that day. This was the first time since her admission one month earlier that her mouth care was provided in line with the national guidance.
81. On 18 and 19 October, no toothbrushing was documented and this was not in line with the Mouthcare Matters guidance. Mrs N’s teeth were brushed twice on 20, 21 and 23 October, which was in line with the Mouthcare Matters guidance. No denture care was recorded for these dates and no mouthcare was recorded for 22 October, which was not in line with the Mouthcare Matters guidance.
82. Between 24 and 27 October, no tooth brushing was documented. On 28 October the nurses documented that her teeth were brushed twice, in line with the guidance. The entries on 29 October indicate her dentures were brushed, but no tooth brushing was provided.
83. In addition to the provision of daily tooth brushing, patients should have their mouthcare needs reviewed weekly. The nurses never documented a review of Mrs N’s mouthcare needs and left the mouthcare screen blank on subsequent nursing assessments. This was not in line with the Mouthcare Matters guidance.
84. The Trust has provided no further mouthcare records to reflect the mouthcare provided to Mrs N after 29 October. We do not know whether this is because the mouthcare was never documented, or because the Trust has lost these records. There are some sporadic instances where the nursing notes reflect some mouthcare took place after this date.
85. From Mrs N’s admission on 16 September and when the Trust’s records end on 29 October the Trust consistently failed to assess her mouthcare needs and provide adequate mouthcare. It is particularly concerning that the records reflect long periods of several weeks where Mrs N’s teeth were not brushed as required, and denture care was not provided. This fell so far short of the Mouthcare Matters guidance and NICE guideline CG138 that it was a failing in the care provided to Mrs N.
86. Dr U says her mother developed oral thrush due to poor mouth care and she suffered unnecessarily during her final months of life. Because the mouthcare screens were not completed after 17 September, and no risk assessment (which outlines the condition of the patient’s mouth in detail) was completed during her admission, we have no evidence of the condition of Mrs N’s mouth. The Trust’s complaint response, however, acknowledged that she developed oral thrush and that she was prescribed medication for this.
87. The Trust’s failure to provide appropriate mouthcare would understandably have caused Mrs N discomfort during the final months of her life. We can also understand that it was likely very distressing for her family to witness such poor mouth care.
88. The Trust has not yet acknowledged the failings in Mrs N’s mouthcare, nor taken steps to put things right. We have made recommendations later in our report which aim to put this right.Continence care 89. Dr U complains the Trust did not change her mother’s incontinence pads regularly, which caused her mother to develop a wound on her sacrum.
90. Our nursing adviser explained that the NMC’s Code for registered nurses (section 1.2) states that nurses should deliver the fundamentals of care effectively. The fundamentals of care includes bladder and bowel care, and ensuring those receiving care are kept in clean and hygienic conditions. This would include ensuring Mrs N’s continence pads were changed as often as required. The NMC Code (section 10) also requires nurses to keep accurate records of care provided.
91. NICE guideline CG138 also states that the Trust should have ensured Mrs N’s personal needs (including continence and personal hygiene) were reviewed regularly and addressed.
92. The nursing assessment undertaken on 16 September did not identify continence as a care need. This should have been identified because Mrs N was incontinent following her stroke. Despite this not being documented, the daily comfort rounds indicate her continence needs were checked and addressed throughout the day from 18-27 September. On 28 September there was a long period of more than eight hours between continence care being provided. Her continence care on 29 September was documented as occurring regularly.
93. On 30 September Mrs N’s care needs were reviewed by the nursing team. This nursing assessment correctly identified that she was incontinent. The records indicate Mrs N’s continence care needs were checked in the morning only that day. This was not in line with her care plan.
94. From 1 to 7 October, regular continence care was documented throughout the day except for on 5 October, when no records were kept.
95. The nursing records for 8 October also reflect regular continence care; however, there is some indication that these records may not be an accurate record of what happened. This is because alongside recording that they had completed her continence care, the nursing staff also recorded they had completed Mrs N’s catheter care. There is no record of a catheter being inserted on this date. The nursing notes say one is in situ, but it is unclear whether this was an error or because a catheter had been inserted that day but not documented. This inconsistency casts doubt on the overall accuracy of the information recorded in the comfort records on this date. This poor documentation falls short of the NMC Code’s requirement to keep accurate records because if a catheter had been inserted, this should have been clearly documented by the nursing team.
96. The Trust has lost the nursing records from 9 to 24 October.
97. On 25 October the nursing team reviewed Mrs N’s nursing needs and correctly identified she was incontinent. The comfort rounds for that day were left blank, meaning we do not have a record of the continence care that took place that day.
98. From 26 to 30 October the nursing team documented regular continence care. They also recorded they had completed Mrs N’s catheter care at the same time. The nursing notes are inconsistent as to whether a catheter was in situ and there is no record of a catheter being inserted or replaced during this period. This inconsistency casts doubt on the overall accuracy of the information recorded in the comfort records.
99. The Trust has lost the nursing records from 31 October to 19 November.
100. Between 20 and 23 November the nursing staff documented regular continence care.
101. The Trust has lost the nursing notes from 24 November to 3 December.
102. On 4 December the nursing team reviewed Mrs N’s care needs. This assessment correctly identified she was incontinent. There is no record of an update to her care plan for continence following this assessment.
103. Between 4 and 7 December the nursing team inconsistently documented a catheter being in situ and the provision of catheter care. Regular continence care was documented; however, the accuracy of these records is in doubt because of the inconsistent references to a catheter, and there being no record of a catheter being inserted or removed.
104. From 7 to 21 December the nursing team documented regular continence care and there are no inconsistencies within the nursing notes that cast doubt on these records.
105. The continence care provided between 22 and 26 December was also inconsistently documented, with references to catheter care despite there being no record of a catheter being inserted on 22, 25 and 26 December. This casts doubt on the accuracy of the comfort rounds recorded during this time.
106. Overall, there are records of regular continence care being provided, with some omissions in terms of the frequency. However, because there were repeated inconsistencies in recording Mrs N’s continence needs, specifically in relation to whether she had a catheter in place, this makes it unclear whether some of the comfort rounds recorded were accurate records of the care that was taking place. This inconsistent and incomplete documentation of her continence needs fell short of the NMC Code and was a failing in record keeping around Mrs N’s continence care.
107. Further, whilst regular continence care was documented as being provided, there are large gaps in the records of what happened due to lost medical records, and inconsistencies in the records we do have. Because of this this we cannot robustly conclude that the evidence shows that Mrs N’s continence care was managed in line with the NMC Code and CG138 throughout her admission. This amounts to service failure.
108. Dr U says these failings caused her mother to develop a pressure ulcer on her sacrum. The first reference to a pressure ulcer was on 26 September. This was during a period of care where her continence needs were being documented as being addressed regularly each day. Further, whilst moisture being present is a risk factor for developing a pressure ulcer, as set out in the Braden assessment, Mrs N also had a number of other risk factors for developing a pressure ulcer, and we, therefore, cannot robustly say she would not have developed the wound had her continence care been optimal.
109. We recognise that knowing Mrs N’s continence care was not provided in line with the national guidance will cause Dr U distress, and this is an injustice to her.
110. The Trust has not acknowledged any errors in its continence care, nor the recording of this care, and has not taken steps to put things right. We have made recommendations for the Trust to address these failings later in our report.
Pressure ulcer care 111. Dr U complains the Trust failed to assess and manage the wound on her mother’s sacrum appropriately.
112. Our nursing adviser explained that with regards to the wound on Mrs N’s sacrum, the Trust should have managed this in line with NICE guideline CG179 (pressure ulcers: prevention and management).
113. NICE guideline CG179 states that the Trust should have carried out and documented an assessment of Mrs N’s pressure ulcer risk, and this should have been reviewed weekly. This is because she had risk factors for pressure ulcers due to significantly limited mobility and incontinence.
114. To assess patients’ pressure ulcer risk, CG179 recommends using a validated scale such as the Waterlow or Braden scale. CG179 also states this should be reviewed weekly and reassessed whenever there is a change in the patient’s clinical status, for example if their mobility or continence needs change.
115. If adults are assessed as being at high risk of developing a pressure ulcer, a skin assessment should take place to check for skin integrity in pressure areas and any changes in skin colour or integrity.
116. CG179 also recommends encouraging patient repositioning at least every 6 hours, assisting the patient to reposition, and documenting the frequency of repositioning. Adults who are assessed as high risk of developing a pressure ulcer should have their position changed at least every four hours. Nursing staff should also complete a care plan for all adults assessed as being at high risk of developing a pressure ulcer and for all pressure ulcers identified.
117. When a pressure ulcer is identified it should be documented using a validated measuring technique if possible, or a photograph. It should also be categorised using a validated clinical scale. This assessment should guide ongoing preventative strategies and management, and the Trust should have offered nutritional assessments/supplements prescribed pressure redistributing devices where required.
118. On admission to hospital on 16 September, Mrs N had no independent mobility. The nursing team undertook daily assessments of her pressure ulcer risk using the Braden tool between 16 and 22 September. At each assessment, she was found to be at moderate risk of developing a pressure ulcer. The Trust completed a skin integrity care plan which documented the need to reposition her at four hourly intervals. This was in line with CG179.
119. On 26 September the nursing staff identified ‘broken skin’ close to Mrs N’s buttocks, and this was assessed and classified as a grade two sacral pressure ulcer. This was appropriately documented using a validated scale and a photograph was taken, in line with CG179.
120. The nurses updated the Braden assessment that day but there was no update to the body map. The skin integrity care plan also did not change to reflect the pressure ulcer that had been identified. This was not in line with CG179.
121. At the point at which Mrs N’s pressure ulcer was documented, she was also at high risk of malnutrition, as identified by the MUST screen dated 23 September. This was an important consideration because malnutrition is a risk factor for developing pressure ulcers.
122. Mrs N’s prescription chart shows she was prescribed nutritional supplements from 27 September, and these were to be administered twice daily. Her prescription charts indicate these were being consistently administered, as prescribed, from 27 September to 19 October. The Trust has lost the prescription charts from 20 October to 30 November.
123. After identifying the pressure ulcer on 26 and 27 September, although there were no updates to Mrs N’s care plan, the nursing team documented that 2-hourly repositioning was required from 27 September. However, the following day 4-hourly repositioning was noted as being required. It is unclear why this changed as there was no further documented reassessment of Mrs N’s needs. There was also a long period of eight hours where she was not repositioned between midday and 8.30pm on 27 September, which was not in line with her care plan.
124. There is a reference to a tissue viability nurse assessing the wound on 27 September in the nursing notes, but we do not have a record of this assessment due to the records lost by the Trust. An air mattress was documented as having been ordered that day. These interventions were in line with CG179, despite the assessment not meeting the requirements of this guidance.
125. On 30 September a new Braden assessment was completed, but the body map was left blank. The skin integrity care plan completed at this time noted Mrs N had no skin damage, which did not align with the clinical narrative of a pressure ulcer on the sacrum in the preceding days. Our nursing adviser told us it is highly unlikely a grade two pressure ulcer could fully heal within three days. This was not in line with CG179 because the assessment and care plan were inaccurate.
126. A further body map completed on 2 October did not note the pressure ulcer on Mrs N’s sacrum, nor did a body map completed on 5 October. Our nursing adviser explained it is unlikely a grade two pressure ulcer could fully heal within eight days. This conflicts with the pressure ulcer being present on 26 and 27 September. On balance, it is more likely than not that these assessments were not an accurate record of Mrs N’s skin integrity at that time.
127. The nursing records from 1 to 8 October reflect that Mrs N was repositioned approximately every two to four hours, except for a long period of time between 5.50pm on 3 October and 10am on 8 October. This amounted to 17 hours between the documented repositioning. There were also no records kept by the Trust for repositioning on 5 October.
128. The Trust has lost the nursing notes from between 9 and 24 October.
129. On 25 October Mrs N was assessed again using the Braden scale, which found her to be at moderate risk of developing a pressure sore. This assessment identified moisture damage to her sacral skin and recommended she be repositioned 2-hourly. The records reflect this happened, overall, between 25 and 30 October. However, there were no further references to the moisture lesion in her clinical notes between 26 and 30 October. This reflects further inconsistency in the clinical narrative surrounding Mrs N’s skin integrity because a moisture lesion would be unlikely to fully heal within one to five days.
130. The Trust has lost the nursing notes from 31 October to 19 November. It has also lost Mrs N’s prescription charts for between 20 October and 30 November, which means we cannot know whether the Trust was correctly administering her nutritional support during that time.
131. A new Braden assessment was undertaken by the nurses on 20 November which indicated Mrs N was at high risk of developing a pressure ulcer. The outcome indicated the need for 2-hourly repositioning. The body map did not indicate any pressure ulcer or tissue damage in the sacral region. Due to the lost medical records, we cannot say whether this was because the moisture lesion identified on 25 October had healed or whether this was poor documentation.
132. Mrs N’s prescription charts from 1 December reflect that she was being prescribed the same nutritional supplements as on 19 October, and that these were being consistently administered in line with her prescription from 1 to 26 December. There were some occasions where the nurses documented that Mrs N had declined the nutrition drink.
133. The Trust has lost the records of how often Mrs N was repositioned between 20 November and 3 December. This means we cannot say whether she was appropriately repositioned during this time.
134. On 4 December a new Braden assessment indicated Mrs N was at moderate risk of developing a pressure sore. The body map did not reference any tissue damage in her sacral area. The skin integrity care plan indicated the need for 2-hourly repositioning to manage her pressure ulcer risk. The nursing records indicate that, in the main, she was repositioned 2-hourly between 4 and 17 December, aside from one afternoon where this dropped to 4-hourly and one morning where she was not repositioned for five hours. Overall, the records we have indicate that in the main, Mrs N was repositioned in line with her care plan during this time.
135. On 11 December another Braden assessment was undertaken that documented a grade two pressure ulcer on Mrs N’s sacrum. This was reviewed on 12 and 13 December. A skin integrity care plan was completed; however, the care plan incorrectly recommended the interventions required for intact skin instead of for individuals with a pressure ulcer. This was not in line with CG179.
136. A new Braden assessment on 18 December found that Mrs N was at moderate risk for developing a pressure ulcer. The skin integrity care plan was incorrectly completed and the nurse did not fully complete the care plan to indicate the frequency of repositioning required. This assessment should also have documented a pressure ulcer but failed to do so. This was not in line with CG179 because the assessment and care plan were not accurately completed.
137. On 20 December, the Trust documented an update to the body map which reflected there was a grade two pressure ulcer on Mrs N’s sacrum. Her care plan and Braden assessment were not updated to reflect this change in clinical status, which was not in line with CG179. Despite this, the nursing records for 18 December indicate repositioning remained at 2-hourly intervals, and this was consistently completed between 18 and 26 December, aside from some minor delays on 23 December where repositioning happened after 3 hours.
138. Whilst the records reflect repositing took place regularly, Dr U says that when her family visited Mrs N they did not witness regular repositioning and their requests for the nursing team to reposition Mrs N were ignored. She also says that she never saw her mother being given nutritional supplements whilst in hospital. Whilst we cannot reconcile these two conflicting accounts of what happened, we understand why this would cause Dr U concern.
139. To summarise, the evidence shows that the Trust’s assessment and management of Mrs N’s sacral pressure ulcer was inconsistently documented and, at times, inaccurate. On some occasions the Trust acted in line with CG179 and at other times its actions fell far short of this guidance. The Trust appropriately implemented nutritional supplements to support the management of her pressure ulcer; however, its documentation of the pressure ulcer itself and her skin integrity care plans were inconsistent and conflicted with the clinical narrative within the nursing notes on several occasions. This fell so far short of NICE guideline CG179 that it amounts to service failure.
140. Dr U says these errors caused her mother unnecessary suffering during the final months of her life and she was not treated with dignity.
141. Our nursing adviser explained that it is more likely than not the extent of the pressure damage could have been prevented had pressure area care been undertaken accurately and consistently. It is possible Mrs N could still have developed a pressure ulcer, but the extent of the wound could have been better prevented and managed had the right care been given. We think this would have caused unnecessary discomfort to Mrs N because research into pressure ulcers in end of life care reflects that pressure ulcers decrease patients’ quality of life (Lovely, Thelly, and Mathew 2023). This would have been, understandably, distressing for Mrs N’s family.
142. The Trust has not yet acknowledged these failings, nor taken steps to put things right. We have addressed this in our recommendations at the end of this report.Wound care 143. Dr U complains that the Trust failed to undertake the proper wound care on her mother’s leg and her bandages were not changed as regularly as they should have been.
144. Our nursing adviser told us there is no national guidance for how gangrenous wounds should be cared for. They explained that the nursing team should have acted in line with the NMC Code (section 13.3). More specifically, they should have asked for help and advice from the Tissue Viability Nursing (TVN) team and changed the wound dressing in line with this advice. This advice should have been clearly documented and the nurses should also have clearly documented the wound care provided Mrs N’s medical records. Our nursing adviser explained that this should have included completing wound care charts.
145. Due to the medical records lost by the Trust, it is difficult to know whether the Trust obtained appropriate advice on wound management from the TVN team. It is difficult to know from these records at what point Mrs N’s skin broke down and became a wound, and it is also difficult to know at what point she was diagnosed with gangrene.
146. The nursing team first documented concerns about Mrs N’s leg on 26 September. Nursing notes from 2 October indicate that her leg was becoming darker in colour. The Trust has lost the nursing records for 9 to 24 October, which appears to be more likely than not when the wound began developing on her leg. This is reflected in a body map dated 25 October, which documents open blisters on her left leg and that her foot was necrotic. It is also likely that Mrs N’s leg required a dressing at this time, which is reflected in the nursing notes on 27 October.
147. There is no record of any member of the nursing team obtaining advice from the TVN team about wound management for Mrs N’s ischaemic leg. Whilst it is possible that the ward’s nurses had the competence to manage her wound without specialist advice, it is unlikely this was the case. Unless these nurses had had specific training in this area, this would fall short of the NMC Code.
148. The Trust completed wound assessment charts on 27 October, which documented that daily wound dressings were indicated on 27 and 28 October. This changed on 29 October to as required; however, there is nothing documented in Mrs N’s nursing notes to indicate why this changed. The nursing notes reflect her wound and dressing changes were accurately documented on the wound chart between 27 and 30 October. The Trust has lost the nursing notes from between 31 October and 19 November.
149. On 20 November a wound assessment chart was commenced which documented that daily dressing changes were required; however, this chart reflects that this happened every other day between 20 and 25 November. This was not in line with Mrs N’s care plan.
150. The nursing notes between 24 November and 4 December are missing, and there is no wound chart for this period. We cannot know if the Trust has lost this or whether it was never completed.
151. The wound assessment chart was not completed between 4 and 6 December. The wound chart reflects the dressing required changing daily, but this was only documented as happening on 7 and 10 of December. The nursing notes from 4 December reflect her dressing was also changed that day. There is no reference to a dressing change in the nursing notes on 5 December. On 6 December, the nurses documented that they did not change the dressing because the family were present; however, there is no reference to this taking place later that day when the family had left.
152. The nursing notes reflect dressing changes took place daily between 8 and 14 December. The nursing notes for 15 December clearly document she required daily wound dressing but did not reflect whether or not this happened, nor was this documented the following day. Daily dressing changes were documented in the nursing notes and wound care charts between 17 and 25 December. Mrs N, sadly, died on 26 December.
153. The care plan for Mrs N’s gangrenous wound was that her dressing should be changed daily. This should have happened at least from 27 October, and possibly sooner, with wound care charts being maintained for this. Sadly, this did not happen consistently.
154. The Trust’s poor record keeping has presented a serious barrier to considering whether or not it appropriately managed Mrs N’s wound during this her admission. The documentation of her wound care fell far below the standard required of registered nurses and was a failing in the care provided to her. We have also seen no evidence that the nurses obtained appropriate advice on managing such a serious wound, and this was also a failing.
155. Our vascular surgeon told us that it is more likely than not Mrs N’s leg was not salvageable from late September and the presence of the ischaemic limb presented a high risk of mortality in and of itself. This means that it is unlikely the failings identified led to a less favourable clinical outcome for Mrs N. However, we do think that this could have caused her additional discomfort and distress in the final months of her life. It also caused her family distress at witnessing dirty bandages when visiting her, and at knowing her care was not documented in line with her care plan and the NMC Code.
156. In its complaint response to Dr U, dated 29 September 2022, the Trust acknowledged some discrepancies in the wound care provided but did not acknowledge the extent of what went wrong. It apologised for the poor wound care. We do not think this is sufficient to put right the impact of what went wrong, and we have outlined the further actions we think the Trust should take at the end of this report.
Therapies input 157. Dr U complains the Trust did not ensure her mother had appropriate therapeutic input during her hospital admission. In this context, therapies input means input from occupational health, speech and language therapy, physiotherapy, and other relevant therapeutic disciplines.
158. We asked our physician adviser what therapies input Mrs N should have received and whether her medical records reflect this happened. They explained that due to the records lost by the Trust we do not have any record of the therapies provided in September, October or November. The only evidence we can see in her medical records are physician entries in December that indicate physiotherapy and occupational therapy were part of her care. There is not enough evidence in the records, however, to tell us what should have happened and whether the therapies input provided by the Trust was in line with national guidance.
159. We have considered the impact of these lost records below.
Lost medical records 160. Dr U complains that the Trust lost a significant portion of her mother’s medical records. She says this means she may never know whether aspects of her mother’s care were in line with the relevant guidance.
161. Comprehensive record-keeping is fundamental in healthcare. Records kept by NHS organisations are public records, as defined by the Public Records Act 1958. This means that all employees of NHS organisations are responsible for any records they create and use, including non-clinical staff.
162. Our Principles of Good Administration set out a framework for what good administration looks like in public services. In line with these Principles, we would expect the Trust to handle information properly and appropriately, and ensure it kept proper records of all care it provided.
163. The lost medical records have limited our ability to provide a thorough review of the care she received and, in some instances, prevented us from reaching a decision about whether there was service failure. The lost records have impacted on our ability to consider:
• whether Mrs N’s atrial fibrillation was identified and treated in line with the national guidance • the treatment provided for her blood clot and whether this was clinically appropriate • whether or not the assessment of Mrs N’s ischaemic leg was accurate and whether the treatments offered were clinically appropriate • whether or not a dietetic assessment took place in September • if the nurses obtained specialist advice on wound management when treating Mrs N’s gangrenous leg.
164. The lost records have also prevented us from reaching a decision as to whether:
• the Trust obtained an accurate clinical history for Mrs N from her GP • it provided sufficient therapies input during her admission.
165. These lost records were so extensive and impacted our consideration of this complaint to such a degree, that it was service failure.
166. These records were more likely than not lost by the Trust during complaint handling. This is because the Trust was able to reference records that it has lost in its complaint responses to Dr U.
167. Dr U says this failing means she may never know what happened or whether mistakes were made in her mother’s care. She says this has compounded the impact of the failings in her mother’s care and caused further distress.
168. Despite the lost records, we have been able to reach a decision in most of the issuesDr U brought to us. However, Dr U will never have answers to two of the concerns she has raised and there are still questions that have been unanswered for issues that we have been able to make a decision on. This is understandably distressing for Dr U, and we can understand why this would compound the impact of the failings we have identified in her mother’s care.
169. The Trust has not yet taken steps to put right the impact of what went wrong with regards to its record-keeping, and we have outlined recommendations at the end of this report.