Records around restraint 14. We have already established the Trust’s decision to use restraint was appropriate. What we have been unable to determine is exactly how the Trust restrained Mr F. Our ED adviser explained there are different restraint techniques that can be used and it is important to consider the situation. RCEM guidance reflects it is about doing the least for the shortest time possible.
15. The Trust’s complaint response said it used ‘standard restraint and that would have been a cradle over the wrist and an interrupter over the shoulder and interrupters just above the knees and ankles to stop [Mr F] kicking upward for sedation to be given’. The Trust told us it explained more about this to Mr F’s family when it met with them after their complaint. We appreciate they do not share this view and the information it provided in writing is not particularly detailed.
16. Our Principles of Good Administration say organisations should create and maintain reliable and usable records as evidence of their activities. We have seen no evidence the Trust acted in line with this. There is limited information in Mr F’s clinical records about the restraint and we have seen no documentation from the Violence and Aggression Team.
17. We consider this a failing. The Trust told us when it reviewed its restraint policy last year (not in response to the complaint), it produced a document for staff to record a restraint formally. We cannot say the absence of a specific document justifies the record keeping at the time. We cannot provide an impartial view on how Mr F was restrained based on the limited information available.
18. During our investigation, the Trust clarified ‘at no point was any mechanical device used to restrain’ Mr F. It said it uses the Maybo restraint technique and four people would have been involved in the restraint – one per limb.
19. The people restraining the arms put one hand in a bridge over the patient’s wrist (known as a ‘cradle’). Mr F would have been able to move his wrist but not remove his hand from the ‘cradle’, stopping him from being able to hit out. The person holding each wrist would have had their other hand hovering in front of Mr F’s shoulder. That hovering hand is the ‘interrupter’.
20. For his legs, the same applied, but the ‘cradle’ is over the ankle and the ‘interrupter’ is the other hand hovering over his thigh, above his knee. Had Mr F flung himself forward or tried to kick then the hovering hand would prevent him getting more than an inch or so off the trolley or bed.
21. Point 33 of the GMC guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. It would therefore have been better if the Trust had spoken to Mr F’s relatives and explained the reasons for the restraint. We consider it a failing it did not do so.
22. Miss F remains concerned about the circumstances around her father’s death. We consider it likely communication and documentation at the time of the restraint would have reduced the uncertainty she experienced. Instead, it added to her bereavement.
23. Following our involvement, the Trust acknowledged more information should have been included in the documentation. It also said any significant restraint should be reported through the Trust’s Datix reporting system. The Trust told us it is reviewing its security services, including how it manages restraint, to ensure patients and staff are safe.
24. We are making recommendations so the Trust can acknowledge this to Miss F and demonstrate how it will embed the learning from her complaint.
Treatment and discharge 25. Point 15 of the GMC guidance says doctors assessing, diagnosing or treating patients must adequately assess them, taking account of their history, and promptly provide treatment where necessary.
26. When Mr F came into hospital, he had been constipated for some time. Our physician adviser explained the Trust treated him for constipation but there was an issue with the Trust’s medical management in terms of considering causes of his delirium.
27. Constipation can cause a blockage, which can lead to acute urinary retention (unable to pass urine) or chronic retention (where the bladder gets big over some time, but can still pass urine). Without an acute change, this is unlikely to cause delirium. If the blockage worsens, this can change to acute on chronic retention (where a patient with chronic retention stops passing urine completely).
28. People with dementia are unable to explain those symptoms. Often they experience abdominal pain, get more muddled and get aggressive. Urinary retention can bring on delirium, and constipation will make urinary retention worse. Severe constipation may not resolve quickly. If the constipation persisted then urinary retention is more likely to recur.
29. NICE CG103 says healthcare staff should ‘think delirium’. They should manage the possible underlying cause or causes of delirium. The Trust identified a potential cause of delirium (constipation), but did not consider another related cause.
30. The Trust’s complaint response said its ‘CT scan did not reveal at this stage either a dissented [sic] bladder or renal issues.’ This is not accurate. The scan report says ‘the urinary bladder appears distended’. It does not quantify how distended Mr F’s bladder was.
31. The Trust now accepts Mr F’s bladder at the time was distended, but says this does not mean that Mr F was in urinary retention at the time. It says urinary retention can be linked to constipation, and he opened his bowels and passed urine after the scan.
32. The Trust noted the bladder diverticulum (pouches on the bladder wall) on the scan suggested Mr F had long-term urinary outflow obstruction. Our adviser agreed this would indeed indicate long term problems with bladder emptying, and may indicate chronic retention. Chronic retention or poor bladder emptying is a risk for recurrent urinary infection.
33. Mr F’s clinical records from 21 January show the Trust had reviewed the scan, but it did not on the results in the way the GMC guidance sets out.
34. Our physician adviser explained the CT scan resulted should have prompted the Trust to catheterise Mr F or do another scan (CT or a handheld ultrasound scan) after Mr F had urinated. Although the records suggest he voided a large amount of urine, there was no re-scan to ensure he was emptying his bladder adequately when he left hospital.
35. This means the Trust did not rule out the possibility Mr F was in some degree of urinary retention when he left hospital. Our physician adviser said there is a possibility his bladder was still distended and that this needed further attention with catheterisation. It is also very possible that urinary retention was contributing to why he was being aggressive.
36. The Trust did not change the medication Mr F had been taking at home. Mr F was sent home on morphine (a strong painkiller), solifenacin (which acts on the bladder), and amitriptyline (used to treat pain and depression). Our physician adviser explained these are also constipating drugs, and the latter two can impair bladder function.
37. Our physician adviser explained if clinicians are managing the symptoms then they can think about where the care can be safely provided, at home for example. The Trust discharged Mr F with laxatives which will have helped treat constipation but there was no documented safety netting regarding Mr F’s bladder or bowel function.
38. Miss F told us the Trust did not give her family information about the treatment it had provided when her father was discharged home. We can see the Trust’s records indicate it sent a discharge summary to Mr F’s GP on 23 January. There is no indication it spoke to his family after 21 January.
39. The Trust’s records include a section to record whether the patient/family/carers have received a copy of the discharge summary. This says ‘no’ and when prompted to specify a reason, the Trust entered ‘delayed’. We consider this a failing.
40. Mr F had no signs of sepsis when he left hospital, he developed them at home. He had no sign of obstruction or kidney failure in hospital either but was apparently in urinary retention when at home. Our physician adviser said this risk potentially could have been foreseen given the distended bladder on the scan.
41. We recognise in view of Mr F’s overall frailty, he was very susceptible to infections and deterioration. Infection can ‘take hold’ more easily and be more severe in a bladder that is not emptying well. On balance it seems more likely than not that more active management and monitoring of the distended bladder would have prevented his rapid deterioration after discharge with urinary retention, infection and bleeding.