Our findings
The Trust
Fall
24. On 27 January, Mrs D fell from her hospital bed. According to the records, staff did not witness her fall, but heard a ‘loud bang’. They unfortunately found Mrs D on the floor with the bed raised and tilted at an angle. Mrs E says the Trust should have prevented this happening.
25. The NICE clinical guideline on assessing risk and preventing falls says people aged 65 or over should be considered as being at increased risk of falling. The guideline says during a hospital stay, they should be offered a multifactorial falls risk assessment (an assessment that identifies the factors that put an individual at risk of falling) and a multifactorial intervention (a care plan that aims to address these risk factors).
26. We looked at this part of the complaint with our nursing adviser. We can see from the records the Trust completed a falls risk assessment on 15 December and then on a weekly basis. The falls risk assessments show the Trust considered the factors that put Mrs D at increased risk of falls, including her stroke and her mobility. The falls risk assessment shows the Trust considered Mrs D to be at risk of falls.
27. The Trust completed a multifactorial intervention care plan on 20 December. The care plan shows how Trust aimed to address the factors that put Mrs D at risk of falling. This included assisting her to change position in bed, ensuring she had access to a call bell and could understand how to use it, and referring her for physiotherapy.
28. The care plan also shows the Trust considered the use of bed rails to reduce the risk of Mrs D falling from bed. The Trust noted that due to Mrs D’s mobility and disorientation, the use of bed rails should be reviewed daily. Our nursing adviser highlighted that a separate bed rails risk assessment shows the Trust did this.
29. Although we can understand why Mrs E would have wanted the Trust to prevent Mrs D’s fall, we do not think this was possible. The Royal College of Physicians audit of falls in hospitals looks at the care inpatients have received before a fall. It says there is no single thing a Trust can do to reduce a fall. It says ‘multifactorial interventions’ can reduce falls by between ‘20% and 30%’. This standard recognises how falls can be caused many different factors, and there are many different factors needed for the likelihood of a fall to be reduced.
30. We hope we have been able to assure Mrs E that the Trust had a falls plan in place for Mrs D in line with the NICE guideline, with interventions taken to reduce her chance of falling. We have not seen anything to indicate the Trust should have done more to try to prevent her fall.
Pain relief
31. Mrs E says on 9 February, a nurse told Mrs D’s granddaughter she’d had some scans to find out why she was in pain. She says the nurse said the Trust had just found out about Mrs D’s suspected lung cancer and it was likely that it had spread, causing her pain. Mrs E says this means the Trust did not give Mrs D sufficient pain relief prior to 9 February.
32. Our geriatrician adviser said they could not see anything in the records to suggest Mrs D needed pain relief for pain specifically caused by her suspected lung cancer. They explained that a typical cause of pain for lung cancer sufferers is a mass in the lungs pressing on the inside of the chest. They said they could see no evidence of a mass like this on the chest X ray the Trust took when Mrs D was first admitted to hospital.
33. We can see Mrs D was suffering pain in her right shoulder. Our geriatrician adviser explained that stroke survivors often experience shoulder pain. The National Clinical Guideline for Stroke (the Stroke Guideline) says up to 65% of stroke survivors will experience musculoskeletal pain, with shoulder pain being the most prevalent.
34. With this in mind, we considered what the Stroke Guideline says about pain relief. It advises people who experience musculoskeletal pain after stroke should be offered ‘simple’ painkillers such as ‘paracetamol’.
35. The records show a doctor prescribed Mrs D paracetamol upon her admission to hospital. The prescription chart shows this was to be given ‘as required’, so whenever Mrs D needed pain relief. We can see from the records that nurses regularly asked her if she was in pain, and she was able to nod or shake her head to communicate her needs. Our geriatrician adviser said they could see no evidence Mrs D needed stronger pain relief prior to 9 February.
36. The Stroke Guideline also says pain relief does not have to be pharmacological (in the form of medication). It gives physiotherapy as an example of a non-pharmacological form of pain relief. We can see Mrs D had regular physiotherapy. Our geriatrician adviser said this would also have helped minimise her pain.
37. We think the Trust gave Mrs D the pain relief she needed for the period we looked at. We could not see any evidence that Mrs D experienced pain specifically relating to suspected lung cancer during this time. We do not doubt Mrs E’s account that Mrs D did experience pain at times, but on balance, we think this was more likely related to her stroke. We think the Trust responded to this in line with the Stroke Guidelines.
38. We have not found a failing for this part of Mrs E’s complaint. We understand how distressing it would have been for Mrs E and her family to think Mrs D did not have sufficient pain relief.
Prognosis
39. Mrs E says the Trust gave the family conflicting information about Mrs D’s prognosis. She says at a meeting on 3 February, a nurse told the family Mrs D had a life expectancy of 12 months. She says this was incorrect because a week later, a doctor told the family that sadly, Mrs D would likely only survive for a few months.
40. The records show the aim of the meeting on 3 February was to set goals for Mrs D’s rehabilitation and make plans for her future. We can see the nurse suggested that Mrs D would need 24 hour care once she was discharged from hospital. The notes from the meeting show the Trust planned to refer Mrs D to a social worker and for the family to discuss what they felt would be best for her.
41. The NICE guideline on end of life care for adults sets out what healthcare professionals should do to make sure they meet the needs of people approaching the end of their life and their families. The guideline includes people who are frail and have conditions that mean they ‘are at increased risk of dying within the next 12 months’. With this guideline in mind, we can understand why the nurse referred to a timeframe of 12 months. We also think it reasonable for the nurse to have given a timeframe in the context of a meeting to talk about Mrs D’s future.
42. On balance, we do not consider the intention of this meeting was to discuss Mrs D’s prognosis. The records clearly show the meeting was focused on what support Mrs D would need when she left hospital.
43. We can see on 11 February, a doctor said Mrs D had a ‘guarded prognosis’ and her deterioration was a result of her other health conditions. We can understand that hearing the sad news that Mrs D’s life expectancy was likely going to be less than what Mrs E and her family initially thought must have been devastating.
44. We consider the Trust did not give conflicting information about Mrs D’s prognosis. We think it more likely than not that it was the doctor that gave a prognosis whereas the nurse was giving a timeframe to help the family plan Mrs D’s future.
45. It is possible the intention of the meeting on 3 February may not have been as clear to Mrs D’s family as it could have been. Although we recognise the situation caused Mrs E and her family distress, we do not consider the evidence shows anything went seriously wrong.
Discharge plan
46. Mrs E says she was shocked to find out the Trust had changed Mrs D’s insulin and instructed nursing home staff to only check her blood glucose once a day. She says Mrs D’s blood sugar was erratic because she could have very high and very low blood sugar throughout the day. She complains the Trust’s instructions in the discharge plan did not consider this or take into account that Mrs D had suffered from DKA before.
47. The guidance on end of life diabetes care sets out recommendations to healthcare professionals who are caring for people with diabetes and who are approaching the end of their life. The guidance says by this stage, diabetes treatment should be ‘minimised’, and the emphasis should be on keeping the individual ‘comfortable’. This includes making sure invasive testing, including blood sugar testing is kept to a minimum. It says a person approaching the end of their life should be treated with a ‘once daily’ dose of slow-release insulin.
48. The discharge plan shows the diabetic consultant reviewed Mrs D’s insulin regime and adjusted her prescription from rapid-acting insulin to slow-release insulin prior to her moving to the nursing home.
49. Our endocrinology adviser explained the difference between these two types of insulin. They said rapid-acting insulin works to regulate blood sugar within 30 minutes. It is taken with meals and requires regular blood sugar testing. They explained the type of insulin the diabetic consultant recommended for Mrs D differs because it releases insulin steadily throughout the day and does not need to be taken with meals.
50. Our endocrinology adviser said slow-release insulin would have been more suitable for Mrs D as she approached the end of her life. They explained rapid-acting insulin is not appropriate for someone approaching the end of their life. They said if a person has a reduced appetite or is only able to manage small amounts of food, a dose of rapid-acting insulin can cause their blood sugar to become too low.
51. Mrs D’s discharge plan also included instructions from her diabetic consultant to the nursing home staff. The discharge plan said the ‘mainstay of treatment’ was to prevent her developing hypoglycaemia (low blood sugar) or DKA. The diabetic consultant said Mrs D was not to be treated with rapid-acting insulin.
52. Given Mrs E’s concern about the risk of Mrs D’s blood sugar becoming very high, we considered whether the diabetic consultant should have included this information in the discharge plan.
53. We think it reasonable for the diabetes consultant not to have given nursing home staff instructions on what to do if Mrs D’s blood sugar became too high. Nursing home staff are expected to be competent in caring for people with diabetes and recognise the signs of hyperglycaemia. We also note the diabetes consultant included instructions for nursing home staff to contact the Trust’s diabetes specialist nurses should they need advice.
54. Our endocrinology adviser said it might have been helpful if the diabetes consultant had included the measurement in mmols per litre they considered to be high and low blood sugar. Although this would have made the plan a little clearer, we do not consider this a serious departure from what should have happened. This is because the measurements are set out in the guidance on end of life diabetes care and would not have been specific to Mrs D.
55. Mrs E was also concerned that Mrs D had a history of DKA but the diabetic consultant did not take this into account in the discharge plan. Our endocrinology adviser said Mrs D’s history of DKA would not be relevant to the discharge planning. They explained as Mrs D had type one diabetes, she was unfortunately at risk regardless of having developed it before.
56. It is important to include our view of why the Trust’s discharge planning could not have made a difference to Mrs D developing DKA. The guidance on end of life diabetes care recommends healthcare professionals should take steps to reduce a person’s blood sugar if it is above 20mmols per litre.
57. The only time Mrs D’s blood sugar went above 20mmols per litre was on 14 February, just after lunchtime and unfortunately she vomited. At this point, nursing home staff took a ketone test which measures the amount of ketones in the blood. We can see from the nursing home records that the test showed Mrs D had sadly already developed DKA.
58. Our endocrinology adviser said there is nothing the discharge plan could have recommended to nursing home staff to avoid this happening. We do not think the nursing home staff had any opportunity to treat Mrs D’s high blood sugar before she developed DKA because it happened at the same time.
59. We do not find a failing for this part of Mrs E’s complaint. We think the Trust planned Mrs D’s discharge in line with the guidance on end of life diabetes care because it minimised her diabetes treatment and prescribed her a slow-release insulin.
60. We do not wish to underestimate how traumatic Mrs D’s sudden deterioration was for Mrs E and the rest of the family. We hope we have helped to assure Mrs E that having considered all the information, we are satisfied the Trust acted within the guidelines and the discharge plan took Mrs D’s circumstances into account.
Communication needs
61. Mrs E complained the discharge plan did not take into account Mrs D’s recent stroke. She said Mrs D was not able to communicate to nursing home staff her needs in relation to her diabetes.
62. NICE guidance on end-of-life care says healthcare professionals should ensure they have a ‘shared understanding’ of a person’s needs.
63. Mrs D had severe expressive dysphagia (difficulty expressing what she needed to say) and was not able to communicate. The discharge plan gave instructions to the nursing home staff. Our endocrinology adviser said it did not place any expectation on Mrs D to communicate her own needs.
64. We consider the evidence suggests the discharge plan was appropriate in relation to Mrs D’s communication needs. We hope Mrs E feels assured in our view that we have seen no failings for this part of the complaint.
Our findings on the complaint about the Home
65. The NMC Code sets out what nurses (and nursing associates) must do to make sure their practice does not put patients at risk. The Code says nurses ‘must accurately identify, observe, and assess signs of normal or worsening physical health in the person receiving care’.
66. The Trust’s discharge plan instructed nursing home staff to check Mrs D’s blood sugar once a day before her evening insulin dose.
67. The records show the Home checked Mrs D’s blood sugar at 6pm on 12 February followed by 18 units of insulin. On 13 February, the Home checked Mrs D’s blood sugar at 5:45pm followed by 18 units of insulin.
68. Our nursing adviser said the Home monitored Mrs D’s blood sugar according to the discharge letter from the hospital and administered the insulin as prescribed.
69. On 14 February, the records show the Home checked Mrs D’s blood sugar at 3:40pm because she had not eaten her lunch and had vomited. The records show her blood sugar was too high for the device to read.
70. We can see the Home immediately gave Mrs D 18 units of insulin and called the Trust’s Community Specialist Practitioner (CSP). The records show the CSP arrived within 30 minutes and identified that Mrs D could be suffering from DKA.
71. We consider the nursing staff at the Home acted in line with The Code. The evidence shows the nursing staff followed the instructions on Mrs D’s discharge plan and should not have done more to monitor her blood sugar. When Mrs D’s blood sugar was very high, staff identified this and flagged this with the CSP at the earliest opportunity.
72. We recognise how distressing this situation was for Mrs E and her family. We hope our work has helped to assure her that the Home did everything it should have for Mrs D during her short stay.
73. We fully empathise with how Mrs E and her family’s life has been affected by Mrs D’s sad death and thank her for sharing her experience with us.