Concerns about DoLS
20. The SCIR guidance explains staff should implement an urgent DoLS authorisation immediately to ensure a patient at risk of harm can receive sufficient care without delay. The urgent DoLS authorisation form confirms this should be implemented when:
• The patient is suffering from a mental disorder or lacks capacity to make their own decision about whether to remain in hospital for care and treatment.
• It is in the patients’ best interests to remain in hospital to receive care or treatment, even though they will be deprived of their liberty.
• Depriving the patient of their liberty is necessary to prevent harm to them and a proportionate response to the harm they are likely to suffer otherwise.
• The need for the patient to be deprived of their liberty is urgent it is appropriate for that deprivation to begin immediately, before the request for the standard authorisation is made or has been determined.
21. Mrs B was suffering from a haemorrhagic stroke and a UTI. NICE guidelines on delirium show that these conditions can impact a patient’s mental state and cause significant confusion, which she was experiencing at the time.
22. Mrs B also required one to one nursing care and support upon admission. This means that a member of staff had to observe and support her consistently. Our adviser explained this is the highest level of care that staff can provide.
23. On 5 and 6 July, staff attempted to speak to Mrs B regarding possible care and treatment. It is documented in Mrs B’s medical records that she was confused at this time and did not understand the information staff were providing.
24. On 6 July, Mrs B attempted to climb out of her bed which put her at significant risk of injuring herself as she had reduced mobility. To reduce this risk, staff proposed to use bed rails so Mrs B could not climb out of bed. The BMA guidelines shows us that bed rails can be used to help reduce the risk of falling, however as these restrict a patient’s movement, consent or a DoLS authorisation is needed.
25. At the time, Mrs B also did not recognise she was in hospital and felt she was still at home. Staff were concerned that because of this, and because she had already tried to climb out of bed when her mobility was reduced, she would attempt to leave the hospital whilst she was confused. This showed Mrs B posed an increased risk to herself.
26. Our adviser explained Mrs B was unable to make decisions or provide informed consent to the care and treatment she should receive at the time. Because of her fluctuating confusion on 5 and 6 July, she posed an immediate risk of harm to herself. Staff implemented an urgent DoLS authorisation to help make decisions in her best interest and keep her safe.
27. Taking this into consideration, we can see staff implemented the urgent DoLS authorisation in line with the requirements set out in the urgent DoLS authorisation form. This allowed staff to make decisions in Mrs B’s best interest, including providing her care and implementing provisions to ensure she was prevented from any harm.
28. We recognise Miss A is also concerned staff did not speak to her about implementing an urgent DoLS authorisation before doing this.
29. The SCIR guidance explains that before implementing an urgent DoLS authorisation, the Trust should try to speak to the patient’s next of kin first. Our adviser explained that even after this discussion, staff may need to still implement an urgent DoLS authorisation to ensure the patient is receiving the best possible care and is kept safe from harm.
30. It is important to note that the urgent DoLS authorisation form shows staff discussed this with Mrs B’s son, who was her next of kin, before implementing it. We understand Miss A disputes this happened. However, medical records are legal documents and we have seen no evidence to suggest the information in these is false.
31. As we have seen above, Mrs B met the requirements for an urgent DoLS authorisation to be implemented. This shows us that even if staff discussed this with Miss A, in addition to Mrs B’s son, it does not mean the urgent DoLS authorisation would not have been implemented.
32. We recognise Miss A is concerned her mother’s liberty was deprived. We hope we have reassured her that staff acted in her mother’s best interest, and in line with national guidelines and clinical standards in place at the time.
Visitation in the emergency department and on ward 7
33. The Trust’s policy explains patients admitted in an emergency who are very unwell and at a high risk of getting worse should be allowed an accompanying visitor until a care plan is agreed. This means that a patient can have a visitor stay with them until they are admitted or discharged.
34. When Mrs B initially attended the emergency department, she was unsettled, confused and very unwell. Miss A was able to stay with her throughout this time and during her admission on ward 7, until staff decided to admit her onto ward 5 for further investigations and specialist care. This works in line with the Trust’s policy on visitation.
Visitation on ward 5
35. Once an inpatient, the Trust’s policy splits visitation into three different levels:
• Level 1 – visiting is permitted for all patients (up to 2 visitors for 1 hour per day) • Level 2 - visiting is permitted only for exceptional circumstances (patients requiring additional support from their family e.g. dementia or other cognitive impairment) • Level 3 – all visiting is suspended except for most exceptional circumstances authorised by the senior leadership team
36. Each ward was given a level depending on their COVID-19 status at the time. Ward 5, which Mrs B was on between 6 and 11 July, was level 2. This meant staff had to consider if exceptional circumstances applied to her before allowing visitors.
37. During the COVID-19 pandemic, staff also had to carefully consider the benefits of allowing patients to have visitors with the risk of all patients and staff on the ward contracting COVID-19. This is because vulnerable elderly patients, such as Mrs B, were at increased risk of becoming seriously unwell and dying if they contracted COVID-19.
38. The Trust’s policy explains that even if patients meet the criteria to warrant visitors, staff must carefully consider the benefits and risks of allowing visitors in individual circumstances. The benefits of permitting visitors must outweigh the risks involved.
39. At the time, Mrs B’s health was improving with treatment. Her national early warning score, which helps identify if a patient is at increased risk of deterioration, was very low and 0 at times. This shows her clinical condition was stable and her risk of deteriorating was very low. Ensuring she did not contract COVID-19 was vital to help her recovery.
40. We recognise that on some occasions Mrs B was still confused and agitated. However, her confusion and agitation was not constant and treatment for her haemorrhagic stroke and UTI were helping improve these symptoms.
41. Our adviser explained Mrs B’s level of confusion was not significant enough to show she needed additional face-to-face support from her family at the time. Even though Miss A could not visit her mother, we can see that she had regular contact with her and the ward through phone calls.
42. Taking this into consideration, we can see it was in Mrs B’s best interests to not allow her to have any face-to-face visitors whilst on ward 5. This reduced the risk of her contracting COVID-19, especially at a time when she was receiving care that was helping improve her condition. Miss A could also communicate with her mother through different means, which did not pose a greater risk to Mrs B’s health.
43. Because Mrs B did not meet the criteria to have visitors, and as the risks of visitation here outweighed the possible benefits, we have not identified any failings.
44. We do not underestimate the upset this would have caused Miss A and Mrs B. We know we cannot take away this pain, but we hope our report has provided Miss A some reassurance that staff were acting in her mother’s best interests.
Visitation on ward 25
45. In the late evening on 11 July, Mrs B was moved to ward 25 for rehabilitative treatment. This ward was level 1. In line with the Trust’s policy, Mrs B should have been allowed up to 2 visitors for 1 hour per day.
46. Miss A confirms she visited her mother on 12, 13 and 14 July. This works in line with the Trusts policy.
47. On 15 July, Miss A told the Trust she had tested positive for COVID-19. From this point, the Trust did not allow her to visit Mrs B. This was in line with its policy, which says visitors who are COVID-19 positive must not attend the hospital.
48. We can see that on 16 July Mrs B’s son attended the hospital. He wanted to see Mrs B and discuss the do not attempt resuscitation order (DNAR) that had been implemented. The nursing team asked the doctor to come and speak with him, however when the doctor arrived, Mrs B’s son had left the hospital.
49. Later that same day, staff spoke to Miss A and Mrs B’s son over the phone. They discussed the DNAR order and why the doctor had implemented this. They did not discuss visiting. From this point, we cannot see that Mrs B’s son asked to visit Mrs B again. We have seen no evidence to suggest staff did not allow Mrs B’s son to visit her during this time.
Conclusion
50. As we have not identified any failings, we are not upholding this complaint. We hope our report has answered Miss A’s concerns and provides her with reassurance that staff acted in her mother’s best interests when implementing the DoLS and visiting restrictions.