LUHFT
20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If we see signs that an organisation got something wrong, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right.
21. For the following aspects of the complaint, we have not found any indications that anything has gone wrong.
ED wait time
22. Mrs I said on her mother’s second admission to the ED on 9 January 2023, she spent up to 30 hours waiting on a corridor before a bed was available for her.
23. The Trust acknowledged that this delay took place. It said it was experiencing unprecedented waiting times and long delays in beds becoming available on its wards. It said work was in progress within the Trust and community to ensure patients can be transferred to the appropriate wards in a timely manner.
24. The Trust said throughout Mrs A’s time spent on the corridor, staff offered her refreshments and administered any medication prescribed, as well as carrying out regular intentional rounding. The Trust acknowledged the long wait that Mrs A experienced in the ED was unacceptable and apologised for any distress this caused.
25. NICE guidelines on essential requirements of care say:
‘All healthcare professionals directly involved in patient care should ensure the patient’s needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. Regularly ask patients who are unable to manage their personal needs what help they need. Address their needs at the time of asking and ensure maximum privacy’.
26. Mrs A’s records show that during the time she spent on the ED corridor, staff regularly offered her refreshments and assessed her hygiene needs. They also began two hourly intentional rounding checks and assisted Mrs A to the bathroom when she needed it.
27. The guidelines also state the importance of assessing and managing pain, encouraging and helping patients to eat and drink if needed and providing regular food and fluid in an environment conducive to eating.
28. Our nursing adviser said the Trust’s actions were all in line with the guidelines. The adviser noted staff also made sure Mrs A had analgesia and her regular medication, delivered pressure area care and assessed her hydration needs.
29. We understand that waiting such a long time for a bed to become available in the ED was incredibly unpleasant, and the lack of privacy likely compromised Mrs A’s dignity. We recognise that the Trust’s resources were extremely strained at this time, and the delay to finding a bed for Mrs A was unfortunately unavoidable. We therefore do not consider this to be a failing.
30. We consider staff did what they could under the difficult circumstances to meet Mrs A’s essential needs, in line with relevant standards and guidelines. The Trust is also actively working to improve its services in case of a similar situation occurring.
Personal hygiene and skin care
31. Mrs I said she felt staff’s support for her mother’s personal hygiene needs during her admission from 9 January – 9 February 2023 did not meet her expectations. She said she had to clean her mother’s fingernails, assist her to clean her teeth and noted that her bed sheets had not been changed.
32. The Trust said there is evidence to support that Mrs A was assisted with her hygiene needs and had her bed linen changed at least daily. It said the nursing team made regular checks throughout the shift. The Trust’s response however acknowledges Mrs I’s view that she witnessed some delays in staff meeting her mother’s care needs.
33. The Nursing and Midwifery Council (NMC) Code sets out professional standards of practice for all nurses, midwives, and nursing associates. It says staff must make sure they deliver the fundamentals of care effectively.
34. The code states that:
‘The fundamentals of care include, but are not limited to, nutrition, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions’.
35. Mrs A’s records document that staff attended to her hygiene needs frequently and on a daily basis. Our nursing adviser said this was in line with NMC standards on delivering the fundamentals of care.
36. We acknowledge that the Trust’s assistance with Mrs A’s personal hygiene did not meet Mrs I’s expectations. We have not seen sufficient evidence to say there are any indications that this level of care fell below the expected standard.
37. Mrs I also said staff did not apply Mrs A’s Hydromol cream, which resulted in her having extremely dry skin. Mrs I explained that her mother is highly allergic to Dermol cream, and staff knew she should only have Hydromol. She said the Clinical Nurse Specialist for skin visited her mother to check on a bed sore and could not believe how dry her skin was. Mrs I said she felt it was evident staff had not used the cream.
38. The Trust said it had prescribed Hydromol cream to Mrs A for use twice daily on 16 January 2023. It said according to Mrs A’s records, staff applied this twice daily between 16 January and 9 February.
39. The Trust acknowledged that on 5 February, the Tissue Viability Nurse (TVN) noted that Mrs A’s skin was extremely dry. The TVN prescribed additional Hydromol Bath and Shower Emollient for daily use and Medihoney Barrier Cream twice a day to supplement the cream she was already having.
40. The NMC code also says that staff must make sure that any treatment, assistance or care for which they are responsible is delivered without undue delay.
41. Based on the evidence we have seen, according to Mrs A’s medication charts, nursing staff did apply the creams twice a day as directed and without any delays. Our nursing adviser said this was in line with standards and guidelines.
42. We recognise Mrs I may have been alarmed at how dry her mother’s skin was. We have not seen any indications this was due to Trust staff failing to apply her prescribed creams, and staff also took action to treat this when it was clear that Mrs A’s skin was very dry.
Communication
43. Mrs I said staff did not keep her and her family updated with changes to her mother’s medication.
44. The Trust acknowledged in its response that it could have done more in communicating changes in medication with Mrs A’s family members. It said it will reflect as a team on the importance of effective communication with patients and their relatives about key changes to treatment.
45. NICE guidelines on patient experience in adult NHS services regarding communication recommend staff:
‘Clarify with the patient at the first point of contact whether and how they would like their partner, family members and/or carers to be involved in key decisions about the management of their condition (or conditions). Review this regularly. If the patient agrees, share information with their partner, family member or carers.
If the patient cannot indicate their agreement to share information, ensure that family members and/or carers are kept involved and appropriately informed, but be mindful of any potentially sensitive issues and the duty of confidentiality’.
46. We have reviewed Mrs A’s records and have not seen any evidence that shows staff regularly communicated with Mrs I regarding her mother’s condition. We appreciate Mrs I’s frustrations that she did not get the updates she was expecting.
47. Our nursing adviser said while there is limited evidence to show communication with Mrs I during her mother’s admission, the records show Mrs A had the capacity to discuss her own medication needs and staff regularly spoke about this with her.
48. Additionally, staff assessed Mrs A on admission to the ED on 9 January as being mobile and self-caring, only requiring assistance to mobilise to use the toilet. The records also show she was able to eat and drink independently.
49. The above guidelines also have a section regarding patient independence. They recommend staff ‘give patients using adult NHS services the support they need to maintain their independence as far as possible’.
50. Our adviser said in line with these guidelines, staff were attempting to foster Mrs A’s independence and keep her involved in the decisions regarding her care.
51. The Trust has made efforts to make improvements to its communication after listening to the concerns Mrs I raised. It has said it now offers patients and their relatives the opportunity to meet with the team providing their care if they wish to. It also said it now displays notices containing the Ward Managers’ and Lead Nurses’ contact details in prominent places in the unit so patients or relatives can escalate any concerns appropriately.
52. We recognise Mrs I found it difficult not getting sufficient information about her mother’s care, specifically her medication and any changes to this. We have not seen any evidence to say that this was an indication of a failing from the Trust, in line with standards and guidelines.
53. However, we are satisfied the Trust has listened to Mrs I’s concerns about communication and has reflected on where it can make improvements to its service.
Acute Macular Degeneration (AMD)
54. For the following aspect of the complaint, we consider the Trust has already done enough to put right the impact of the events on Mrs A.
55. Mrs I said once her mother was on the ward, she asked staff to support her and approach her in a sensitive manner as, due to her AMD, she struggles to see the person speaking to her and cannot always hear what they say. Mrs I said her mother was weak and vulnerable, and needed a sensitive approach.
56. AMD is a common condition that can affect the middle part of someone’s vision. It does not cause total blindness but can make everyday activities like reading and recognising faces difficult.
57. The Trust said there was evidence from Mrs A’s records that staff assisted her at mealtimes in acknowledgment of her sight impairment. It said it expects staff to care for patients with compassion and provide individualised care in a sensitive manner and accepted that Mrs I did not witness this.
58. The NMC Code explains that staff must:
‘put the interests of people using or needing nursing or midwifery services first. You make their care and safety your main concern and make sure that their dignity is preserved and their needs are recognised, assessed and responded to.
You make sure that those receiving care are treated with respect, that their rights are upheld and that any discriminatory attitudes and behaviours towards those receiving care are challenged.’
59. We have reviewed Mrs A’s records and there does not appear to be any mention of her AMD or visual impairment in the nursing documentation. There is one reference within Mrs A’s falls care plan that she has a visual impairment and wears glasses. However, there is no plan for a sensitive approach to take her individual circumstances into account.
60. Our nursing adviser said, in line with the NMC Code, staff should have ensured they recognised and responded to Mrs A’s individual needs, specifically with regard to her visual impairment.
61. The Trust has acknowledged that staff did not provide care to Mrs A in an individualised and sensitive manner. It said its Assistant Director of Nursing is working with nursing teams to provide further training in compassion and sensitivity, to ensure that future patient experiences are improved.
62. Our Principles for Remedy say organisations should seek continuous improvement. The principles say part of a remedy may be to ensure that changes are made to policies, procedures, systems, staff training or all of these, to ensure that poor service is not repeated. It is important that lessons are learnt, and the complainant should receive an explanation of changes made to prevent poor service being repeated.
63. We recognise that the lack of sensitivity to Mrs A’s individual circumstances from staff may have had a negative effect on her experience in the hospital. We are satisfied that this did not have an impact on the standard of healthcare that Mrs A received, however we understand that she found this to be a frightening and distressing experience.
64. The Trust has shown in its response that it has listened carefully to Mrs I’s concerns about how she felt the lack of compassion from some staff affected her mother’s experience in hospital. It has taken action to address this and put measures in place to improve its service for other patients. We consider the Trust’s actions to be in line with our principles.
North West Ambulance Service NHS Trust (NWAS)
Ambulance transfer
65. Mrs I said the ambulance transfer team who assisted with her mother’s discharge were too rough when transferring her from her hospital bed to the stretcher. She said the staff caused Mrs A to suffer an injury to her shoulder.
66. The Trust explained that it had reviewed the incident log to locate the staff members who had attended to Mrs A on the day of her discharge and carried out interviews with them. It said neither staff member could recall specific details of Mrs A’s transfer but disputed that any injury occurred while in their care.
67. NHS England guidelines on patient safety say that healthcare staff are encouraged to record any incidents, whether they result in harm or not, to its national service for recording, sharing and learning from patient safety events.
68. In this situation, there was no incident form. The Trust said staff were not aware of any injury at the time and therefore did not record any incidents. Mrs A did not mention to the staff carrying out the transfer that she was in pain. It was only the following day that Mrs A brought this to the attention of the staff in the care home that she had been transferred to. Therefore, there is a limited amount of evidence for us to come to a view on what happened during Mrs A’s transfer.
69. NHS complaint standards say an effective complaint handling system makes sure staff take a thorough, proportionate and balanced look into the issues raised in a complaint. It gives people fair and open answers to their questions based on facts and takes full accountability for mistakes identified.
70. We have reviewed the Trust’s internal complaint file which shows the detailed investigation it did into Mrs I’s complaint. The Trust interviewed the staff involved in the transfer and showed that it had listened carefully to Mrs I’s concerns. We are satisfied the Trust took Mrs I’s complaint seriously and investigated it thoroughly and proportionately.
71. We appreciate that Mrs I has raised serious concerns that Trust staff caused a significant injury to her mother. We make our decisions based on evidence. In relation to this part of Mrs I’s complaint, there are no independent witnesses that can corroborate Mrs A’s account of events, and due to the routine nature of the transfer, there are no records that document this.
72. We are unfortunately unable to reach a view based on the evidence we have available to us. We hope Mrs I will be reassured that we have carefully considered how the Trust investigated her complaint and have seen no indications the Trust did anything wrong.