Dementia
28. Mrs T said she suspected her father had dementia but when she had raised this with the Trust it was dismissed, and not acted on. Mrs T said on one occasion her father called her at 2am confused saying he was with his friends, and she needed to collect him. She said she tried calling staff, but no-one answered. Mrs T said when she informed the Trust the next day what had happened, she was told her father was asleep all night.
29. The Trust said patients can suffer bouts of confusion while in hospital. It also said Mr U had significant health problems which can cause confusion and it can be hard to decide if a patient has dementia whilst also taking that into account.
30. NICE guidance on dementia says if it is not possible to tell whether a person has delirium or dementia, to treat for delirium first. It also says if indicators of delirium are identified, clinicians should complete the Confusion Assessment Method (CAM) or Delirium assessment (4AT).
31. The NHS webpage describes delirium as a sudden confusion which can cause disorientation and hallucinations.
32. From the records, we can see during Mr U’s first admittance to the Trust (30 September to 9 October) there were three references to confusion. On 30 and 31 October the Trust noted Mr U appeared muddled at times. On 8 October it was documented Mr U was very confused.
33. From Mr U’s second admittance (25 October to 23 November) we can see the Trust first documented confusion on 10 November. On the 10, 11, 14 and 17 November, the Trust documented Mr U was confused at times.
34. On 21 and 22 November we can see the Trust noted Mr U was confused. Mr U was discharged on 23 November and readmitted two days later.
35. On 25 November we can see the Trust documented Mr U was experiencing a new confusion and requested a medical review. We can see the Trust documented Mr U thought he was in Spain and was trying to get to the train station. We can see a doctor reviewed Mr U and queried if he had delirium. On 26 November the Trust noted he was confused and unable to follow instructions.
36. From the evidence we have seen, we have found the Trust has acted in line with NICE guidance on dementia by not diagnosing Mr U with dementia. NICE guidance on dementia says if it is not possible to tell if a patient has dementia or delirium, to treat as delirium. Our adviser said as Mr U was experiencing a new confusion, alongside changes to his physical state, it was more likely he had delirium and not dementia.
37. We can see both the Trust and Mrs T reported Mr U’s confusion was new and, in line with the NICE guidance, the Trust queried if it was delirium. We can see the Trust requested a head CT scan and was providing medication to treat Mr U’s heart failure and antibiotics for a chest infection.
38. Our adviser said Mr U’s heart failure was the presumed cause of the delirium and so this treatment was appropriate. Based on this, we have found the Trust acted in line with NICE guidance which says to treat patients for delirium, not dementia, in the first instance.
39. Mrs T said when she received Mr U’s medical records it was documented nearly every day that her father was confused. Mrs T said despite this the Trust did not perform any investigations to determine the cause of this. She said there was also reference to a possible diagnosis of vascular dementia, but she was not informed of this, and it was not acted upon.
40. We have found the Trust did not act in line with NICE guidance on dementia in its investigation of Mr U’s confusion, which was thought to be due to delirium. We have not seen any evidence the Trust completed a CAM or 4AT assessment during any of Mr U’s inpatient stays.
41. We can see Mr U was confused and displaying symptoms of possible delirium (as set out on the NHS webpage) as early as 30 September. Based on this we found the Trust should have completed the CAM and 4AT assessment in line with NICE guidance on dementia.
42. In summary, we have found no failings in the Trust not diagnosing Mr U with dementia. It was in line with the NICE guidance on dementia to consider whether he had delirium first. We have found failings in the Trust’s lack of investigation into the cause of his confusion. We will consider the impact of this below.
Communication
43. Mrs T said the Trust did not communicate with her regarding the severity of her father’s condition, the procedures that took place or a fall he suffered. Mrs T said due to the lack of communication she does not understand what happened to her father whilst he was in hospital and how this led to his sad death.
44. The Trust said family members are only contacted when there are significant changes to a patient’s condition or treatment. The Trust apologised to Mrs T that she was not informed of Mr U’s fall. The Trust said the next-of-kin should be informed in a timely manner and this has been communicated to all staff.
45. The NICE guidance on patient experience says if the patient agrees, clinicians can share information with their partner or family members.
46. From the records we can see Mr U’s wife was listed as his next of kin on his admittance to the Trust on 30 September. His wife was also present in the emergency department with him.
47. We can see the Trust completed an angiogram on 4 October and following this the Trust completed an angioplasty on 7 October to improve the blood supply to Mr U’s leg and foot. In the procedure notes the Trust documented there was swelling in Mr U’s groin that was consistent with a haematoma. We have not seen any evidence Mr U’s family was informed of this.
48. We can see following the angioplasty the Trust documented Mr U had a large haematoma post-operatively which was bleeding and required manual compression. The Trust performed a blood transfusion the same day due to blood loss. We have not seen any evidence within the medical records the Trust contacted Mr U’s wife, or any other family member, regarding this procedure or the subsequent blood transfusions.
49. On 9 October, the Trust contacted Mr U’s wife to discuss his discharge for that day. We have not seen any evidence the Trust informed Mr U’s wife of the angioplasty or blood transfusions during this call.
50. Mr U was readmitted to the Trust on 25 October with a haematoma in his groin. On 26 October we can see the Trust spoke with Mr U’s daughter and documented it informed her Mr U required analgesia due to pain. Mr U has two daughters, and it is unclear who the Trust spoke to here.
51. We can see on 29 October the Trust documented Mr U fell from his bedside chair. We can see the Trust completed an incident report and completed post falls check documentation. We can see the next of kin contact section of the post falls check documentation was not completed.
52. On 30 October the Trust documented Mr U’s family called, and it provided a brief update. It does not say whether the fall Mr U suffered the day before was included in this update.
53. We can see Mr U suffered a second fall at the Trust on 14 November. The Trust documented Mr U fell while walking to the toilet and hit his head on another patient’s bed. We can see on the post fall check documentation the Trust did not complete the contact next of kin section.
54. We can see Mr U’s wife contacted the Trust the following day and was unhappy she had not been informed of the fall he had suffered the previous day. Mr U’s wife informed the Trust her husband’s phone battery had not been charged and he had only just been able to contact her to tell her.
55. On 27 November we can see the Trust noted Mr U was receiving 4L of oxygen and had a NEWS2 score of 3. The Trust documented this was due to his high blood pressure and oxygen requirements. The Trust documented it had updated Mr U’s wife and daughter.
56. We can see Mr U’s wife was listed as his next of kin on admittance. Whilst we have not seen evidence the Trust discussed with Mr U what it could communicate to his family, we also have not seen any restrictions to communication in place. We have found the Trust should have been providing updates to Mr U’s family, including Mrs T.
57. We recognise that communication would have been affected due to COVID-19. However, we have found the Trust should have contacted Mr U’s family to provide more regular updates on Mr U’s condition and procedures he was having.
58. From the evidence we have seen, we have found the Trust has not acted in line with NICE guidance on patient experience. We can see the Trust performed an angiogram, angioplasty, and blood transfusions during Mr U’s first admittance. We have not seen any evidence the Trust informed Mr U’s family of any of these procedures or information of his recovery.
59. We think there was missed opportunity on 9 October when the Trust could have informed Mr U’s family of the procedures it had undertaken during a discussion about his discharge. We have found this is not in line with NICE guidance on patient experience which says clinicians should keep family members informed.
60. We can also see Mr U sadly suffered two falls whilst under the care of the Trust. We have not seen any evidence either fall was discussed with the family. We can see Mr U informed his wife of the second fall the next day.
61. On the post falls check document, we can see the options for contact following a fall are listed as ‘informed immediately’ and ‘appropriate to call at end of shift’. We can see the Trust did not complete this form on either occasion. We have also not seen any evidence the Trust contacted Mr U’s next of kin following either fall. We found the Trust should have contacted Mr U’s family to inform them of the falls he suffered in line with NICE guidance on patient experience.
62. Our adviser said that it was likely Mr U was suffering with delirium and we can see there are numerous references to Mr U being confused within the records. We think this should have prompted the Trust to provide more pro-active communication with Mr U’s family.
63. Our adviser said due to confusion, Mr U may have been unable to communicate important information about his condition and treatment to his family. We have only seen two instances within the records where the Trust provided an update to Mr U’s family about his condition.
64. Our adviser said even if Mr U was not confused, he was still an elderly man who was unwell. Our adviser said the Trust should have been pro-actively discussing his management plan and planned procedures with his family.
65. In summary, we have found the Trust did not act in line with NICE guidance on patient experience in its communication with Mr U’s family. We acknowledge COVID-19 would have had an impact on the Trust at this time. Even when taking this into account, we have seen a number of occasions when we think the Trust should have updated Mr U’s family and did not. We will consider the impact of this below.
Visiting
66. Mrs T said she was only allowed to visit her father on one occasion during his 12-week admittance. Mrs T said due to not being able to see her father she did not realise how ill he was, and this was compounded by the Trust’s lack of communication.
67. The Trust said due to the pandemic there was restricted visiting with strict criteria for when visiting could be allowed. The Trust acknowledged when Mrs T was able to visit Mr U, he was not in the condition she expected.
68. The Trust’s COVID-19 visiting policy says patients may be accompanied by one family member when it is appropriate and necessary to assist with the patient’s communication and health needs. It describes one of the circumstances of this as being if the patient is confused and may need support with their communication.
69. Our nurse adviser said visitors should be considered on an individualised basis. They said Mr U was confused and the Trust should have allowed a friend or relative to visit him.
70. On review of Mr U’s medical records, we have not seen any evidence Mr U had any visitors throughout his time at the Trust. We understand Mrs T has told us she was allowed to visit on one occasion and the Trust has not disputed this. We think it is likely Mrs T was able to visit her father on one occasion and the Trust had not documented this within the records.
71. We have found the Trust has not acted in line with its own COVID-19 visiting policy. From the records we can see there are at least ten references on different dates to Mr U being confused throughout his admittances to the Trust (see paragraphs 32 to 35). In line with its policy on COVID-19 guidance, the Trust should have allowed Mr U to have one family member visit to assist with his communication needs, given his confusion.
72. We have found the Trust has not acted in line with its COVID-19 visiting policy, as it did not allow Mr U to have a visitor despite him being confused. We will consider the impact of this below.
Aftercare following discharge on 9 October
73. Mrs T said the Trust discharged Mr U on 9 October and did not provide any follow-up care. Mrs T said the Trust should have referred Mr U to the district nurses for wound care to his groin. She believes Mr U’s groin wound was still infected when the Trust discharged him on 9 October.
74. The Trust said on 7 October Mr U’s groin wound was bruised, but clean and dry and therefore there was no indication any aftercare or referral was required. The Trust said blood tests taken prior to Mr U’s discharge showed the results were on a downward trend, which meant the infection had been treated and was under control.
75. NICE guidance on community care says once assessment for discharge is complete, the discharge coordinator should agree the plan for ongoing treatment and support with the community-based multidisciplinary team.
76. This is supported by the Trust’s discharge procedure which says the registered nurse on the ward is responsible for coordinating the planning of a patient’s discharge and they must pursue any referrals.
77. Following the angioplasty on 7 October, we can see the Trust noted Mr U had a large haematoma post-operatively which was bleeding. We can see the Trust attempted to stop the bleeding with manual compression.
78. Mr U was noted to be very confused and was trying to get out of bed and remove his oxygen mask despite being on bed rest. That evening, the Trust gave Mr U two units of blood due to his haemoglobin levels dropping. Haemoglobin is a protein in red blood cells that carries oxygen and carbon dioxide between the lungs and the rest of the body.
79. We can see on 9 October the Trust documented there was bruising to Mr U’s groin area and the doctor noted they had no concerns. The Trust informed Mr U he would be discharged, and his transport home was booked. There is no evidence the Trust considered or made any community referrals.
80. We can see Mr U was noted to have a large groin haematoma on 7 October which continued to bleed despite manual compression. Our adviser said Mr U lost a significant amount of blood into the haematoma. We can see Mr U also had to have two units of blood transferred the same day.
81. We understand the Trust said that as Mr U’s groin wound was clean and dry, he did not require any onward referrals for wound care. Our nurse adviser said the Trust should have completed referrals for Mr U to receive wound care in the community.
82. This is because even if a wound is clean and dry it still requires dressings to be applied and for the healing to be monitored. Our nurse adviser said the Trust should have completed referrals to the district nurse service and community tissue viability nurse for them to do this.
83. Based on this, we have found the Trust should have referred Mr U for wound care in the community on discharge. By not doing this we have found the Trust did not act in line with its discharge procedure, which says nurses should pursue any referrals needed for a safe discharge.
84. We have also found the Trust did not act in line with NICE guidance on community care. We have not seen any evidence it agreed a plan for Mr U’s ongoing treatment within the community with the community-based multidisciplinary team.
85. We will consider the impact of this below.
Discharge on 23 November 2021
86. Mrs T said on 24 November, the day after the Trust had discharged Mr U, the district nurses informed her the Trust should not have discharged Mr U in his condition. She said the district nurses told her to call an ambulance, and the Trust re-admitted Mr U on 25 November, where he sadly died three days later of pneumonia. Mrs T complains the Trust discharged Mr U before his chest infection had resolved and this contributed to his death.
87. The Trust said on 23 November Mr U’s observation parameters were within the normal range and it had deemed him medically stable for discharge. The Trust said it had treated Mr U’s chest infection with antibiotics and his blood tests suggested the chest infection was under control and resolving.
88. The Government discharge policy says discharge will be organised as soon as clinically appropriate. It also says people will not be able to stay in a bed after the point where this is clinically necessary.
89. From the records we can see the Trust completed blood tests on 18 November and Mr U’s C-reactive protein (CRP) level was high at 169. CRP levels in the blood indicate if there is inflammation in the body. The Trust’s blood report indicates a normal CRP level should be between 0 and 5.
90. On 22 November, we can see the Trust documented Mr U was confused during the night. The Trust completed blood tests and noted Mr U’s CRP levels had decreased to 128.
91. From the evidence we have seen, we found the Trust did not act in line with the Government discharge policy. We can see the Trust stopped the use of antibiotics on 19 November and began planning for his discharge the following day.
92. However, when the Trust repeated Mr U’s blood tests on 22 November, we can see the CRP level was still raised. Although this had decreased from the 18 November when it was 169, it was 128, which is still above normal levels.
93. Our adviser said an ongoing raised CRP of 128 suggested there was still an ongoing infection. We recognise this contrasts with the Trust’s account, as it said the raised CRP was from the resolving chest infection. We think it is likely the raised CRP was from an ongoing infection.
94. Our adviser explained the raised CRP could be from an infection elsewhere in the body, and not just from the previous chest infection. Whilst we can see the CRP had decreased, it was still significantly above normal levels (0-5). Our adviser said this should have prompted the Trust to perform further investigations into the source of the raised CRP.
95. We found the Trust did not act in line with the Government discharge policy. Mr U had a very high CRP level that likely indicated an ongoing infection, and he was experiencing a new episode of confusion. The day before his discharge we can see the Trust noted he was confused in the night and was disorientated.
96. We found Mr U was likely not medically fit for discharge on 23 November, as it appears he had an ongoing infection and was confused. We have found his discharge was not in line with the Government discharge policy which says to organise discharge only when clinically appropriate. We appreciate this will be distressing for Mrs T, and we will consider the impact of this below.
Observations on 27 November 2021
97. Mrs T said following Mr U’s death the day before, she spoke with the medical examiner. She said the medical examiner informed her the Trust had not performed observations during the night of 27 November into 28 November. Mrs T said this is the night before her father died and by not performing observations the Trust did not identify Mr U’s deterioration in a timely manner.
98. The Trust’s NEWS2 guidance says if a patient scores between 1 and 4, observations should be completed a minimum of 4 to 6 hourly.
99. From the records we can see Mr U’s observations were taken at 8.55pm on the evening of 27 November. The Trust completed the NEWS2 chart and documented Mr U had a NEWS2 score of 2 at this time.
100. In the nursing records we can see the Trust documented Mr U had a NEWS2 score of 2 at 12.54am on 28 November. This was around four hours after the Trust had last taken his observations.
101. We can see Mr U’s observations were taken again at approximately 7am. The Trust completed the NEWS2 chart and noted Mr U scored 4. This was around six hours after the Trust had last completed his observations.
102. From the evidence we have seen, we found the Trust has acted in line with its NEWS2 guidance. We can see from the NEWS2 chart the Trust completed Mr U’s observations at four and six hourly intervals after Mr U had scored 2. This is in line with the Trust’s NEWS2 guidance which says if a patient scored between 1 and 4 observations should be completed a minimum of 4 to 6 hourly.
103. We understand Mrs T has told us she was informed that observations were not taken during the night of 27 November to 28 November. We can see the Trust did not complete the NEWS2 chart for the observations it had taken at 12.54am on 28 November.
104. However, the Trust documented within the nursing records that Mr U’s observations were checked, and he had a NEWS2 score of 2. We think that because this entry was not completed on the NEWS2 chart, this was likely the reason Mrs T was informed that observations were not taken.
105. We can also see Mr U was reviewed by a doctor at 2.30am on 28 November. We hope that by providing this information it will reassure Mrs T that Mr U’s observations were being taken in line with NEWS2 guidance and that his condition was being monitored.
106. We can understand why Mrs T was so concerned to be told observations had not been taken, particularly given Mr U’s condition deteriorated after this. Based on the evidence we have seen, we have found no failings in the Trust’s observations during the night of 27 November. We hope our decision will provide Mrs T with reassurance that nothing went wrong here.
Impact
107. In summary, we have found the Trust failed to provide updates and communicate with Mr U's family in line with relevant guidance. We have also found the Trust did not investigate Mr U’s confusion and failed to allow visitors in line with relevant guidance.
108. We have found the Trust failed to arrange wound care in the community on Mr U’s 9 October discharge. Lastly, we have found Mr U was not medically fit for discharge on 23 November.
109. We have considered the impact of these failings.
110. Mrs T said her father would contact her whilst he was in hospital and tell her he did not understand what was happening. Mrs T said due to the Trust not communicating with her or other family members she also did not know what was happening. She said this meant she was unable to provide reassurance or information on what was happening to him. Mrs T said this was very distressing and upsetting for her.
111. Mrs T said she did not know what her father’s condition was throughout his three admittances and was unaware of how poorly he was due to the Trust not providing updates or regularly communicating with family. Mrs T said she only learnt of the falls her father suffered and the blood transfusion he received when she requested his medical records after his death.
112. Our nurse adviser said the Trust not engaging with family will have increased their anxiety and caused an unsettled patient stay. It is unclear from the records if Mr U would have been able to communicate important information to his family because we can see he was confused.
113. We acknowledge the Trust not communicating with Mrs T, and her family, regarding her father’s condition would have been upsetting and distressing for Mrs T. We understand this meant she was unable to provide her father with information when he asked, and she was unable to reassure him. This understandably caused her further distress at an already difficult time, which we think could have been avoided if the failings had not occurred.
114. We also recognise how distressing it was for Mrs T to learn of procedures that took place, and falls her father experienced from reading his medical records after his death. We think this prolonged the unnecessary distress Mrs T experienced.
115. Mrs T said the Trust not investigating her father’s confusion meant she was not allowed to visit him. Mrs T said if she was able to visit her father, she would have been able to help look after him in hospital and advocate for his care.
116. We recognise that if Mrs T had been able to visit her father, she would have been able to assist with his needs and raise any changes to his condition. We think this also would have avoid some of the distress she experienced caused by the failings in communication.
117. Mrs T said not being able to visit her father and then seeing how much he had deteriorated was very traumatic. She said due to the lack of communication she was not aware of how poorly he was. Mrs T said this has also caused feelings of guilt as she was not able to help him.
118. We recognise Mrs T not being able to visit her father for a prolonged period, and then seeing his deterioration when she was able to, was shocking and traumatic for her. We also recognise it would have caused feelings of guilt. We think this would have been avoided if the failings in visitation and communication had not occurred.
119. Mrs T said she was unable to say goodbye to her father as she was unable to visit, and he died alone. Mrs T said she has struggled to cope following his death. We do not underestimate the impact of not saying goodbye had, and continues to have, on Mrs T and her family. We recognise Mrs T being unable to say goodbye to her father would have impacted on her ability to grieve.
120. To summarise, we have found the Trust failed to provide updates and communicate with Mr U’s family, and to allow them to visit. We have found this has led to additional and prolonged distress for Mrs T at an already difficult time. We also found this has impacted her ability to grieve for Mr U following his death. We think this could have been avoided if these failings had not occurred.
121. Mrs T says because the Trust did not arrange any aftercare following Mr U’s discharge on 9 October, this resulted in his re-admission to the Trust on 25 October with a haematoma.
122. We have also found the Trust failed to arrange wound care in the community prior to Mr U’s discharge on 9 October. Our nurse adviser said this put Mr U at risk of poor wound healing and infection. Our nurse adviser said this can be linked to Mr U’s re-admittance to the Trust on 25 October.
123. We can see on 25 October the Trust documented it was likely Mr U’s haematoma was infected and commenced antibiotics. Based on this we think the Trust not providing wound care in the community contributed to the haematoma becoming infected and Mr U being re-admitted to the Trust. We think this caused worry and distress to Mrs T about whether this could have been avoided.
124. We have found Mr U was not medically fit for discharge on 23 November. Mrs T told us she believes this contributed to his death as he was discharged whilst still having an infection. Mrs T said she has been unable to sleep thinking about the failings that occurred in the Trust’s care of her father. We are sorry to hear of the ongoing impact this has had on Mrs T.
125. As set out in paragraphs 92 to 95 above, the Trust discharged Mr U with a CPR level well above the normal range. We think this indicates it was likely the Trust discharged Mr U with a possible ongoing infection. Our adviser said if the Trust had undertaken further investigations, this could have led to the Trust providing further treatment to resolve this.
126. The Trust also discharged Mr U following a new episode of confusion, which the Trust had not assessed. Our adviser said if this had occurred, it could have led to the Trust delaying Mr U’s discharge.
127. We are sadly unable to say whether, if the Trust had not discharged Mr U before he was medically fit, this would have changed the outcome for him. We cannot say whether the Trust delaying the discharge to undertake further assessments or investigations, or to provide further treatment for an infection would have made a difference for Mr U.
128. We recognise this leaves Mrs T with uncertainty regarding whether the outcome could have been different for her father. We understand this will be incredibly upsetting for her. We are sorry we have not been able to resolve this uncertainty for her.