A delay in providing an enema
18. Mrs K complains her mother did not receive an arachis oil enema after admission and instead had to wait around three days for this medication. Mrs K says an arachis oil enema was needed to resolve her mother’s faecal impaction and the delay in providing it prolonged her mother’s constipation and caused unnecessary distress.
19. The Trust says an arachis oil enema was out of stock and therefore unavailable to staff. It says its pharmacy had to order it from another source, which caused the delay in administering it.
20. It says Mrs L was also treated with lactulose and glycerine laxatives, a phosphate enema and a manual bowel evacuation by a doctor on 9 November (where finger is used to manually remove faeces from the rectum) when laxatives did not have the desired effect.
21. NICE constipation guidance recommends using macrogol (a laxative) initially. If this does not work, it recommends using glycerol (another type of laxative). It also says sodium phosphate and arachis oil enemas can be used should faecal impaction persist.
22. We can see the Trust initially treated Mrs L with macrogol (twice daily) from 6 November alongside lactulose (twice daily) from 7 November. The Trust administered a phosphate enema on 6, 8 and 9 November. It also provided a glycerol suppository (a mild laxative) on 7 November and the arachis oil enema on 8 November.
23. As previously mentioned in paragraph 20, Mrs L had a manual evacuation on 9 November due to a poor response to the laxatives and enemas.
24. Our physician adviser says there is no benefit of arachis oil over phosphate enema as both are options when treating faecal impaction. They do not see the delay in administering arachis oil had any clinical impact upon Mrs L.
25. In support of this, we can see the arachis oil enema does not appear to have had a dramatic effect once administered and manual evacuation was ultimately required to move Mrs L’s faecal impaction.
26. The Trust’s delay in providing an arachis oil enema does not indicate a failing. The Trust, overall, appears to have treated Mrs L’s faecal impaction in line with NICE constipation guidance.
A delay in diagnosing and treating Mrs L’s UTI
27. Mrs K says during the initial admission (5 to 11 November) no attempts were made to test whether her mother had a UTI until 9 November, when a Midstream Specimen of Urine (MSU) was taken. She says it was not until the second admission (12 to 24 November) that her mother was diagnosed with a UTI and received antibiotic treatment.
28. The Trust says a nurse noted Mrs K’s urine had ‘sediment in it’ on 8 November and a CSU (catheter specimen of urine) was sent for analysis at the lab the next day. It says by the time Mrs L returned to hospital on 12 November, the results had returned showing e-coli bacterial infection in the urine, which she received antibiotics for.
29. NICE UTI guidance recommends against antibiotic treatment of bacteria found in the urine where there are no symptoms of UTI (known as asymptomatic bacteriuria).
30. During the first admission, we can see doctors reported Mrs L was not suffering from dysuria (pain on passing urine). Mrs L also had no fever, normal white cell count (white cell count would be elevated if infection is present) and c-reactive protein (CRP) levels were virtually normal (CRP is a blood test which indicates inflammation in the body and would be elevated if an infection is present).
31. Upon Mrs L’s second admission on 12 November, we can see doctors reported dysuria. They also found Mrs L’s CRP had gone up, though her white cell count remained normal. In response, we can see doctors began antibiotic treatment for a UTI promptly with the first dose being given the day she arrived.
32. We do not see there was a delay in either diagnosing or treating Mrs L’s UTI. Even if bacteria had been found by the CSU on 9 November, there were no clear symptoms of UTI at this stage to warrant antibiotic treatment.
33. It was only when Mrs L returned to hospital on 12 November were clear signs of a UTI found which necessitated antibiotic treatment. Antibiotics were administered that same day.
34. We therefore see no indication of a failing. The Trust appears to have acted in line with NICE UTI guidance in its testing and treatment of Mrs L’s UTI.
Mrs L was not mobilised regularly enough
35. Mrs K says staff were afraid Mrs L would fall and restricted her movement which had a detrimental effect on her. She says regularly mobilising Mrs L was important as she had Parkinson’s disease, so it is ‘very much about use it or lose it.’
36. The Trust says Mrs L was regularly reviewed by physiotherapists and nurses helped her to mobilise ‘from her bed to the chair for meals as well as trying to assist her to walk.’
37. There are no guidelines for how often someone should be mobilised as this is very much dependent on the patient’s individual circumstances.
38. EP guidance, however, says clinicians must consult a physiotherapist when a person with Parkinson’s is admitted to hospital. This same guidance sets out physiotherapy goals in the ‘Hoehn and Yhar scale’. This scale says physiotherapists should support nursing to maintain transfer practice (the movement of a person from one place or surface to another), mobility and have appropriate care plans in place.
39. We have carefully reviewed Mrs L’s records and can find no evidence to indicate her physiotherapy care, with specific reference to mobility, was lacking throughout her admissions.
40. During each admission we can see Mrs L appears to have received comprehensive assessment and care planning which included getting a collateral history (information gathering from someone other than the patient) from her husband, who was involved in her mobilising at home. Mrs L was regularly mobilised at hospital with the help of one staff member in a similar nature to her home arrangement.
41. Our physiotherapist adviser says there is evidence Mrs L was regularly mobilised to her chair and to the toilet and where further input was needed, further physiotherapy assessment was arranged. For example, on 23 November a nurse reported Mrs L was ‘unsteady on her feet’ after mobilising to the toilet with a frame. The nurse requested physiotherapy review, which took place shortly afterward.
42. We are therefore satisfied the Trust acted in line with EP guidance in its assessment of Mrs L’s mobility and its attempts to mobilise her.
Mrs L was discharged to a community hospital on 24 November and 27 November despite her poor condition
43. Mrs L says the Trust should not have discharged her mother on either 24 or 27 November as it had not treated her infection. She says as a result, those discharges ‘failed’, and this meant she needed to attend hospital repeatedly to receive further treatment.
44. The Trust says Mrs L was ‘well in herself’ and happy to be transferred to a community hospital for rehabilitation on 24 and 27 November.
45. Annexe D of DOHSC discharge guidance sets out the criteria for someone to remain in hospital.
46. For example, Annexe D, says where a patient requires intensive care unit (ICU) or high-dependency unit (HDU) input, requires oxygen therapy, intravenous fluids, has undergone recent lower limb or abdominal surgery or has a NEWS2 score greater than 3 (an early warning scoring system to assess acute illness), they should be considered for a further stay in hospital.
47. If each criterion does not apply to the patient, Annexe D says discharge ‘to a less acute setting must be made.’
48. Our physician adviser says there do not appear to have been any areas of concern in the run-up to Mrs L’s discharges on 24 and 27 November. Her vital signs (observations) during both admission periods were normal, aside from her blood pressure, which was a little high, or low, during the later admission period, but this settled before her discharge. They also found no concerning abnormalities in Mrs L’s blood test results during these admissions.
49. We cannot see Mrs L displayed any of the criteria set out in Annexe D of DOHSC discharge guidance.
50. As a further point, our physician adviser says Mr L was at increased risk of acquiring infections due to her suffering from lymphoma and due to her usual medication ibrutinib, which can impair the function of cells which defend the body from infection. As such, our physician adviser noted the importance of prompt discharge once Mrs L was medically ready.
51. Because Mrs L did not display any of the DOHSC criteria prior to these discharges, we are satisfied the Trust discharged Mrs L on 24 and 27 November in line with DOHSC discharge guidance. We have therefore decided to take no further action.
Mrs L’s Parkinson’s disease medication was not administered at the correct times between 6 and 24 November
52. We discussed this part of the complaint with Mrs K on 2 September. Following a further review of the Trust’s responses, we are not satisfied it has properly addressed this particular issue.
53. We contacted the Trust on 2 September and made it aware of Mrs K’s outstanding concerns. It agreed to provide Mrs K with a further response and will contact her soon.
54. Once the Trust has provided its final response, and if Mrs K wants to come back to us, we would encourage her to do so promptly. We have time limits and if there are any delays in Mrs K coming back to us, it may mean we cannot consider this outstanding issue.