COVID-19 – test, record keeping and decision to discharge
14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Mr K has claimed.
15. Mr K complains the Trust took too long to test his mother for COVID-19, discharged his mother when she was COVID-positive and incorrectly recorded that she was COVID-negative.
16. Looking at NHS England’s testing guidance from the time, it appears Mrs K should have been tested on 2 August in the ED. She should then have been tested on day 3 and days 5-7. Instead, it appears she was only tested when she became symptomatic on day 10. Given Mrs K was COVID-negative on 3 August, there is no evidence the initial delay had an impact.
17. GMC ‘Good medical practice’ says doctors must give patients the information they want or need to know in a way they can understand. They must be considerate to those close to the patient. They must also record their work accurately.
18. Our orthopaedic adviser said the records do not make it clear what Mrs K’s COVID status was when the Trust discharged her. There is evidence she tested positive on 13 August but the discharge summary says she had a negative test result.
19. The Trust’s complaint response said Mrs K was screened for COVID-19 on 3 August and was negative. It said she developed a chesty cough on 13 August and tested positive on a lateral flow test at that point. It acknowledged the records suggest it did not make Mr K, her next of kin, aware of this at the time.
20. The Trust appears to have fallen short of the GMC guidance. It seems the discharge summary was prepared in advance, the day before the positive COVID-19 test, and was not updated with the new result. Mr K told us the false negative COVID-19 report put his family and his mother’s carers at risk of acquiring COVID-19. We reviewed the evidence around this.
21. The Trust’s complaint response said it would amend the discharge summary to rectify the error. It said the social services team and the care agency were aware of Mrs K’s COVID19 status before it discharged her. The Trust referred to an email Mr K sent to the social services team and it has shared a copy of this with us.
22. Mr K sent his email on 15 August and said his mother was waiting to be discharged from hospital. He explained she needed equipment and carers to support her after her discharge. He mentioned his mother had tested positive for COVID-19 but this was not expected to delay her discharge. It therefore appears Mr K was aware of her COVID-19 status.
23. We appreciate Mr K also questions the decision to discharge his mother. Having a positive test for COVID-19 would in itself not be a reason to keep a person in hospital. We recognise Mr K may not share this view.
24. We considered Annex D of the DHSC discharge guidance. This reflected that when any person is reviewed on a ward round, doctors should actively consider discharging them to a less acute setting. This should happen unless there is a clinical need or exception.
25. The DHSC guidance sets out ‘criteria to reside’. Mrs K’s records do not suggest there was any clinical reason to keep her in hospital. In line with the criteria in the DHSC guidance, the Trust discharged her.
26. We do not dispute the Trust should have done some things differently. We have decided not to investigate this further because we cannot see that this affected Mr K in the way he described.
Record keeping – pressure areas
27. 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. We have done this and have not found any indications that something has gone wrong in relation to the record keeping.
28. Mr K says the Trust incorrectly recorded that his mother had no pressure areas. In its complaint response, the Trust said Mrs K had a moisture lesion rather than pressure damage.
29. The NMC Code says must ensure patients’ needs are recognised, assessed and responded to. They must keep clear and accurate records.
30. Our nursing adviser explained there are ways to differentiate pressure and moisture damage. Pressure damage normally happens over a bony prominence and differs in appearance to a moisture lesion.
31. The Trust’s complaint response reflects what we have seen in Mrs K’s records. In ED and the emergency medical unit, the record say there were moisture lesions on Mrs K’s groin and her apron (under her tummy). The staff identified this as moisture-associated skin damage (MASD).
32. Throughout her inpatient stay she was identified as having MASD to her groin and apron fold. Her sacrum, at the base of the spine, was identified as being red and blanching (turns white when pressure applied) but this did appear to progress to MASD towards the end of her inpatient stay.
33. There was no clear description, either in the nursing or the medical records, about how the MASD occurred but our nursing adviser said there is no indication it was pressure damage. We hope this reassures Mr K. We appreciate his underlying concern is about how the Trust cared for his mother’s skin.
34. Our nursing adviser explained at the time of the events, the aSSKINg pathway model focusing on key aspects of preventative care (assessment, Surface, Skin inspection, Keep moving, Incontinence, Nutrition and giving information) was in place.
35. The Trust used the Waterlow score to assess Mrs K’s risk of developing a pressure sore. This was in line with the NICE guidance on pressure ulcers. This risk assessment was done on admission and showed her to be at high risk.
36. The Trust went from regularly repositioning her on a static mattress to moving her onto an alternating mattress (which undulates to redistribute pressure) a few days into her admission.
37. Mrs K’s skin was assessed up to 3 times each day, and she was moved every two to four hours during each day as an inpatient. Mrs K was nursed on her back a lot, she was often in a sitting position. There is no evidence of a discussion or staff recommending she start spending time on her side. We consider this a learning point for the Trust.
38. The Waterlow score should be re-assessed weekly, when the patient’s condition changes, or when they are transferred to another clinical area. This did not happen. Mrs K had surgery in the interim and there was no further assessment until 13 August. At that point, she was found to be at very high risk.
39. Continence and nutrition can also contribute to skin integrity. We have not identified a cause for concern in relation to this. Medi-honey barrier cream was used to manage the MASD to Mrs K’s sacrum, which was our nursing adviser said was appropriate.
40. Before we decide if we should conduct a detailed investigation of a complaint, we also look at whether there are signs the event complained about had a negative effect which the organisation has not put right.
41. The Trust should have reassessed Mrs K’s Waterlow score sooner and kept clearer records if it was advising her to reposition onto her side and if she was non-compliant. Fortunately, despite this, Mrs K did not develop any pressure ulcers so there was no impact on her. We hope this helps Mr K understand our decision not to investigate this aspect further.
Discharge – lack of pain relief and clothing
42. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has acknowledged the issues Mr K raised and already done enough to address them.
Pain relief
43. Mrs K’s records show the Trust had prescribed pain relief during her admission. She had been given paracetamol and morphine as an inpatient.
44. The discharge summary has a section on discharge medications which has been completed but does not include any pain relief medication. The Trust acknowledged it did not discharge Mrs K with any analgesia and said it had spoken to the doctor who completed the discharge summary about this.
45. The Trust said it introduced a process on the ward for two registered nurses to check the discharge summary against the patient record. It also shared the case as an example during junior doctors’ induction to the department.
46. We were sorry to hear Mr K’s concern that his spent avoidable time in pain when she was discharged. We can see the Trust has acknowledged something went wrong and taken action to help prevent this happening again.
Clothing
47. Mr K says his mother was discharged in a hospital gown and not her own clothes. He says this was not appropriate clothing for her to be taken across the hospital to its car park and on a long journey home in.
48. The Trust’s day of discharge check list has a section on whether the patient ‘Has dignified clothing for discharge’ which staff completed on 18 August. The options are ‘Patient’s own Yes / No – then dignified hospital clothing provided Yes’. The text circled in Mrs K’s records is ‘Patient’s own’. This does not match Mr K’s account.
49. This suggests there is an indication of a failing in the Trust’s record keeping as well as its actions on the day. The Trust said it had discussed this in a daily safety huddle and fed back to the transport provider. It said it would also share this more widely in its staff forums for learning and improving care.
50. We appreciate this does not change how Mr K feels or how his mother felt at the time. We hope the action the Trust has taken will prevent another patient going through this.
51. Overall, we have decided not to investigate the complaint further. We do not dispute how difficult Mr K’s experience was and we are sorry we are unable to assist him in the way he expected. We would like to wish him well and we hope this decision statement clearly explains our reasoning.