Feeding assistance and mouth care
12. Mrs Y complains the Trust did not provide adequate mouth-care to her husband during his stay in hospital between January and March 2022. She says family members would visit and regularly find there was food remaining in her husband’s mouth, or around his face. She says this was a choking hazard for him, due to his feeding issues. She also says this was distressing to see because it was clearly not comfortable for him to have food left over in his mouth or on his face.
13. The Trust has apologised for if the family feel it provided inadequate mouth care to Mr Y. Its’ response does not accept any wrongdoing regarding the mouth care it provided.
14. The records show there are several occasions where food was left in Mr Y’s mouth and he was struggling to swallow.
15. Our adviser has explained the relevant guideline is NICE guideline (NG 48): Oral health for adults in care homes (2) which can be relevant to nursing care delivered in an inpatient setting. The guideline says:
1.3.1 Ensure care staff provide residents with daily support to meet their mouth care needs and preferences, as set out in their personal care plan after their assessment.
16. Our adviser suggests that if the Trust carried out regular mouthcare, in line with this guideline, it would have ensured there was no food left in his mouth after eating.
17. The records reflect the Trust carried out a swallowing screening test on 19 January 2022. This concluded Mr Y was safe for oral intake at that time. The Trust then referred him to a speech and language therapist (SALT) for regular reviews of his swallowing ability. The records show SALT reviewed Mr Y on 20 January. The Trust also conducted several nursing reviews.
18. A nursing review on 27 January outlined the need for full assistance required to meet personal care and hygiene needs. This therefore means Mr Y required full assistance with ensuring his mouth was clean.
19. Mrs Y says there was food left in her husband's mouth on 11 and 15 February. She also says there was a tablet left in his mouth on 3 March, and food left in his mouth on 7 March. We do not doubt Mrs Y’s recollection and appreciate this must have been distressing for her and her family to witness. We will now address what the records show on these dates.
20. The records show oral care was carried out on 11 February at 2:14am, 1:34pm and 2pm, 15 February at 8am, 10am, 12pm, 1:49pm. On 2 March, a dietician assessed Mr Y, they noted build up in Mr Y’s mouth and there being a risk of aspiration if he is given too much food. There are no further notes around oral care for this date. On 7 March it is documented oral care was given at 2am, 9am, 4pm, 7pm and 10pm.
21. The Trust has acted in line with the guidelines by ensuring they were regularly reviewing Mr Y’s swallowing ability and providing regular oral care to him. However, there are some days where the records are lacking detail with regards to the oral care provided. Specifically on the afternoon of 11 and 15 February, as well as 3 March, when a tablet was found to still be in his mouth.
22. These dates mostly coincide with the dates Mrs Y says food was left in her husband’s mouth. Therefore, in the absence of any evidence otherwise, on balance it appears food was left in Mr Y’s mouth on these dates. It is clear the Trust were actively reviewing Mr Y’s swallowing ability and were aware of the risk him retaining food in his mouth. We consider this to be a failing with the oral care provided, since the nursing review carried out established the Trust should provide full hygiene assistance to Mr Y. We will discuss the impact of this in the impact section below.
Aspirin prescription
23. Mrs Y is also unhappy the Trust failed to properly alert staff to her husband’s aspirin allergy. She believes he should have been wearing a band which would have identified this. She says this put him at risk of suffering from an allergic reaction, she is unsure if this happened.
24. The Trust accepts Mr Y should have had a red wristband. However, it says it had clearly documented in Mr Y’s medical records that he was allergic to aspirin and therefore there was no real problem with him not having a notifying wristband on.
25. In the emergency department record it clearly notes Mr Y’s allergy to aspirin on 19 January 2022. The records show the doctor who reviewed Mr Y, recommended aspirin to him on the same day as part of his management plan. Our adviser highlights this as a concern.
26. The Trust did not initially provide any prescription records. However, during our investigation, it has provided prescription records that do not reflect any aspirin was prescribed to Mr Y. There are also no records that reflect any aspirin was administered to Mr Y. However, the Trust do accept they should have supplied a red wristband to Mr Y. We will discuss the impact of this in the below impact section.
Feeding issues
27. Mrs Y also says the Trust failed to adequately maintain her husband’s nutrition and hydration. Specifically, the Trust failed to feed him any dinner on 27 and 28 January; failed to maintain his nutrition on 7 February by not putting him on a drip; took his food away on 20 February without him eating it; delayed an intravenous (IV) drip on 27 February and failed to feed him on 9 March.
28. Mrs Y says this resulted in her husband being hungry and dehydrated several times throughout his hospital stay. She says this was very distressing to witness. Mrs Y says she had to constantly chase hospital staff to feed her husband and ensure they were adequately maintaining his fluids.
29. The Trust say Mr Y was nil by mouth on 27 January. It has not addressed what happened on 28 January. It has apologised for the IV issues, but explained nurses are busy and delays can occur. In response to the 20 February issue, it has explained the nurses would not leave cold food out when patients do not eat it.
30. The food chart from 27 January shows a referral to a dietician. There is nothing written in the chart for ‘evening meal’ on 27 and 28 January. The records do not contain any food charts from 20 February. The food chart from 9 March does not reflect Mr Y was fed an evening meal. Therefore, there is evidence the Trust did not feed Mr Y on several occasions.
31. NICE guidance: Nutrition support in adults (3) makes recommendations for quality care by stating, ‘People in care settings are screened for the risk of malnutrition using a validated screening tool’.
32. The records highlight one occasion where the Trust used a screening tool. There was a Malnutrition Universal Screening Tool (MUST) score of 0 documented on 27 January 2022. However, there is no record reflecting the screening tool assessment itself. This is not enough, since the NICE nutrition support guidelines require weekly malnutrition screening. This is therefore a breach of the guideline.
33. NICE guidance: Nutrition support in adults (1.3) says nutrition support should be considered in people at risk of malnutrition who have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer.
34. The records clearly show Mr Y was struggling with his oral intake. He was refusing meals and only eating small portions of the meals provided throughout his admission.
35. Initially, it is clear the Trust tried to maximise Mr Y’s oral intake as much as possible. In a dietician’s review on 27 January 2022, they encouraged oral intake, following a recommendation from the speech and language therapist. In a dietician review on 4 February 2022, their aim was to provide a texture modified diet and nutritional supplements.
36. During this assessment it is noted a nasogastric (NG) tube might be required to maximise nutritional intake. The dietician’s assessment on 10 February acknowledges Mr Y was struggling to achieve his nutritional requirements via oral intake and they agreed to trial feeding via an NG tube. This review does not advise on the duration of time for feeding but a review by a nutritional nurse on 16 February recommended a further two weeks.
37. Therefore, there is evidence the Trust monitored Mr Y’s ability to eat enough to satisfy his nutritional requirements. When it became clear this was too difficult, it decided to place him on nutritional support. This is in line with the NICE guidance.
38. The NICE guidance: Nutrition support in adults (3) goes further to require: ‘People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their complete nutritional requirements’.
39. Within the records, as discussed above, there is evidence of a management plan in relation to initially attempting to maximise Mr Y’s oral intake, via a modified diet and food supplements. Later, when it became clear he was struggling with oral intake, an alternative (enteral) feeding regime that give clear time duration for feeding for Mr Y.
40. Therefore, the Trust appropriately planned Mr Y’s management in relation to alternative measures, given the difficulty he had feeding. We consider this mitigates the impact of the failure to carry out a malnutrition screening.
41. The records demonstrate the enteral feed was administered to Mr Y on 10, 11, 13, 14, 15, 16, 17, 24 and 25 February. There is no documented feed administered for 12, 18, 19, 20, 21, 22, and 23 February according to the fluid balance charts provided. On these dates, it appears Mr Y either pulled out or refused his NG feeding tube, or he was eating solid foods. We will now analyse each date.
42. On 12 February it is noted by the nutritional nurse Mr Y pulled his NG tube out. On 18 February it is documented Mr Y ate his breakfast and lunch but refused dinner. On 19 February, it is documented he ate some of his breakfast and it is unclear if he ate lunch or dinner. On 20 February it is documented Mr Y did not have an NG tube in, IV fluids were commenced. There are no feeding records from this date. However, the family say food was brought to Mr Y but he did not eat it and staff took it away when it went cold.
43. On 21 February it is documented Mr Y was refusing the NG tube. The food charts state he ate some breakfast and lunch but no dinner. On 22 February it is documented Mr Y ate some breakfast and dinner but no lunch. On 23 February, he ate some breakfast and lunch but no dinner. On this date, it is documented again that he is refusing the NG tube. According to the dietitian's documentation from 3 March 2022, Mr Y continued to pull NG tubes out and refused reinsertion.
44. Therefore, Mr Y ate some food on the days where there is no documented feed administered to him. The records show the reasons the NG tube was not administered was because Mr Y either refused it, the nurses could not fit the tube, or he was eating. The records indicate Mr Y was deemed to have capacity to refuse the feed at that time.
45. It is clear the Trust had difficulty feeding Mr Y on some of these days and his intake was low. The records document a speech and language speciality review on 24 February which outlines Mr Y is struggling to swallow food and as a result should again be nil-by-mouth. The review recommends trialling another short-term trial of an NG tube. We can see from the records the Trust began this NG tube feeding regime on this date.
46. Therefore, on all the dates where both Mrs Y’s account and the Trust’s records reflect gaps in the feeding regimen of Mr Y, there is adequate explanation as to the reasons for this. In addition, the Trust was providing Mr Y with IV fluids to supplement his nutrition. Our adviser has explained the documentation of these factors provides adequate explanation as to why there were gaps in Mr Y’s feeding regimen and demonstrates the Trust did enough to supplement Mr Y’s nutrition, given the circumstances and his condition.
47. Mrs Y has specifically outlined that on 7 February, she believes the Trust failed to put her husband on a drip and that it delayed the drip on 27 February. The records indicate the IV drip was administered on both these dates. On 7 February a saline drip was started at 1am, then at 2:23pm a sodium chloride/potassium chloride IV drip was started. On 27 February, Mrs Y says the nurses struggled to get the machine to work and it took over an hour to resolve and get the drip started. The records reflect sodium chloride/potassium chloride were started at 12:16pm and saline was started at 3pm.
48. Therefore, the records do slightly conflict with Mrs Y’s account from 7 February. The contemporaneous records offer a more reliable account of what happened on both occasions. Regarding the delayed drip on 27 February, the Trust accepted this and explained some delays can happen due to the business of wards and nurses having many patients to tend to. Mrs Y has not explained there was any serious impact of this delay. There is also no evidence of any impact of this delay contained within the records. Therefore, no further action from us is necessary regarding these dates.
49. We appreciate Mrs Y’s complaint, and how upsetting and difficult it must have been for her family to witness Mr Y’s decline along with the mouth care issues.
50. It is clear there was a complex, and at times confusing, picture with regards to Mr Y’s ability to eat. We can appreciate some meals were missed and this must have been very upsetting for the family to witness. We can also appreciate the difficulty the Trust faced with Mr Y’s constantly changing ability to eat.
51. We have investigated and established the reasons for the sporadic gaps in the food charts. Enteral feeding was started as an appropriate alternative, when it became clear he was not eating enough food. We have also identified the Trust were providing IV drips and supplements to make up for the nutrition that was lost when Mr Y was not eating.
52. In addition, despite the lack of a malnutrition screen when Mr Y was first admitted, we can see the Trust created an appropriate plan to manage Mr Y’s feeding difficulties, which mitigates any impact of this.
53. Therefore, the management of Mr Y’s nutrition was difficult and clearly had some issues. However, the overall picture of the care provided was satisfactory and where we see a failing to conduct a malnutrition screen, we have not seen indications it had a negative impact on Mr Y.
Communication
54. Mrs Y complains staff at the Trust constantly changed the feeding status of her husband. She says the family would visit one day and Mr Y would be nil by mouth; however, other times he would be cleared to eat solid foods. She says they constantly changed their mind, at times seemingly without reason and this was confusing for the whole family.
55. The Trust’s response explains it had good reason to update Mr Y’s nil by mouth status, based on his demonstrative ability to eat solid foods on each date.
56. NICE guidance: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (1) states:
‘1.3.2 Nutrition support should be considered in people at risk of malnutrition, defined as those who have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer.
5.5 share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way, they can understand’
57. In addition, NICE guidance: Patient experience in adult NHS services: improving the experience of care for people using adult NHS services (7) recommends:
1.3.10 ‘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 members and/or carers.’
58. The Trust, in line with the above guidance, is required to consider nutrition support (i.e. nil-by-mouth status) in people who have eaten little for more than five days and appropriately document the reasons for any decision it makes in this regard. We have established in a previous section the Trust carried this out appropriately and in line with guidance.
59. However, the Trust, in line with the guidance, are also required to share relevant information with the family. The Trust, for any reason to implement nil-by-mouth status for a patient, must clearly document the reason and rationale. Our adviser explains family and carers must also be kept up to date and documentation of discussions recorded.
60. There is no documentation to reflect any discussion with Mr Y’s family of the reasons for changes with his dietary intake. This is not in line with the NICE guidelines mentioned above. We will discuss the impact of this in the ‘impact’ section below.
Insensitive comments
61. Mrs Y complains on 13 March, a nurse made an insensitive comment to her. When Mrs Y asked why the nurse was taking them away, the nurse replied, ‘Well, you’re not taking him home, are you?’ Mrs Y says that considering her husband was very close to passing away, this was an insensitive comment to make. Another nurse was also heard complaining about the amount of time the family were staying. Mrs Y explains this was insensitive considering Mr Y was so close to passing away.
62. The Trust accept this happened. It says it investigated the matter and took appropriate action. The response does not specify what action it took. Therefore, there is no dispute of the facts here. We can understand how upsetting these comments would be at such a difficult time.
63. The Trust provided evidence to us of the action it took over this issue. The Trust explained it had spoken with the staff involved, reiterating the correct approach. We will discuss this in the impact section below.
Impact
64. We have identified issues with the Trust failing to conduct adequate malnutrition screenings for Mr Y. The Trust also failed to adequately conduct oral care for Mr Y, by ensuring his mouth was clean after eating. There were issues with the Trust’s communication with the family about Mr Y’s feeding status and the insensitive comments made by staff to the family. Finally, the Trust did accept it should have provided a red wristband to Mr Y to reflect his aspirin allergy.
65. As established in the prior section, the Trust’s nutritional care planning was satisfactory and so there was no impact of the failure to carry out a malnutrition screening.
66. Regarding the lack of oral care, there is nothing to suggest the food left in Mr Y’s mouth on occasion caused him any harm or had any serious impact on his discomfort. We can appreciate that it will have been distressing for the family to witness Mr Y having food left in his mouth, and this will have caused some loss of dignity for Mr Y. We consider an apology is an appropriate remedy for these impacts.
67. In the Trust response, it acknowledged the poor oral care provided on 11 and 15 February and apologised for this. The Trust did not acknowledge the tablet left in Mr Y’s mouth on 3 March, or there being any food left in his mouth on 7 March. However, when acknowledging and apologising for food being left in his mouth on 15 February, the Trust’s response says ‘we would like to reassure you this issue has been discussed with the LN of ward C8 and shared with the learning team so they can reflect and learn from this shortfall’.
68. Therefore, whilst it has not acknowledged every instance where it did not properly provide oral care, there is evidence the Trust has retrospectively acknowledged its failings regarding this and recognised the wider issue. It has also taken action to decrease the likelihood of it occurring again. We are satisfied this is sufficient to remedy the impact of the failings.
69. Regarding the lack of communication with the family. We appreciate how distressing it must have been for Mrs Y and the rest of her family to experience such a stressful life event, made worse by poor communication. We can appreciate Mr Y’s situation was complicated and his ability to eat changed regularly. However, in not keeping the family updated about the reasons for changing his feeding status, this caused a lot of confusion and stress for them.
70. The Trust response dated 6 July 2022 says: ‘I apologise for any misunderstanding or breakdown in communication in respect of your husband’s ability to eat and the need for assistance, as it is accepted his family knew him best’. This apology acknowledges its poor communication and apologises for it.
71. The Trust response also comments on the changing feeding status of Mr Y: ‘it is acknowledged that feeding and IV fluid plans did fluctuate throughout [Mr Y]’s admission, but this was due to the fact that our patients are continually reassessed and treatment plans changed accordingly.’ It is understandable the Trust needed to change Mr Y’s feeding status regularly, due to his fluctuating ability to eat. Therefore, we consider this explanation to be reasonable.
72. The impact of the insensitive comments made by staff members, may not have had a huge impact on their own. However, in the context of the whole complaint, given the sensitive nature of the family’s situation, and along with the other communication issues we have identified, it is important we consider the impact of this as a whole. The insensitive comments made will have added to the distress and upset caused to the family by the Trust’s poor communication with the family.
73. Regarding the Trust not providing a red wristband to Mr Y. As we have discussed in the previous section, the Trust did not go on to prescribe or administer any aspiring to Mr Y. Therefore, there is no impact arising from the lack of a red wristband.