Complaint about being kept in hospital
17. Miss P says her mother was elderly and vulnerable, and would have been better off cared for at home rather than staying in hospital, where she was exposed to COVID-19.
18. The Trust said sending her home would have put her health at risk and led to her having limited function and a high level of need. It explained she was a candidate for inpatient rehabilitation despite her advanced age, and this could not be provided at home.
19. The GMC guidance says doctors must adequately assess patients’ conditions, taking account of their history and symptoms. They must also arrange suitable advice, investigations, or treatment where necessary.
20. In this context, part of that assessment would be to consider what needs and health problems the patient has, and whether they need to remain in hospital to have treatment for this. Our physician adviser explained when considering this, doctors think about risks to the patient if they are discharged with unmet needs or unresolved health problems.
21. When Mrs N was admitted on 12 December the doctors reviewed her and identified she had suffered five falls in five days. They noted she had dementia but was more confused than normal. She was also dehydrated and had an acute kidney injury (AKI – this is where the kidneys stop working properly and waste products build up in the bloodstream).
22. Doctors and physiotherapists saw Mrs N was not at her physical baseline. She could normally move around the home she shared with her daughter with a degree of independence, relying on furniture for support where needed. But she was now unable to move in bed or sit up without considerable support. She could not stand or walk.
23. Physiotherapists reviewed her on 16 December and felt she had the potential to improve. The records say the physiotherapist discussed inpatient rehabilitation with Miss P on 16 December, and she was in agreement with this. We note Miss P’s account is different, and that when she spoke to doctors on 17 December she expressed concern about her mother being exposed to COVID-19 by not returning home.
24. Doctors made the referral for inpatient rehabilitation on 17 December but Mrs N’s health did not improve enough for her to transfer there. She continued to need treatment, and developed COVID-19 pneumonia. She sadly died in hospital on 27 December.
25. Considering the events of this admission, our physician adviser told us Mrs N’s health problems needed hospital based treatment and investigations. It appears she would have deteriorated and died sooner if she had returned home. We therefore think the doctors acted in line with the GMC guidance when they admitted her to hospital and kept her in.
26. Although Mrs N was never well enough to leave hospital for rehabilitation, we think the doctor’s referral for this in anticipation of her health improving was appropriate and in line with GMC guidance.
27. They acted on the recommendations from their specialist physiotherapy colleagues. We found this recommendation was appropriate. Our physiotherapy adviser said Mrs N had the potential to return to her baseline with rehabilitation, but her high level of need meant it would not have been possible to receive this in her home environment. We cannot see that her age ruled out her suitability for rehabilitation.
28. As things turned out, Mrs N never went to rehabilitation. Our view is that it was appropriate for Mrs N to be admitted in hospital and to remain there for treatment given this could not be provided at home. We found no failings in this aspect of the complaint. We hope this reassures Miss P that her mother was in the best environment for her needs at the time.
Complaint about hydration
29. Miss P says the Trust allowed her mother to become dehydrated. The Trust disputes it was responsible for her dehydration. It said her AKI put her at high risk of this, and it had to balance how much fluid it gave her as it did not want to overload her kidneys.
30. The NMC code explains a fundamental aspect of nursing care is making sure patients have access to adequate hydration. It also says nurses must keep clear and accurate records.
31. The fluids guidelines say patients’ fluid needs should be assessed in hospital, and they should receive intravenous (IV) fluids if their needs cannot be met any other way. IV fluids are those given via a drip.
32. Patients should be monitored to make sure they receive the right fluids. The fluids guidelines recommend the use of fluid balance charts. These are charts where staff, usually the nursing team, document a person’s fluid input (the amount of fluids consumed or given) and their fluid output (the amount of fluid lost such as through urination).
33. In Mrs N’s case she was prescribed IV fluids when she was admitted because there were signs she was dehydrated, and her oral intake of fluids was not enough to meet her needs. She could only manage sips of water.
34. Although there were fluid balance charts in place, the nurses did not complete these regularly enough and they lacked detail. The amount of IV fluids given was not recorded despite there being a space for this, and on some days the charts were left blank. This inadequate monitoring and poor documentation meant the Trust did not follow the right steps to ensure Mrs N’s fluid needs were being met.
35. The lack of information in the records made it difficult for our physician and nursing advisers to determine the amount of fluids Mrs N received. Other parts of the records did not make things much clearer. However, both advisers agree the available information indicates Mrs N did not receive enough fluids.
36. There were some days where it is documented she received no fluid or only 100mls of fluid. Whilst IV fluids may have been running at the same time, these are not properly documented. We can also see that IV fluids were not always given when required.
37. The Trust said there were issues with the drip at times which prevented staff from giving IV fluids. On other occasions, it appears staff had to be reminded to give fluids, fluids were not given when prescribed, and there were delays in new bags of fluid being attached to the drip. The Trust accepted some of this in its complaint response.
38. When we considered all this evidence, we found on balance it is more likely than not that Mrs N did not receive enough fluids to meet her needs. We also found the Trust did not adequately monitor her fluid balance. This was not in line with the NMC code and constitutes a failing.
39. Our physician adviser says this failing led to Mrs N becoming more dehydrated. They explained the blood test results support this, as they show her dehydration markers were getting worse during the admission and this was a result of inadequate hydration. We consider the impact of this later in the report.
Complaint about nutrition
40. The nutrition guidelines say all patients should be screened for malnutrition when admitted to hospital. Malnutrition is a serious condition that happens when your diet does not contain the right amount of nutrients. The outcome of this screening helps clinicians decide what level of nutrition support a person needs, this should be repeated weekly.
41. The Trust’s hydration and nutrition policy says the Trust uses the malnutrition universal screening tool (MUST) to see whether someone is at low, medium, or high risk of malnutrition. The higher someone’s risk, the more support they will receive with their nutrition. This could include referral to a dietician for specialist input, or prescription of dietary supplements.
42. Alongside this screening, The Trust’s policy says clinicians should monitor patient’s nutritional status by recording what food they eat every day in documents called food charts. They also use a red tray system. This is where patients are given their food on a red tray so staff can easily identify that they need extra attention and support with eating.
43. In Mrs N case, the Trust did not carry out screening until 20 December, eight days after she was admitted. This was not in line with the nutrition guidelines.
44. Although screening was delayed, it appeared the Trust recognised Mrs N’s poor appetite and limited food intake meant she needed to be monitored and supported. It used food charts and the red tray system for Mrs N.
45. Despite this however, the Trust did not properly complete the food charts. There were gaps in the charts where some meals were not recorded, and there were some days where no food intake was recorded at all. This could be due to poor record keeping but could also be because staff were not ensuring she was getting enough eat.
46. In addition to the inadequate monitoring and delayed screening, our nurse adviser said the screening on 20 December was incorrect. The Trust estimated Mrs N’s weight but did not consider that she would have likely lost weight recently from eating very little. The Trust calculated her MUST score as zero (low risk). Our nurse adviser says the MUST score, and malnutrition risk, was likely higher.
47. She therefore missed out on the opportunity to be considered for additional support with her nutrition, such as the dietician or supplement support mentioned above. On balance, it is likely her nutrition needs were not met. This was a failing. We consider the impact of this later in the report.
Complaint about skin integrity
48. The pressure ulcer guidelines say staff should be aware all patients are potentially at risk of developing pressure ulcers. They should document and carry out an assessment of pressure ulcer risk for adults who are admitted to hospital. The guidelines say to consider using a validated scale to do this assessment.
49. The Trust’s tissue viability policy says it uses the Waterlow risk assessment scale. This is a scale that measures various aspects of skin condition and integrity, and risk factors for skin changes, to see how at risk a person is.
50. In Mrs N’s case, staff carried out skin checks in the ED on 12 December and first completed an assessment of her pressure ulcer risk at 7am on 13 December.
51. This assessment identified she had factors that put her at higher risk of pressure ulcers. No Waterlow score was calculated, and it appears this is because staff could not measure her weight. Whilst not ideal, this was still in line with the pressure ulcer guidelines. They do not say that calculating a Waterlow score is mandatory. The priority is identifying patients that are high risk. The Trust did this.
52. Although no Waterlow score was calculated, staff treated her as being high risk of pressure ulcers, which was appropriate. The pressure ulcer guidance says people who are considered at high risk of pressure damage should:
• be provided with specialist pressure relieving mattresses • be encouraged, or assisted, to reposition at least every four hours • have barrier creams applied to high risk areas of skin.
53. Our nurse adviser examined the evidence and confirmed these interventions were in place for Mrs N. So, although a specific Waterlow score was not calculated, this did not affect the care Mrs N received.
54. Staff monitored Mrs N’s skin on a daily basis as part of their routine nursing checks. Staff also reassessed Mrs N’s pressure ulcer risk on 20 and 22 December. They estimated her weight and calculated a Waterlow score. The score indicated she was still at high risk. The interventions to manage this risk that were already in place, continued.
55. Our nursing adviser identified one occasion on 22 December where it looked like Mrs N’s repositioning was delayed. There was a gap in the records where no repositioning was documented over a 10 hour period.
56. This should not have happened. However, this appears to have been an isolated incident, and the records otherwise indicate staff provided adequate care and attention to Mrs N’s skin needs. We understand this was an important concern for Miss P. We hope she is reassured that we have found no failing here.
Complaint about communication
57. There are two aspects to this complaint. Miss P says updates were lacking, and she was not told about problems with her mother’s care. She also complains about the information given on Mrs N’s health before she died. We have addressed these in turn.
General updates and information provided
58. Good communication is a fundamental aspect of care. The GMC guidance says doctors should communicate effectively. They should give people ‘the information they want or need to know in a way they can understand’. Similarly, the NMC code says nurses must give people (or their families and carers) ‘the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’.
59. There are no specific guidelines which set out how often families should be updated about their relatives in hospital. This would depend on the individual circumstances. In Mrs N’s case, her dementia and confusion meant she could not update her family herself, so she was reliant on staff to do this.
60. To address this part of the complaint we looked at communication up to 25 December. Communication after this date is addressed in the next part of the report.
61. On 13 December nurses updated Miss P about her mother’s poor appetite. No further nursing updates were provided for over a week. Then, on 22 December nurses wrote that family were updated but they did not document what was said, or who they spoke to. The next nursing update was about Mrs N’s poor appetite on 25 December.
62. Doctors updated Mrs N’s family three times during this period. They spoke about inpatient rehabilitation on 17 December, a resuscitation decision on 21 December, and general treatment aims on 24 December.
63. Our physician adviser explained communication between staff and families was challenging during the COVID-19 pandemic. This was because staff were under pressure performing their core duties, and communication suffered. However, we note the Trust accepts there were a lack of updates to Mrs N’s family during this admission.
64. We also found there were a lack of updates. Our nursing adviser told us updates were inadequate. They do not appear to have occurred often enough and were not suitably detailed. Key issues, such as the care being given to maintain her skin integrity, further issues with appetite, or starting antibiotics for a urine infection, were not included in updates.
65. Whilst we accept communication was a challenge due to the pressures of the pandemic, we think the poor communication here constitutes a failing. Given Mrs N could not update her family and they could not visit her, communication was very important. We can see how the lack of information caused Miss P’s worry and distress. We explain how the Trust should put this right in our recommendations section.
Communication before Mrs N died
66. Miss P says she was not told her mother was dying when she became unwell.
67. The medical team reviewed Mrs N on 25 December in response to concerns she had a high temperature and low oxygen. The doctors suspected a chest infection or COVID-19. Although there was a change in her condition, the medical team did not feel she was dying at this stage. We note Miss P was on the ward at this time.
68. Mrs N sadly became more unwell on 26 December. The records show the doctors were concerned she was not responding to treatment for her infection and may not recover. They wrote that they explained this to Miss P, and told her that if there was no improvement in 24 to 48 hours they may need to consider providing end of life care.
69. Then, on 27 December, Mrs N’s condition worsened further. The COVID-19 swab came back positive, and she had shown no response to treatment.
70. A doctor wrote at 10.15am that they told Miss P about this, and explained they would stop active treatment for her infection, instead providing end of life care focussed on maintaining comfort. The doctor said Miss P could visit the ward. Mrs N very sadly died around an hour later, before Miss P arrived.
71. Our physician adviser told us from the point that it became apparent Mrs N was deteriorating and could die, the records indicate communication was appropriate.
72. We think the doctors acted in line with the GMC guidance when they explained the situation and the possible outcomes for Mrs N. We recognise Miss P has a different recollection of those discussions. However, in the absence of any other evidence, we did not see any failings in this aspect of the Trust’s communication.
73. It must have been incredibly difficult for Miss P when her mother died before she got to the hospital. We hope the explanations provided here help her see that the Trust kept her informed of Mrs N’s prognosis and did not withhold any information.
Complaint about visiting
74. Miss P considers the Trust should have allowed her to visit her mother during her whole admission because she had dementia and needed additional support, and she was her mother’s main carer. She says she could have helped with things like eating and drinking. The Trust does not accept that visiting should have been allowed.
75. To give context to this, at the start of the COVID-19 pandemic there were strict restrictions to inpatient visiting. There were exceptions where visiting was allowed, and as time went on restrictions were eased further, and then lifted.
76. The NHS England visiting guidelines from the time of events said visiting could take place, but only ‘in a very careful and Covid-secure way’. It said organisations should have ‘careful visiting policies… while coronavirus continues to be in general circulation’.
77. The Trust’s visiting policy from the time said ‘people with specific care needs (e.g. dementia or other disabilities) are allowed one visitor or named carer’. The policy defines a carer as ‘an individual who normally provides daily care for the patient when at home, or place of residence (4 hours or more)’.
78. We think Mrs N could be considered a person with ‘specific care needs’. She had dementia and needed round the clock care. Miss P supported her with all aspects of care and indicated to staff that she had specific needs.
79. The Trust’s policy does not describe the decision making process or the severity of need required to be allowed visitor. However, in its complaint response, it said visiting was not allowed because ‘there was no indication or concern that [Mrs N’s] physical care needs were not being met and there was no indication that she was distressed, or her emotional needs had been neglected’.
80. The evidence does not support the Trust’s explanation. As set out earlier in this report, we have seen failings in the monitoring of Mrs N’s nutrition and hydration, and likely inadequate provision of both, meaning it cannot be said all her needs were being met.
81. There is also evidence she was unsettled, disorientated, and restless at times. Or other times she was more settled, but would not communicate with staff meaning it may have been harder to anticipate her needs.
82. Whilst the Trust has retrospectively given its opinion on visiting, there is nothing documented at the time to show staff thought about whether having a carer visit Mrs N would be of benefit, or the rationale for not allowing visiting.
83. According to the Trust’s own policy, and considering the evidence in the records and our nurse adviser’s view, we found Mrs N met the Trust’s criteria to have a visitor and it failed to consider this.
84. This means Miss P was denied the opportunity to visit her mother and assist with her care. This caused distress and worry at an already challenging time. We appreciate why Miss P feels she may have been able to get her mother to eat and drink more. We further consider the impact of this failing, and the other failings we have seen, next.
Impact of the failings
85. Miss P considers the failings contributed to her mother’s death. She also says they caused her worry and distress.
86. We found the Trust failed to properly monitor Mrs N’s nutrition and hydration, and there was likely inadequate provision of both. To further compound this, the Trust failed to allow Miss P to visit her mother, so she lost the chance to assist with her care needs and encourage her mother to eat and drink more. As set out earlier, there was also a lack of detailed updates about Mrs N’s condition.
87. We cannot say these failings contributed to Mrs N’s death. Our physician adviser explained her co-morbidities, age, and frailty sadly meant she was at high risk of death from COVID-19. Even without the failings, she had low chances of survival. Meeting her hydration and nutrition needs would not have been enough to prevent her death. The outcome also would not have changed had she been allowed visitors or if the family were better updated.
88. We found the failings caused distress and worry. When Miss P got copies of her mother’s medical records during the complaints process in 2021 she was distressed to see the issues with hydration and nutrition. This added to the distress she was already feeling at not being able to visit her mother, and receiving limited updates from staff, some of which included updates about her limited eating and drinking.
89. The combined impact of these failings was that Miss P was left worrying that they contributed to her mother’s death, and she was left with doubts about whether things could have been different. Whilst we hope our findings now offer her some reassurance about her mother’s death, we also think the Trust should act to put things right.