Care and treatment
18. During the admission, the family raised concerns that they had not been contacted by a consultant as promised to give an update on Mrs K. This was raised with the ward and with the patient advice and liaison service (PALS).
19. On 13 January, a consultant contacted the family to explain what action had been taken and what tests were being conducted. The consultant asked about Mrs K’s history and explained they had been on leave and only just returned. The consultant told the family Mrs K had been put onto antibiotics, and that it may take time before she would feel the benefit. It was agreed the family would receive regular updates.
20. This caused concern for the family that no one had been responsible for Mrs K’s care between her admission on 6 January and the conversation with the consultant on 13 January.
21. In response to the complaint, the Trust provided a detailed history of the care Mrs K received during her admission. This explains how, when, and by who she was reviewed during this time, what actions were taken, what tests were conducted, and what her treatment plan was.
22. The Trust explained that Mrs K was reviewed every day from the day of admission by the surgical team. There was a nominated register for the daily ward round. On-call consultants were contacted for urgent advice/complex issues when needed. In the Trust’s view, Mrs K was treated with appropriate medications, antibiotics and received the required treatment.
23. We reviewed this part of the complaint with our physician adviser. The GMC’s Good Medical Practice guidance states:
“15 – you must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must: • Adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values, where necessary, examine the patient • Promptly provide or arrange suitable advice, investigations or treatment where necessary • Refer a patient to another practitioner when this serves the patient’s needs
24. - In providing clinical care you must: • Consult colleagues where appropriate”
25. We can see that Mrs K was reviewed daily. She was assessed and her treatment plan was reviewed and amended as needed. When further investigations were needed, plans were put into place to ensure they were conducted in a timely manner. There is evidence that she was reviewed by and discussed with: a registrar, a junior doctor, a consultant surgeon, the haematology team, the dietitian team, the gastroenterology team, the microbiology team, and the cardiology team. When Mrs K began to deteriorate further, she was reviewed by the intensive care unit doctors who provided advice and had input on her treatment plan.
26. Overall, it is evident that there was a shared responsibility for Mrs K’s care and that plans were put into place to treat the symptoms Mrs K was presenting with. The clinical teams worked collaboratively to make sure Mrs K underwent several investigations, and it is clear efforts were made to ensure she was as comfortable as possible during her admission.
27. For these reasons, we consider there are indications that the clinical teams acted in line with the GMC’s Good Medical Practice guidance. We have not seen any indications that something went wrong in Mrs K’s care and our physician adviser commented that after reviewing Mrs K’s timeline of care, they did not identify any errors or omissions in the care and treatment provided, and we hope this provides some reassurance to Mr L and the family.
28. We will not be taking any further action on this part of the complaint.
Assistance with mobilising and personal hygiene
29. The family say that prior to admission, Mrs K had been able to get up, wash, and dress with help and support. However, during her admission, her mobility level was lost completely.
30. In response to the complaint the Trust says Mrs K was vulnerable and acknowledged the family’s comments that she had been mobile prior to her acute deterioration. It therefore feels it is likely she suffered from deconditioning syndrome.
31. The Trust explained that the British Geriatrics Society acknowledges that deconditioning in older people with frailty can occur within hours of lying on a trolley or bed. Up to 65% of older patients experience a decline in functional abilities during hospitalisation. Older people are at more risk of reduced muscle strength, reduced mobility and falls, confusion due to changes in the environment and demotivation.
• Assistance with personal hygiene
32. The NMC’s code highlights personal hygiene as one of the fundamentals of care:
“1 Treat people as individuals and uphold their dignity. To achieve this, you must: 1.2 make sure you deliver the fundamentals of care effectively
The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions…”
33. Our nursing adviser explains this means that the nursing staff had a responsibility to Mrs K to ensure her personal hygiene needs such as washing and dressing were met.
34. We have reviewed the medical records with our nursing adviser, and we can see that a bathing/personal care plan was put into place on 6 January. The plan indicated that Mrs K required supervision to make her hygiene needs. The comfort rounding charts in the medical records evidence that Mrs K’s personal hygiene needs were tended to by providing assistance throughout her admission.
35. For this reason, we consider the nurses acted in line with NMC guidance, and there are no indications that something has gone wrong in this area of Mrs K’s care.
• Mobilising
36. We considered this part of the complaint with our nursing adviser. The records show us that Mrs K underwent a mobility assessment upon admission to hospital, and confirmed she required the assistance of one person for all aspects of mobility.
37. Our nursing adviser explains that mobility should be a part of routine assessment to help plan care and discharges. We consider there is evidence that Mrs Barker’s level of mobility was assessed upon admission in line with the NMC’s Code in relation to delivering the fundamentals of care effectively (1.2), and making sure people’s physical, social, and psychological needs are assessed and responded to (3).
38. We have considered if the mobility assessment plan was followed. The Trust has not given any information about whether Mrs K was mobilised during the admission within its response. There is not a consistent picture of mobilisation throughout the admission and so we cannot be sure that Mrs K was up and out of bed regularly.
39. There are some entries within the records which document Mrs K was assisted to sit out of bed and back into bed, and that she was mobilising with assistance. We can also see Mrs K’s hygiene needs were met, which would suggest some element of mobilisation as she was helped with this throughout her admission.
40. Overall, there are indications that the nursing team acted in line with the NMC’s Code, as efforts were made to promote Mrs K’s wellbeing and meet her needs where possible. It is important to recognise that Mrs K was notably frail and unwell upon admission to hospital. She began to deteriorate during the admission despite the investigations and treatment she received. Her blood pressure was low, and she was reportedly nauseous with episodes of vomiting.
41. Our nursing adviser highlighted that it may have been the case that Mrs K did not feel well enough to mobilise as often as she may have done when feeling well in herself at home. For this reason, it is possible the lack of mobilisation led to some physical deconditioning. We understand from the advice we have received it is unlikely this led to the deterioration in Mrs K’s clinical condition, and it is more likely the deterioration led to the physical deconditioning.
42. Taking all of this into consideration, we conclude there are no indications that something has gone wrong in this area of Mrs K’s care.
Communication
• Following a verbal cancer diagnosis on 6 December 2021, it was not mentioned again or followed up with a care plan
43. The family tell us that Mrs K had been undergoing various tests and treatments over several months, and this culminated in a verbal diagnosis of cancer on 6 December 2021. They are concerned this was never mentioned again or followed up.
44. The Trust’s response to the complaint explains that Mrs K was seen on 6 December 2021 by an assistant nurse practitioner (ANP) in urology. In the clinic letter, it is said Mrs K was awaiting her trans urethral resection of bladder tumour (TURBT) histology results.
45. The Trust explains that an abnormality was seen on a flexible cystoscopy which was thought to be a suspected bladder cancer. However, investigations showed this was not the case. The histology results were reported on 15 December 2021 and confirmed that there were no malignant cells seen. The diagnosis was severe cystitis only. The Trust has apologised the family were given conflicting information and has acknowledged the distress this must have caused.
46. The GMC’s Good Medical Practice guidance says:
“31 – You must listen to patients, take account of their views, and respond honestly to their questions 32 – You must give patients the information they want or need to know in a way they can understand.
33 – You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support”
47. We have looked at the medical records and can see that the histology report states there were no malignant cells seen during the TURBT, the diagnosis given was severe cystitis only. There is no evidence that Mrs K had cancer, and so there was no requirement for follow up treatment.
48. At the time of the clinic appointment, the results had not yet been sent, therefore no diagnosis should have been given. We would expect that patients and their families are given accurate information in a sensitive manner in line with the GMC’s Good Medical Practice guidance. It is understandable that if Mrs K was told she had cancer, it would have been considerably upsetting.
49. We do not dispute the family’s recollection of events and we are sorry to hear this was their experience. There are no entries within the records which reflect this conversation, and we were not present at the time to independently know what, and how, things were said. We accept that a miscommunication about a diagnosis could have occurred.
50. We also recognise that in some instances, each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what was said does not invalidate another person’s opposing perception of the same comment.
51. For this reason, we are left without independent supporting evidence that would indicate to us that a service failure took place. Despite this, we can see from the Trust’s response it has acknowledged Mr L’s concerns and the impact they had. It has also provided an apology to the family.
52. We consider this response is in line with the NHS Complaint Standards with regards to giving fair and accountable responses through meaningful and sincere apologies and explanations. We will not be taking any further action on this part of the complaint as we consider the Trust has provided a proportionate remedy for the impact faced.
• The family received a lack of communication and information from the team treating Mrs K, in the context of COVID-19 visiting restrictions,
53. The family say because of Covid-19 restrictions they were unable to visit. Mrs K was able to contact them using her mobile phone, but she was unable to tell them what was being done or about any tests.
54. In response to the complaint the Trust has acknowledged that visiting restrictions were in place due to Covid-19. It explained that judgements about visiting were difficult to make, and the Trust had to consider the recommendations and guidance issued by the government, infection prevention, and NHS England.
55. Because cases of Covid-19 had increased substantially in the local community, the Trust decided to no longer allow visitors unless in exceptional circumstances. The Trust has recognised the difficulty these restrictions caused both patients and their loved ones. Additionally, it has acknowledged that the lack of visiting meant that sometimes, valuable bespoke information and history from family members and carers could be harder to access. It also meant opportunities for nurses to communicate and explain to the families were constrained.
56. The Trust has recognised that its explanations cannot negate the distress and upset that the family suffered and has offered its sincere apologies for this.
57. Having looked through the records, there is minimal evidence of communication with the family during the admission, until one of Mrs K’s daughters raised concerns with PALS on 13 February. Unfortunately, this was the day before Mrs K died.
58. It is documented throughout the records that Mrs K was unwell and deteriorating and our physician adviser explained that in such patients, sudden deterioration and cardiac arrest can happen at any time. When considering this, and the restrictions on physical visiting, we consider there are indications of service failure in relation to the level of communication with the family. The clinical teams should have been more considerate to the family and been in contact much more frequently to provide them with information and support, in line with the GMC’s Good Practice guidance (point 33).
59. The lack of communication, understandably, caused great concern for Mrs K’s family. They were keen to understand Mrs K’s treatment plan, and how she was progressing. Instead, the family felt they were left in the dark about what was happening and became increasingly anxious about Mrs K’s treatment.
60. We can see from the Trust’s response it has recognised the impact the visiting restrictions had, and the strain this had on communication between patients, families, and staff. It has also provided a sincere apology to the family. We consider this response is in line with the NHS Complaint Standards with regards to giving fair and accountable responses through meaningful and sincere apologies and explanations. We will not be taking any further action on this part of the complaint as we consider the Trust has provided a proportionate remedy to the impact faced.
• The family were told not to worry about Mrs K’s condition, but within hours of this conversation, Mrs K had died.
61. The family recall receiving a call from the Trust on 14 January at 2:15pm in which they were told of the treatment plan. The family were told they could visit Mrs K in the afternoon. They were met by the consultant who they had spoken to on the phone, and recall being told there was nothing to worry about and that Mrs K’s condition was not life threatening.
62. The family explain that when Mrs K expressed a need to use the bathroom, they left the ward. However, upon their return, they heard the buzzer going off and nurses hurrying to Mrs K’s bed. They were then asked to wait in a side room. Sadly, Mrs K passed away shortly afterwards.
63. The family are still left with concerns and questions about Mrs K’s treatment and ask how this deterioration could have happened so suddenly without warning.
64. We have reviewed the corresponding entries within the medical records, which detail that the consultant provided an update to the family over the phone. They explained Mrs K’s deterioration and what treatment had been given, including the plan going forwards. The consultant advised the family could come to visit Mrs K.
65. The notes do not indicate that the consultant gave any indication on prognosis, however, we do not dispute the family’s recollection of events. We were not present at the time to independently know what, and how, things were said. We accept that a miscommunication about a diagnosis could have occurred. We also recognise that in some instances, each person involved in the same conversation can come away with a different perception of its contents and what happened.
66. It is documented throughout the records that Mrs K was unwell and deteriorating and our physician adviser explained that in such patients, sudden deterioration and cardiac arrest can happen at any time. If communication had been better throughout the admission, it is likely the family would have been more aware of Mrs K’s deterioration.
67. Our physician adviser added that there was no specific indication that cardiac arrest was imminent, however, it was evident Mrs K had deteriorated further and was unwell overnight and through 14 January. For this reason, we consider the family should have been contacted and told of her further deterioration. It is evident the family felt that the deterioration had happened suddenly and without warning.
68. For these reasons we consider there are indications of poor communication in this case. We recognise that the lack of communication throughout the admission contributed to the shock the family felt at Mrs K’s deterioration. If communication had been better, it is likely this would have been less of a shock for them as they would have been aware how poorly she was. We understand this is something that has continued to trouble them as time has gone on and has made the bereavement process more difficult for them.
69. In response to the complaint, the Trust apologised for the breakdown in communication and has recognised that not being kept informed of the treatment and plans for Mrs K’s care caused the family anxiety and distress. The Trust has acknowledged the hurt caused to the family and has offered its heartfelt apologies. It has shared the complaint with the team, so that they can reflect on the unintended impact of the service it provided.
70. We consider this response is in line with the NHS Complaint Standards with regards to giving fair and accountable responses through meaningful and sincere apologies and explanations. It has acknowledged the hurt caused to the family and has offered its heartfelt apologies. It has also shared the complaint with staff to ensure learning is taken from this sad set of circumstances, and we consider this demonstrates a willingness to use cases like this to improve services going forward.
71. We will not be taking any further action on this part of the complaint as we consider the Trust has provided a proportionate remedy to the impact faced.