Discharge
21. Mrs U told us the Trust discharged Mr O on 31 December. She said he was too ill for the Trust to discharge him. She told us when Mr O arrived home, he had slurred speech and was disoriented. She said the ambulance crew told her he was clearly very dehydrated.
22. The Trust said based on blood tests and an examination in the emergency room there was no evidence Mr O was dehydrated on 31 December. It also said there was no evidence of an infection.
23. Hospital discharge guidance says health care providers should ensure patients are only hospitalised for as long as they require hospital care. It says no patient should be discharged until it is safe to do so. To determine this a Multi-Disciplinary Team (MDT) should manage risk carefully, involving carers and the patient themselves in decisions.
24. The Hospital discharge guidance also lists twelve criteria. If a patient meets any of the criteria it would mean the patient should not be discharged. These criteria include needing intravenous fluids, oxygen therapy or a diminished level of consciousness.
25. NICE guidance says the patient and their families should be involved in discharge discussions. It says as soon as patients with complex needs are admitted to hospital, clinicians should assess their health and social needs. They should also start discharge planning.
26. Medical records show evidence there was MDT involvement in planning Mr O’s discharge. The medical team reviewed him in the days leading up to discharge and considered him medically optimised for discharge. His observations (temperature, pulse, blood pressure, heart rate, respiratory rate) were within normal range, including on the day of discharge.
27. Medical records also show the therapy team reviewed Mr O on 30 December. The team did not raise any concerns raised about his suitability for discharge.
28. Our physician adviser told us there were risks for Mr O remaining in an acute hospital environment, including infection, falls, delirium and deconditioning. They said there was also risk in him returning home. They said Mr O’s underlying medical conditions put him at risk of acute deterioration at any time, regardless of his location of care.
29. Our physician adviser said Mr O did not meet any of the 12 criteria set out in Hospital discharge guidance which would have warranted him staying in hospital. They also said there was no indication from medical, nursing or therapy reviews that would require the discharge plan to be changed.
30. Medical records also show the MDT involved Mrs U in the discharge planning. On 29 December, a discussion took place between her and the therapy team. This discussion occurred after a comprehensive assessment the previous day. Mrs U was present during the medical review on 29 December and Mr O’s intended discharge was again discussed.
31. We appreciate how distressing it must have been to see Mr O in a poor state of health when he returned home. We have seen no evidence to suggest the Trust failed to follow guidance when reaching the decision to discharge Mr O.
Zimmer frame at discharge
32. Mrs U said the Trust also did not provide Mr O with a Zimmer frame at discharge.
33. The Trust said when it assessed Mr O he could mobilise independently when using a Zimmer frame. It could find no evidence that staff had provided him with a Zimmer frame before 31 December. It apologised for this error. The issue was discussed at the following MDT safety meeting and the Discharge Governance meeting.
34. NMC guidance says nurses must use appropriate moving and handling equipment to support people with their mobility including mobility aids.
35. Medical records show Mr O was mobilising with a Zimmer frame during his inpatient stay. Records from 28 December, show he had returned to his normal level of mobility and was using a Zimmer frame. We can see on the morning of 30 December, the therapy team advised Mr O to continue to practice with his wheeled Zimmer frame.
36. The last nursing notes from 31 December, before the Trust discharged Mr O, said he was mobilising without requiring ‘any aids, fully independent’. This appears to be an error as previous assessments suggested he required a Zimmer frame. There is no evidence to suggest his mobility had improved.
37. Considering the evidence available, we think it is likely that Mr O still needed the Zimmer frame when he was discharged. There is no reference to the Trust providing Mr O with a Zimmer frame on the 31 December discharge summary.
38. In summary we have seen no evidence from the medical records to suggest the Trust provided Mr O with a Zimmer frame at discharge. We have found the Trust has failed to follow NMC guidance around providing patients mobility aids when they are required. We will consider the impact of this failing in the impact section below.
Fall risk assessment and fall interventions
39. Mrs U told us following Mr O’s re-admission the Trust incorrectly completed a falls risk assessment. This meant it placed him in a normal height bed and did not provide an ‘at risk of falls’ sign. She says the Trust did not place a fall sensor until after his fall on 3 January 2023.
40. The Trust said it recognised a nurse in the emergency department had completed a falls risk assessment incorrectly. It told us the nurse recorded that Mr O had not had a fall within the last 12 months, when that was incorrect. It said based on this, a safety mobility and falls risk care plan was not initiated on 31 December. The Trust apologised for this error and the matron of the relevant ward provided feedback to the nurse involved.
41. The Trust said a falls risk assessment was carried out on ward on 2 January. It said this assessment found Mr O to be at risk of falls.
42. Falls guidance says healthcare professionals should routinely ask older people whether they have fallen in the last year. It also says if an older person reports a fall they should be offered a falls risk assessment.
43. Local guidance recommends patients that are found to be high risk of falls are allocated a bed in a high visibility area. Nurses will also allocate equipment including low beds and fall sensors.
44. RCP guidance recommends high-low beds for those patients at risk of falling. It also says that a patients mobility status should be clearly documented, the call bell should be within reach and appropriate footwear should be used.
45. NMC guidance says nurses must use appropriate moving and handling equipment to support people with their mobility including mobility aids.
46. Medical records from 31 December show the Trust did carry out a falls assessment in the emergency department. This occurred at the time of Mr O’s readmission. However, it recorded he had not fallen in 12 months. This was incorrect as the Trust admitted him on 20 December having suffered a fall at home. This is a failing. This is because the Trust failed to correctly complete the falls risk assessment in line with the Falls guidance. We will consider the impact of this in the impact section below.
47. Records show when the Trust transferred Mr O to ward on 31 December, he was recorded as being admitted due to an elderly fall. The records also recorded he had some social problems.
48. Medical records show the Trust did put in place falls interventions on 1 January. This included recording Mr O required assistance of one when mobilising, non-slip socks, a call bell within reach, and being nursed on a high-low bed. In our view this was in line with RCP guidance which recommends the interventions listed above for patients at risk of falls.
49. As we have seen in paragraph 42, the Trust said a falls risk assessment was completed on 2 January. We have seen no evidence the Trust completed a full falls risk assessment on 2 January.
50. We have seen the Trust completed an enhanced patient (EPO) assessment on 2 January at 5.17pm. The EPO found Mr O score five out of 12 and had an elevated risk of falls. As we have seen in paragraph 44, local guidance recommends patients deemed to be high risk of falls are allocated a bed in a high visibility area and the use of equipment including low beds and fall sensors.
51. The records say around 12.24am on 3 January Mr O got out of bed and moved to the reception desk in the hallway. There he suffered a fall with head trauma.
52. Our nursing adviser said there was no evidence Mr O had a wheeled Zimmer frame available to him at his bedside at the time. This is despite the Trust previously finding he required a Zimmer to mobilise. We have found the Trust failed to follow NMC guidance about providing mobility aids. Records suggest the therapy team did not provide him with a Zimmer frame until 5 January.
53. The records suggest the Trust attached a fall sensor on 3 January to Mr O’s bed and chair. Fall sensors do not stop falls instead they detect when a patient has fallen. The sensors can provide an early warning for staff. Local guidance suggests this should have been in place following the EPO assessment on 2 January. We have found the Trust failed to follow local guidance.
54. In summary our work suggests the Trust failed to follow the relevant Falls guidance in completing an accurate falls risk assessment on 31 December. In our view the Trust has also failed to act in line with the NMC guidance and provide Mr O with a Zimmer frame until 5 January. We have also found it did not provide fall sensors on 2 January in line with the relevant local guidance. We will consider the impacts of these failings in the relevant section below.
55. We appreciate the distress Mrs U experienced on learning Mr O had fallen while he was in hospital. We can understand how learning of the Trust’s failings, both during the local resolution process, and with our findings above, are likely to have exacerbated the distress she experienced.
Inaccurate information
56. Mrs U said during Mr O’s second admission, a nurse told her that her uncle was mobilising to the toilet with the help of a nurse. She said this was untrue as her uncle was wearing incontinence pads. She had not seen any evidence of nurses helping him to the toilet.
57. The NMC Code says nurses should share with people and their families, as far as the law allows, the information they want or need to know about their health and care.
58. Medical records show a therapy team assessed Mr O on 30 December. The team found he was able to mobilise independently with a wheeled Zimmer frame for ten meters. However, he complained of slight giddiness towards last few steps.
59. During his second admission the Trust completed a therapy assessment on 5 January. Records show the Trust found it would not be safe for Mr O to mobilise with the assistance of one. This is because he required a wheeled Zimmer frame and could become unsteady due to confusion.
60. We have seen no evidence in the medical records to confirm whether a nurse told Mrs U her uncle could mobilise to the bathroom with the assistance of one. We have no reason here to doubt what Mrs U has told us.
61. Our nursing adviser said it was inaccurate for the nurse to advise Mrs U her uncle could mobilise with the assistance of one. This is because he required a wheeled Zimmer frame to mobilise and because of the references to him becoming unsteady.
62. We appreciate this information must have caused Mrs U distress. This especially given Mr O’s failed discharge and his previous falls. In our view the Trust providing incorrect information to Mrs U was not in line with the NMC Code. This is a service failing. We will consider the impact of this in the section below.
Impact
63. We have seen several instances of care which did not follow relevant guidelines. These are the failure of the Trust to:
• provide Mr O a Zimmer frame at discharge or at the time of his fall • provide him with a fall sensor after the EPO assessment • complete a falls risk assessment accurately • communication accurately about Mr O’s ability to mobilise.
64. Mrs U told us these events have been distressing and continue to haunt her. She also said the Trust staff did not treat her uncle with respect and dignity.
65. RCP fall audit guidance suggests interventions by an MDT can reduce the frequency of falls by 20 to 30%. We cannot say whether, if these failings had not occurred, this would have stopped Mr O falling. We can say providing Mr O with a Zimmer frame and accurately completing the risk assessment would likely have reduced the risk of him suffering a fall.
66. We understand how the uncertainty regarding this, and also learning the Trust did not give Mr O the best chance of avoiding the fall are distressing for Mrs U. Although we do not think the failure to provide Mr O with the fall sensor had a clinical impact on him, we appreciate this caused Mrs U distress.
67. We understand how failings in care would lead to her believing the Trust did not treat Mr O with respect or dignity. We can also understand how the Trust’s failure to accurately communicate with Mrs U added to her concerns. In our view, if these failings had not occurred, Mrs U would not have suffered these impacts. We will make recommendations to remedy this in the section below.