Falls prevention
15. Mrs T says Mrs H fell on three occasions whilst in hospital. She says this shows the lack of care afforded to her mother by the Trust. The Trust did not directly respond to this part of her complaint.
16. 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.
17. We can see what should have happened by looking at what the relevant standards and guidelines recommend. In this case, there are national guidelines setting out what clinicians should do to reduce the risk of falling in hospital.
18. NICE guideline 161 explains how clinicians should assess the needs of older people, to determine the level of care needed to prevent falls. It says that clinicians from different disciplines should be involved in assessing a patient, enabling identification and addressing of all relevant needs and risk factors. It also explains staff should ask the patient about their falls (section 1.2.2.4).
19. The NMC code (paragraphs 7.1-2) says that nurses should use evidence-based risk assessments to optimise mobility and safety, and to manage the risk of falls. It says nurses should use mobility aids If needed.
20. To see whether the Trust acted in line with these standards, we considered Mrs H’s medical records, as well as the view of our nursing adviser.
21. Mrs H’s first hospital admission was on 5 November, following an unwitnessed fall at home. Her records show Trust staff considered her falls history and what happened on this occasion: ‘2 falls in last 12 months… denies dizziness…can’t remember how she ended up on the floor’. Clinicians found no obvious medical cause for the fall but did note that her blood pressure dropped on standing.
22. We can also see staff assessed her usual and current level of mobility. They recorded that she was ‘independent with walking stick’ and that a physiotherapist previously recommended a Zimmer frame ‘but [she] doesn’t like to use it.’ Our nurse adviser gave their view that these assessments were in line with NICE guidance, and agreed there was no obvious medical cause for her fall.
23. The records show staff put falls prevention measures in place for Mrs H. This included having her ‘bed at the lowest level’ and her ‘call bell and personal things within reach.’ Staff placed a ‘falls leaf’ above her bed to indicate she was at risk of falling and referred her to physiotherapy and occupational therapy. Staff advised Mrs H ‘stand slowly’ and wear stockings’ to reduce the risk of her blood pressure dropping. Our nurse adviser felt that these measures were in line with NICE/NMC guidance.
24. We can also see staff recorded the need to encourage Mrs H to mobilise ‘encourage to mobilise or sit out…to prevent deconditioning,’ and to help her with mobility where needed. Our review of the records shows this encouragement and assistance took place regularly.
25. Mrs H also had regular physiotherapy reviews during her admission. In the first review, the physiotherapist noted she could mobilise well with a frame over short distances but needed encouragement. Further reviews show she was making ‘good progress’ with her mobility and was ‘managing well.’ An occupational therapist also saw her on several occasions. Our nurse adviser felt this showed clear involvement from different clinical specialties (in line with NICE guidance).
26. After discharge, Mrs H sadly experienced another unwitnessed fall at home on 3 December. The records show the cause of this was unknown, but it occurred when she got up to go to the toilet. We recognise how distressing this must have been for Mrs H and Mrs T.
27. She was readmitted to the Trust and staff again recorded her falls history, mobility, risk factors (including poor cognition), and information about her most recent fall. Staff noted she was experiencing stiffness in her legs and was unsteady, even with her frame. Our adviser again felt these assessments were in line with NICE guidance.
28. The Trust’s records refer to further visits from physiotherapist. The records from 4 December show she was able to use her frame to mobilise six to seven metres with prompting. They recorded she ‘would not be safe to mobilise unsupervised’ and needed mobility practice. As with the first admission, our nurse adviser felt the above showed comprehensive consideration of her risk factors, in line with NICE guidance.
29. The Trust again put measures in place to try and reduce Mrs H’s risk of falling. They placed her call bell within reach and ensured her bed was low. They ordered a ‘falls mat,’ provided ‘anti-slip socks,’ and monitored/assisted Mrs H whilst using her frame. The records show staff ‘observed [her] closely to avoid falls.’ Our nurse adviser felt these measures were in line with NMC/NICE guidance. A physiotherapy assessment on 10 December showed her mobility and balance was improving.
30. Despite these measures, Mrs H sadly experienced another unwitnessed fall in hospital on 11 December. The records show staff found her on the floor in the bathroom at around 8am. Staff thought this fall was likely due to a drop in blood pressure on standing. They referred her to cardiology for further investigation of this.
31. The Trust put further fall prevention measures in place following the fall. The records show they monitored her frequently and kept the side rails on her bed up (with Mrs H’s consent). We can see they assisted her whenever she tried to get up to go to the bathroom.
32. Mrs H then had ‘a funny turn’ on 14 December whilst a nurse was assisting her to the bathroom. She was cold, clammy, and unresponsive for a few seconds, and the nurse had to help her back to bed. Our adviser explained the records show her blood pressure was low, and we can see clinicians started her on new medication to address this.
33. We again recognise how distressing it must have been for Mrs H and Mrs T that she fell again in hospital. Our nurse adviser explained that preventing people from falling in hospital is particularly challenging as patient safety must be balanced against their dignity and a right to make their own decisions about mobility and the risks, they are willing to take.
34. As above, we consider the Trust tried to address this challenge by comprehensively assessing Mrs H’s needs/risk factors, involving various specialisms, and putting in place measures to try and reduce the risk. Although this did not prevent her fall, we feel the Trust’s actions were in line with NICE and NMC guidance. As such we have decided to take no further action on this part of the complaint.
Decision to discharge Mrs H
35. On 15 November, the Trust discharged Mrs H home. Mrs T says this ought not to have happened as Mrs H was unwell with COVID-19. She feels the failure to keep her in hospital contributed to her deterioration. In responding to the complaint, the Trust explained she was medically fit for discharge at the time.
36. At this time, NHS guidance on hospital discharge for patients with COVID-19 (section 1.2) stated that, unless a patient needs hospital care, they should not remain in hospital just because they have the virus.
37. Further NHS guidance explains prolonged stays in hospital can be bad for patients, especially for those who are frail or elderly. It says that spending a long time in hospital can lead to an increased risk of falling, sleep deprivation, catching infections and sometimes mental and physical deconditioning.
38. The Trusts medical records show Mrs H tested positive for COVID-19 on 12 November, during her first admission. The notes from 13 November state she had a ‘mild’ infection and was ‘fighting the virus nicely’. Staff planned to discharge her home, with a package of care (four visits per day). Clinical observations after this point show there were no respiratory concerns.
39. On 14 November, the records show Mrs H reported she was feeling unwell. Doctors recommended that it best keep her in for one more night. Staff advised Mrs T of this and that she would be back home tomorrow in time for her first care visit. Records from the day of her discharge show she was ‘stable,’ ‘independent [mobility-wise]’ and able to meet her own needs. The notes show there were no concerns about her oxygen levels.
40. We asked our adviser whether the Trust was correct to discharge Mrs H whilst she was positive with COVID-19. Our adviser gave their view that Mrs H was suitable for discharge and that the discharge was well-thought out and planned. They explained COVID-19 should not be an automatic barrier to discharge due to the significant risks of remaining in hospital.
41. As Mrs H was not acutely unwell, the Trust made the correct decision to discharge her home. We think it followed NHS guidance by ensuring she was in a safer environment, as she did not need hospital care. As such, we have decided not to take any further action on this part of the complaint.
Transfer to a delirium bed
42. Mrs T explains the Trust transferred Mrs H to a delirium bed in a care home 30 miles away without discussing this with her. She says she knew her mother needed a delirium bed, but she believed this would be in the hospital and a temporary move. She says her mother's condition deteriorated because of the move, and she is now in the care home permanently.
43. In its complaint response, the Trust said it spoke with Mrs T prior to the transfer but acknowledged communication could have been clearer. It explained processes were ‘fluid’ at the time because of COVID-19. It said it now has a tick list for family contact when transferring a patient to a delirium bed to ensure staff share all details.
44. When deciding if we should carry out a detailed investigation of a complaint, we look at whether there are signs something has gone wrong and whether this had a negative effect. We look to see if the organisation has taken steps to put this right, in line with our principles.
45. HYPERLINK "https://www.nice.org.uk/guidance/cg103/chapter/Context" \hNICE guidance in respect of a patient with delirium, says a patient showing signs of delirium is ‘more likely to need to be admitted to long-term care if they are in hospital.’
46. NHS guidance in respect of hospital discharge during the pandemic said that ‘during the COVID-19 pandemic, patients will not be able to wait in hospital until their first choice of care home has a vacancy’.
47. Our principles for good administration require public bodies to ‘communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances.’
48. Mrs H’s medical records include details of several discussions held with Mrs T and note her concerns about not being able to look after her mother at home. During a call on 4 December 2020, the Trust records show staff agreed to look for an alternative such as a delirium bed in a care home. Later the same day Mrs H’s consultant spoke with Mrs H with notes saying:
‘...it is likely she [Mrs H] has underlying dementia. This is not something we would diagnose when someone is unwell...it is likely this is delirium...In terms of her [Mrs H’s] discharge...we will assess what level of help she is needing in hospital and discuss further with her [Mrs T] and her husband [partner] but our [the Trust] initial assessment suggests that she [Mrs H] may need 24 hour care possibly in a care home setting...they [Mrs T and her partner] would be in agreement with this if this was our advice.’
49. Notes following a call with a physiotherapist on 8 December state a discussion with Mrs T took place about Mrs H’s discharge plan. The records say Mrs T agreed to an interim delirium bed for her mother, but she did not want to commit to long term care.
50. On 22 December, the records say the Trust had found a delirium bed in a care home close to Mrs T. The Trust notes show staff spoke with Mrs T to tell her of the pending discharge to the care home giving her its name and location. The transfer did not then happen as the care home was then unable to take Mrs H.
51. The Trust found an alternate placement in a care home 30 miles from Mrs T. The Trust medical records show it contacted Mrs T about this. However, the details of the conversation are not recorded.
52. Whilst the care home was not local, we consider the Trust met the requirements of NHS discharge requirements during the pandemic. This explains placement may not be in the care home of choice.
53. The Trust medical records show it made Mrs T aware of the need to place her mother in a care home. The records show the Trust to have followed our principles for good administration as communication had taken place and had the notes of conversation show these included the information needed.
54. Mrs T told us this is not what happened, and the Trust led her to believe the delirium bed would be in the hospital in every conversation they had. She explained she was shocked and distressed when the Trust explained her mother would transfer to the care home, particularly as it is 30 miles from home.
55. The balance of evidence suggests that the Trust did make her aware it would be outside of the hospital. As above, there are detailed notes of conversations where Mrs T agreed she could not care at home for Mrs H, accepting the offer of a delirium bed. There is reference to this being in a ‘care home setting’ with Mrs T saying she was not ready to decide about whether her mother should remain in a care home long term.
56. In summary, the Trust’s notes do not indicate anything went wrong in transferring Mrs H to a delirium bed or in its communication with Mrs T overall.
57. However, there is nothing to clearly support the Trust telling Mrs T the delirium bed may not be in a local care home. We consider this indicates the Trust may not have set Mrs T’s expectations properly, and it will have been a shock to her when hearing her mother would be in a care home 30 miles away.
58. We consider this to be an indication that the Trust failed to communicate properly, as per our principles.
59. Mrs T has asked for financial compensation in recognition of the failure to communicate properly. We have considered whether the potential impact of this poor communication might warrant this.
60. In deciding this, we consider our ‘Severity of injustice scale’ which sets out the amounts of money we might potentially recommend, depending on how seriously someone was impacted, if we were to investigate and uphold their complaint.
61. As above, we recognise that it would have been a shock for Mrs T to learn that the care home was 30 miles away. We feel this impact would sit within level 1 of our scale, which includes distress arising from a one-off incident. As explained previously, we have not seen indications of failings in the choice of care home, only that the distance was not communicated. As such, the overall frustration and inconvenience she experienced would not have been avoided if the Trust had communicated properly.
62. Level 1 of our scale explains that financial remedy is not indicated. We therefore do not feel that this is something we would likely recommend if we were to investigate. As such, we do not feel that we could do anything further to remedy the impact Mrs T experienced and will take no further action.
63. The Trust has apologised if the communication was not clear about the potential of the care home being some distance away, and explained it set up a tick list to ensure all information was shared when speaking with relatives. We are glad to see that the Trust has made improvements to its service as a result of what happened.
64. We have been very sad to read of Mrs T and Mrs H’s experiences and of the changes needed to adapt to this. We acknowledge we have not reached the decision Mrs T wanted and hope our explanations help her understand why this is the case.