The Wolverhampton Trust
15. Mr L told us his family’s experience was ‘harrowing’. We do not underestimate how challenging it must have been feeling they did not have the information or the support they needed.
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 have done this and have not found any indications that something has gone wrong in relation to most of Mr L’s concerns. As we will go on to explain, the exception is in relation to the Trust’s management of Mr M’s bedsores.
Bowel impaction
18. Mr L complains the Trust did not take action to prevent his father’s bowel impaction, such as managing his nutrition. Mr M’s records say he had opened his bowels on 27 February, the day before his admission. However, by 31 March, a scan of his abdomen revealed faecal loading (prolonged constipation). Mr M declined nutritional support.
19. Sections 13.2 and 13.3 of the NMC Code says nurses must make timely referrals to other practitioners, and ask for help from suitably qualified professionals, when required. The Trust referred Mr M to the mental health team and the palliative care team, in line with the NMC Code, as it was felt that his low mood was impacting on his appetite.
20. Sections 2.2 to 2.5 of the NMC Code reflect nurses must listen to people and respond to their preferences and concerns. This means they empower people to share decisions about their treatment, and respect, support and document a person’s right to accept or refuse care.
21. Mr M revealed he had no interest in living ‘due to increased frailty’. He had full capacity and thus his wishes not to take medications (to manage bowel impaction) or to eat and drink were respected. This was in line with the NMC Code.
22. In summary, nurses offered Mr M nutrition such as supplements he sometimes took, hydration and medication (he was prescribed senna, Movicol and enemas). All of these would have helped with faecal loading. Mr M made an informed choice not to take these on occasions. We hope this helps Mr L understand the care his father received.
Medication – use of IV pain relief and no butterfly needle
23. IV analgesia is not the first-choice route in a patient refusing to take oral medications. This route is used for patients who are unable to take medications by mouth as a result of persistent nausea, vomiting, swallowing difficulties, severe weakness or unconsciousness.
24. Mr M could swallow pain relieving medications if he wanted to so oral medication would be the first choice. Mr M took oral paracetamol and codeine. He had oral oxycodone and morphine. Mr M was also given strong pain-relieving patches (buprenorphine).
25. A butterfly needle is used to deliver subcutaneous medications or fluids, it is used for a syringe driver. Butterfly needles are not suitable for many medications and whilst there is no national guidance stating when it should be considered, it is generally used towards the end of life when patients cannot swallow and are having multiple ‘standard injections’.
26. Based on the clinical records, our adviser said during this admission, this did not apply to Mr M. As there was also no indication for IV analgesia, we have not identified any signs something went wrong in relation to Mr M’s pain relief.
Bedsores
27. Mr L complains the Trust did not take action to prevent his father’s bedsores or tell his family he had developed them. NICE CG179 says health professionals should assess patients’ pressure ulcer risk, and consider using a risk assessment scale such as the Waterlow score. They should reassess this risk if there is a change in clinical status.
28. Adults who have been assessed as being at high risk of developing a pressure ulcer should be offered a skin assessment and encouraged to change their position frequently, at least every 4 hours. The frequency of repositioning required should be documented.
29. NICE QS89 says people at high risk of developing pressure ulcers should be provided with pressure redistribution devices. These include highspecification mattresses, pressure redistribution cushions and equipment that offloads heel pressure. Using pressure redistribution devices as soon as possible can prevent pressure ulcers developing and help to treat them if they do arise.
30. In its complaint response, the Trust said Mr M had two pressure ulcers and one moisture lesion. It said the area initially reported as a pressure ulcer was de-escalated to moisture associated skin damage when it reviewed Mr M’s care in late April 2023.
31. Mr M’s pressure areas are documented as ‘intact’ on admission. An assessment of Mr M’s pressure ulcer risk indicated that his skin was vulnerable. He was assessed as ‘at risk’ of pressure ulcers. A ‘high risk static’ mattress (which helps to reduce pressure across the whole body) was used, which was in line with statement 8 in the NICE QS89.
32. Mr M’s position was checked two hourly. There were occasions when he would refuse a skin check and positional changes. It is documented that Mr M developed a grade 2 pressure ulcer to his sacrum during his admission. A grade 2 pressure sore is partial loss of dermis (the deeper layer of skin) and looks like a shallow open ulcer with a red pink wound bed without slough (dead tissue within a wound).
33. Pressure damage was noted from 6 March as a grade 1 (the least severe type, where there is no open wound). From 14 March, this had deteriorated further to a grade 2. Mr M’s healing grade 2 pressure ulcer continued to heal up until the Trust discharged him.
34. Our adviser noted the photos we have show a moisture lesion and not a ‘bedsore’ (category/ grade 2 pressure ulcer). A moisture lesion is defined as being caused by urine and/or faeces and perspiration which is in continuous contact with intact skin of the perineum, buttocks, groins, inner thighs, natal cleft, skin folds and where skin is in contact with skin.
35. Moisture lesions cause superficial loss of epidermis (the outer surface of the skin) and/or dermis, which may be preceded by areas of erythema (redness) on intact skin. In line with section 1.1.18 of NICE CG179, the Trust should have used a barrier cream to prevent skin damage as Mr M was at high risk of developing a moisture lesion.
36. There is evidence that this may have been used towards the end of the admission but no evidence to show it was used earlier. It should have been used once damage was noted, which was 6 March 2023.
37. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
38. The Trust told us since receiving this complaint, it is now utilising Contiplan Wipes. These wipes provide protective barrier cream preventing bodily fluids breaking down the skin. It utilises them for patients who are at risk or have developed a moisture lesion.
39. This change indicates an improvement in the service the Trust is providing. We recognise it does not change Mr M’s experience and the worry Mr L felt. We hope it reassures them other families are now less likely to have a similar experience.
Visiting
40. Mr L complains the Trust did not make it clear the family could visit with ‘open access’. Our adviser explained there is no national standard stating when patients can receive visitors. Visiting is therefore in line with local policy and/or at the discretion of the senior nurse. As a general rule, open access is usually only in place when a patient is at the end of life, and this did not apply to Mr M.
41. This appears to reflect the Trust’s approach. In its complaint response, the Trust said open visiting is offered to families when patients are thought to be in the last few hours or days of life but a flexible approach to visiting is also available at the ward manager’s discretion. It said it had enabled this by inviting the family to visit at mealtimes.
42. We recognise Mr L felt his family could have spent more time with Mr M. We hope this reassures him that this may not have been to the extent that he thought.
Discharge arrangements
43. Mr L complains about how the Trust made discharge arrangements. We have considered his account about his father’s wish to die at home. We have also looked at the Trust’s records which reflect the views Mr M expressed during his admission.
44. DHSC guidance on hospital discharge and community support explains individuals leaving hospital should be discharged to an environment best suited to meet any ongoing health and care needs they may have.
45. Our adviser said it was not clear from the records that Mr M wanted to die at home. It was clear that he wanted to be discharged to a care home. By the 14 March it was documented that he ‘does not care what we organise and we can liaise with his family to do this’. By 23 March, Mr M confirmed he would go home with a package of care and that his family would clear his flat.
46. The evidence shows Mr M was communicated with regularly regarding his discharge plans, and that his wishes were respected. His family were also communicated with. The Trust carried out a capacity assessment to ensure that he had the capacity to be fully involved in his discharge plans and it concluded that he did have capacity.
47. Discharge plans were discussed with Mr M early on in the admission and on 1 March, he stated that he ‘liked the idea of a residential home’. The next day, the Trust appears to have been exploring a package of care at home. On 4 March, it is documented Mr M’s son said he will need a package of care at home, but that Mr M said ‘it’s better if I go to a care home’.
48. This was discussed further on 5 March and Mr M was advised that a care home would need to be funded privately. He said he would discuss this with his son. On the next two days, he reiterated he would like to go to a care home. On 8 March it is documented that he was ‘adamant’ that he wanted to go to a care home.
49. On 13 March, it appears a referral for 24-hour care had been submitted and Mr M and his family were aware of, and agreed to the plan. The next day, Mr M said he ‘did not care’ where he was discharged, and would leave it to his family to decide.
50. A referral for funded 24-hour care was rejected and therefore a package of care at home was agreed with Mr M. The Trust’s records indicate the discharge team were involved in discharge plans.
51. Based on the available information, it appears Mr M’s wishes were respected. We have seen no indication something went wrong here.
Communication at discharge
52. Mr L complains the Trust did not communicate his father’s needs to his family, GP or district nurses when it discharged him.
53. Our adviser said Mr M had the capacity to be involved in his own discharge plans. Capacity is decision-specific and a capacity assessment was specifically conducted for this purpose. The Trust sent a copy of the discharge summary to Mr M’s GP and it sent a district nursing referral. His family was fully communicated with, when Mr M consented.
54. The records indicate Mr M’s family were fully aware that he was being discharged home and there are documented discussions with about this. Mr M’s children attended the ward to discuss discharge on 28 March. We have not seen any indication of a failing here.
55. In its complaint response, the Trust apologised if no details were provided to Mr M or his family about how to contact the district nursing team. It said it had made the referral and shared information on the day it discharged Mr M.
The Walsall Trust
56. 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. We have done this and have not found any indications that something has gone seriously wrong.
57. Mr L complains the Trust's community nurse took too long to arrange and administer pain relief. The NMC Code says nurses must make sure patients’ needs are recognised, assessed and responded to. Our adviser explained there is no national directive on the time it should take the community service to visit.
58. It is not clear from the available records when the family contacted the community nursing service and how long it then took for them to arrive and administer pain relief. Mr L has explained his father complained of pain at 11am on 6 April. His GP prescribed morphine and a nurse arrived at 3pm, after his father had been in pain for four hours.
59. We can see Mr M’s records say ‘OOH [out of hours] called for pain relief’ at 9.06pm on 6 April and 7.45pm on 7 April. The palliative care team had arranged for a syringe driver to be put in place from 8 April but community nurses arranged for this to be started on the evening of 7 April.
60. Mr L also complains the Trust's community nurse did not arrange a prescription for cream to treat his father’s bedsores. He says the nurse was unaware of the bedsores until the family pointed them out. The nurse said they would write out a prescription but did not do so.
61. Section 1.1.18 of NICE CG179 says ‘Consider using a barrier preparation to prevent skin damage in adults who are at high risk of developing a moisture lesion or incontinence-associated dermatitis, as identified by skin assessment (such as those with incontinence, oedema, dry or inflamed skin).’
62. The Walsall Trust’s care plan states ‘patient/ carer advised of appropriate skin care routine’. However, this is a populated field (rather than free text) and it is not documented that nurses advised to put barrier cream on the Mr M’s sacrum. Our adviser explained barrier cream does not have to be prescribed, it can be bought over the counter. We therefore have seen no indications of a failing here.
63. However, we recognise Mr L’s experience would have been different if he had been given this information. It is clear he has concerns about a particular nurse, whose colleagues he felt provided much better care. The Trust said it would ensure the staff member involved would undergo additional training and they would have supervision with a senior nurse.
64. Overall, we have decided not to investigate the complaint further. We hope it is clear why we have reached this decision. We were sorry to hear of Mr M’s sad death and the impact this had on Mr L. We would like to thank Mr L for giving us the opportunity to consider his concerns.