When staff checked Mr B’s preoperative samples
20. Prior to the ureteroscopy staff scheduled for Mr B, Miss Y told us he provided a preoperative blood sample and a urine sample. She expected staff to check his samples much sooner than they did. She said staff only checked them on the Friday (10 September 2021) before his planned procedure on 14 September.
21. She added, had staff checked his samples soon after he provided them, they could have identified his urine infection earlier. Staff could then have prescribed him antibiotics to resolve his infection in time for his ureteroscopy, and they would not have needed to cancel it.
22. In its complaint process, the Trust said Mr B gave just a urine sample at its preoperative assessment clinic on 2 September. Staff had the results available from 6 September. The Trust acknowledged staff reviewed them on 10 September. When they reviewed the result, they saw they needed to postpone his surgery because of his infection.
23. The Trust said, due to the high number of day procedures it does, its normal practice is not to review samples until three days before a patient’s procedure.
24. We saw staff acted in line with guidelines on this matter.
25. Mr B’s care records confirm staff obtained just a urine sample from him. Section 1.7 in NICE Guideline 45 says a urine test is appropriate before an elective surgery if the presence of a urine infection influences whether staff can operate. Our surgeon said the presence of a urine infection would mean Mr B’s ureteroscopy could not go ahead, and this was an appropriate test to check for such an infection.
26. This means we saw staff acted in line with this guideline by obtaining just a urine sample from Mr B before his surgery.
27. NICE Guideline 45 does not specify when staff should take this sample or review the result, other than before a patient’s surgery. The purpose of the test is to check for the presence of a urine infection and whether it is safe for staff to do the patient’s procedure as planned. If they see the patient has a urine infection prior to their surgery, staff should consider postponing it.
28. Staff obtained Mr B’s urine test for this purpose and reviewed the result before his planned surgery date. This is in line with NICE Guideline 45. This means we saw no failing in the timing of staff collecting Mr B’s urine sample or when they reviewed the result.
29. Based on the result showing he had a urine infection, our surgeon said staff needed to postpone his procedure. It would not have been safe to do it until he had treatment to clear his infection.
30. We appreciate Miss Y wanted Mr B to have his surgery without delay. We are sorry to hear how worried her family were when staff postponed Mr B’s surgery.
31. We hope we have clearly explained what staff needed to do according to NICE Guideline 45. We hope this helps provide Miss Y some reassurance on this matter.
Mr B’s discharge from the Trust’s ED
32. We saw the Trust acknowledged the failings Miss Y alleged in Mr B’s ED discharge. We also saw the Trust addressed the impact of these failings in line with our Complaint Standards.
33. We use our Complaint Standards to determine our approach to securing remedy. We also have regard to what outcome(s) the person complaining wants. Our Complaint Standards say the things Miss Y wants (which we described in paragraph six) are appropriate remedies. Therefore, we checked whether the Trust provided these things during its complaint process.
34. In response to Miss Y’s complaint, the Trust said staff found Mr B had fractured his hip when he came to its ED. As staff decided against surgery, they planned to discharge him with a pain management strategy in place.
35. Having given him paracetamol and Oramorph in the ED (a liquid form of morphine), staff prescribed morphine to manage his pain at home. The Trust explained staff made an error requesting this medication for him from the pharmacy. ED staff told pharmacists they needed to deliver the morphine to Mr B.
36. They should have told pharmacists to dispense the medication immediately so he could take it home with him when he left the ED. The Trust said this error meant Mr B did not get the pain medication he needed to take following his discharge.
37. The Trust added ED staff did not assess Mr B’s circumstances before discharging him. It said they should have considered a package of care about what support he needed at home to manage with his injury. The Trust explained the ED staff overseeing his care should have sought input from orthopaedic colleagues about any treatment or support he needed. However, they did not do this.
38. The Trust acknowledged these mistakes meant staff left Mr B without adequate pain relief when he was at home. The amount of pain he was in meant he needed to return to the ED the next day. It also recognised, with no package of care planned, he and Miss Y did not cope at home with his injury. The Trust apologised about all this.
39. In the Trust’s letter to Miss Y following its later resolution meeting with her, it said it planned to share what happened in Mr B’s care as a teaching case so staff could learn from it. We contacted the Trust during our enquiries to confirm it took this action.
40. The Trust’s complaint team sent us evidence it shared details on Mr B’s case, and the failings it identified from its investigation, with its urgent and emergency care governance directorate. This was so the directorate lead could share what happened with all their staff in their next monthly staff meeting as a form of training and learning.
41. Our Complaint Standards say, to learn lessons, improve, and support their staff, organisations can:
• revise policies and procedures to stop the same thing happening again • train or supervise their staff.
42. Considering all the above, we saw the Trust gave explanations about why failings around Mr B’s ED discharge happened. It apologised about the impact Miss Y described linked to these events. It also arranged training for relevant staff to learn from what happened. This is in line with our Complaint Standards and matches the outcomes Miss Y told us she wants.
43. We recognise the Trust’s actions do not change Mr B’s experience. We do not underestimate how difficult Mr B and Miss Y found the period after his discharge.
44. We hope we have clearly explained our decision, and it assures Miss Y we only reached it after carefully considering her outcomes and the actions the Trust has taken. We also hope it provides her some reassurance the Trust has acted to learn lessons from what happened.
Updates from AMU staff
45. We saw the Trust acknowledged the failings Miss Y alleged on this matter and their impact. We also saw the Trust acted in line with our Complaint Standards to address this.
46. In her complaint to the Trust, Miss Y said she called the AMU for updates about Mr B. She added she called at certain times on the advice from staff about when nurses would be available to update her.
47. Despite following these instructions, she said she waited a long time for the AMU to answer her calls. When this happened, she then had to wait a long time for staff to find the nurse looking after Mr B and get them to come to the phone.
48. She explained, when nurses got to the phone, they repeatedly said her calls dragged them away from providing patient care. Sometimes nurses told her how many patients needed their care on the ward. She said nurses gave her little information about Mr B and instead made comments like this when she called.
49. Miss Y said she found this stressful. She accepted nurses were busy. That said, given the visiting restrictions in place, the only way she could get updates was through telephone calls with staff. She could not get updates from Mr B, who was experiencing confusion at the time. Therefore, she found what happened, and how nurses spoke to her, unacceptable.
50. Responding to Miss Y’s complaint, the Trust acknowledged how staff handled her calls. It recognised calling was the only way she could get updates about Mr B. Therefore, it appreciated the reasons for her calls and the difficulties she experienced because of the responses AMU staff gave her.
51. The Trust explained staff were under increased pressure throughout the COVID-19 pandemic. However, it expected them to be professional and compassionate when they spoke to Miss Y. The Trust apologised about the difficulties she described when she called.
52. The Trust also explained how it used Miss Y’s experience to support staff and improve. The Trust confirmed the AMU’s manager shared her complaint with the staff team working on the AMU in the team’s next governance meeting for learning.
53. In the Trust’s letter following its later resolution meeting with Miss Y, it confirmed an action plan it made. To try and improve communication with relatives, it asked ward managers within the Trust’s medicine directorate to:
• explore how wards allow relatives to raise their concerns to help clinicians gain more information/history on patients • explore ways for relatives to speak to staff on wards during non-visiting times • update the phone numbers for wards on the Trust’s website.
54. All the above is in line with our Complaint Standards. We also saw how the Trust’s action plan may help relatives in accessing information from relevant wards and staff in the future when they cannot visit the Trust’s hospital.
55. We are sorry how upsetting Miss Y found the responses she got from staff when she sought updates on Mr B’s care. We hope our review helps assure her about the actions the Trust has taken to learn from her experience and improve.
Visits to see Mr B in hospital and in the Nursing Unit
56. In her complaint to the Trust, Miss Y said she asked repeatedly to visit Mr B. She said staff had told her he was worried about her. Because he could not use his mobile phone and speak to her, he felt distressed. Miss Y said she felt this way too, and visits would have reduced this distress. Despite this, staff did not allow her to visit.
57. She noted the Trust had COVID-19 restrictions in place. However, she said staff should have had a procedure to consider visiting for more unwell and vulnerable patients.
58. Miss Y also told us the Nursing Unit applied visiting restrictions when Mr B’s son travelled from Ireland to see him. She said, ahead of his visit, staff told Mr B’s son he could see Mr B. However, when he arrived, staff did not permit him inside. Instead, staff only allowed him to see Mr B through a window.
59. In its complaint process, the Trust said it needed to restrict visiting at the time because of COVID-19. However, it acknowledged it could allow visits on compassionate grounds.
60. It said, noting Mr B had not seen his son for two years, staff should have reviewed this situation and considered whether to permit a visit. It apologised staff did not give this further consideration. It also acknowledged staff set an expectation his son could visit on the condition he provided a negative lateral flow test result.
61. However, when he arrived, staff on duty did not permit him inside on the basis they needed to restrict visiting. This meant Mr B could only see his son through a window. The Trust added its head nurse for medicine would have permitted the visit on compassionate grounds had they reviewed this situation.
62. Regarding restricting Miss Y’s visits, we saw the Trust acted in line with guidelines. This was not the case when Mr B’s son tried to visit him. That said, the Trust has taken the action we would expect to address this. We explain our decision in more detail below.
63. The Infection Prevention Recommendations say the Trust could limit visiting due to the prevalence of COVID-19. However, it could ease these restrictions dependant on the number of COVID-19 cases declining. If it did permit visitors, staff needed to follow the Trust’s standard infection control measures.
64. The Visiting Principles said the Trust could permit visits in a COVID-secure way. However, it could exercise discretion not to permit visits when COVID-19 cases were higher. This was to help prioritise the wellbeing of patients, staff, and the community.
65. Even at these times, the Visiting Principles set out exceptional circumstances when staff could allow one visitor to visit an adult patient. This included:
• when they were receiving end-of-life care • where they needed this visitor to assist their communication and/or to meet their health, emotional, religious, or spiritual care needs.
66. If staff applied exceptional circumstances, they had to plan arrangements with the visitor before their visit and give them advice on following infection prevention measures. For example, on social distancing, wearing PPE, and handwashing during their visit. If the visitor had or displayed symptoms of COVID-19 when they arrived, staff could not permit the visit.
67. We saw the Trust acknowledged it made prior arrangements like this with Mr B’s son. This included asking him to bring proof he did not have COVID-19 as a condition of his visit. However, when he arrived, the staff on duty did not permit him inside the Nursing Unit.
68. Our Principles say public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it. Having gone through the initial steps from the Visiting Principles in arranging a visit, staff did not keep to the commitment they made with Mr B’s son.
69. Regarding Miss Y’s requests to visit Mr B, we saw the Trust used the discretion the Visiting Principles allowed not to permit her to visit, in the interest of infection prevention. While Mr B was in hospital until 11 October, and while he was in the Nursing Unit, staff were not giving him end-of-life care.
70. We saw the Trust permitted Miss Y to visit Mr B on 29 September. This was at a time staff noted he was very confused. Through discussions with Miss Y, following the loss of Mr B’s mobile phone, and concerns she raised about his mental health, staff agreed a visit would help him. The Visiting Principles allowed staff to permit a visit in these circumstances.
71. Addressing what happened when Mr B’s son tried to visit, we saw the Trust explained the staff on duty at the time did not permit the visit because they believed they were required to restrict visiting. The Trust acknowledged this event was distressing for Mr B and his son, and it apologised its actions caused this distress.
72. To learn from what happened, the matron responsible for the Nursing Unit reminded staff about policies allowing visiting where there may be compassionate grounds. This is a form of staff training. We saw how this action would increase staff awareness of relevant policy and reduce the risk of them making similar mistakes again.
73. We appreciate it was distressing for Miss Y to not be able to visit Mr B as she wanted. Combined with not getting the updates she wanted about his condition, we recognise this was a worrying period for her.
74. We hope we have clearly explained our decision, and how we saw the Trust took actions in line with our Complaint Standards where it got things wrong on this matter.
Assistance to get out of bed in the Nursing Unit
75. Miss Y told us few staff working in the Nursing Unit had training with equipment to transfer patients to and from their bed. Staff trained to use this equipment did not work at weekends. She said if a patient was in their bed on Friday afternoon, staff would not assist them to get out until Monday morning.
76. This meant, over weekends, staff left Mr B in bed when he wanted to get out of bed and sit on a chair.
77. In its complaint process, the Trust said staff offered to assist Mr B out of bed during these periods. However, he often declined these offers and said he wanted to remain in bed.
78. First, we noted a conflict between what Miss Y and the Trust said about whether Mr B wanted to get out of bed. Therefore, we reviewed the other available information to try and reconcile this conflict.
79. Mr B’s care records show he could communicate his needs to staff. While in the Nursing Unit, we saw instances where he transferred in and out of bed with assistance from staff. We also saw staff recorded instances when he declined this help, he opted to remain in bed, and staff left him in bed. Staff recorded events like this throughout his stay both during the week and at weekends.
80. As entries recorded at the time by the staff looking after Mr B, we decided this is compelling evidence supporting the Trust’s account on what happened. This shows staff did support him in and out of bed. However, there were times when staff offered him assistance to get out of bed, but he did not want to. Staff respected his wishes at these times, and he remained in bed.
81. Therefore, we needed to address whether staff acted in line with guidelines by helping him out of bed when he wanted to transfer, and respecting his wishes to leave him there when he did not want to. Having considered this, we saw staff acted in line with guidelines.
82. Section one of the NMC Code says nursing staff must deliver the fundamentals of care effectively. They must provide any assistance or care for which they are responsible for without undue delay.
83. Our nurse said such care and assistance would include supporting Mr B out of bed when he wanted to transfer. As we explained above, in line with the NMC Code, Mr B’s care records show staff assisted him to transfer out of bed when he wanted to.
84. Sections two and four of the NMC Code contain guidelines about listening and responding to the preferences of patients. Staff must respect a patient’s right to refuse care or assistance. They must get consent before carrying out any action. They need to keep to relevant laws about mental capacity and apply them in their practice.
85. Section one of the Mental Capacity Act says:
• staff must assume a patient has capacity to make decisions unless they establish otherwise • staff must not treat a patient as unable to make decisions unless they have taken all practical steps to help them to do so without success • staff must not treat a patient as being unable to make a decision merely because they make an unwise decision.
86. Our nurse saw the assessments staff did found Mr B had capacity to make his own decisions. Staff noted he could clearly communicate his needs in his care records.
87. On this basis, when Mr B said he did not want to get out of bed, we saw staff acted in line with the NMC Code by respecting his right to refuse this assistance and leaving him in bed. This means we saw no failing in care on this matter.
88. We hope we have clearly explained our consideration and it reassures Miss Y staff supported Mr B out of bed when he wanted to get up. We hope our review on this matter and the other issues Miss Y raised help bring her closure on what we recognise are difficult and distressing events for her.