21. Before we decide if we should conduct a detailed investigation of a complaint, we look if the standard of care has fallen below what we would expect to see, in line with relevant guidelines. From this, we go onto consider if there is an injustice and an impact which can be linked to the failing (we refer to this as an injustice ‘flowing’ from the event).
22. Next, we consider what the organisation has done to put matters right and if the Ombudsman considers this is enough (we refer to this as the ‘remedy’). If we can see a failing, an injustice, and impact linked and consider more needs doing, we may consider making a range of recommendations.
Wheelchair lap strap
23. Mr A complains staff did not use the lap strap on his wheelchair and so he fell out of his wheelchair.
24. In handling the complaint, we note the Trust were concerned that Mr A was more unsettled at the beginning of his hospital admission and when being nursed in a side room. Staff assessed his risk of falls and to mitigate this risk staff placed Mr A at the entrance of his room where staff could see him.
25. We can see that the Trust explain the general rule on the ward is to not use lap straps on wheelchairs as this can cause more damage if the patient tries to get out of the wheelchair for example the chair falling on top of the patient or the lap strap causing a ligature incident (a risk that the strap could become caught around a patient’s neck). It said the ward recognised his risk of falls and had implemented measures to aim to avoid this, however it said it is not possible to entirely eliminate risk and on this occasion the staff were unable to prevent the fall.
26. The medical records show Mr A had a fall from his wheelchair on 24 April at around 10.30am.
27. From the lead clinician advice, Sheffield Teaching Hospitals NHS Foundation Trust’s ‘The safe use & adjustment of lap-belts and pelvic straps on wheelchairs’ guidance and National Library of Medicine ‘Review of the use of physical restraints and lap belts with wheelchair users’, we understand lap straps are not intended to be used as restraint and are to help keep the users position and posture in the chair correct.
28. If lap straps are used as restraint to try to stop the user from getting out of the chair, then there are risks involved such as causing injury.
29. Royal College of Occupational Therapists (RCOT) ‘Care homes and equipment, guiding principles for assessment and provision’ guidance states ‘alongside an assessment of need, a full assessment of risk should be made. This defines how the right equipment will be used appropriately to enable the safe movement and care of a resident, whilst protecting both the resident and the care staff from injury.’
30. As such, informed by our lead clinician’s advice and the guidance above, we understand there is no requirement for the Trust to supply and use a lap strap unless the clinicians felt Mr A needed one of these to help his posture or positioning in the chair.
31. From the nursing clinical advice we received, we understand the medical records do not indicate staff assessed Mr A as needing a lap strap.
32. The records show staff assessed Mr A’s degree of disability and dependence following the stroke with the ‘Modified Ranking Scale for Neurologic Disability’. This scale measures the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The scale ranges from zero, no symptoms at all, to five, classified as severe disability (bedridden, incontinent, requiring constant nursing care and attention) and six, which is classified as dead.
33. The records indicate staff noted Mr A’s score as four on the scale. This is categorised as moderately severe disability, unable to walk without assistance and unable to attend to own bodily needs without assistance. The scale in the records also states patients given a score of four will need help with daily tasks such as dressing, toileting or eating and will need to be visited at least daily or live in close proximity to a carer.
34. Informed by the nursing advice, the above indicates a lap strap would not be suitable for Mr A due to risk of injury if he attempted to move himself whilst unattended.
35. We understand why Mr and Mrs A are concerned that staff did not use the lap strap on Mr A’s wheelchair, and we appreciate this was distressing for them.
36. Considering the above, we can see the Trust rightly assessed Mr A’s needs, in line with the RCOT guidance, and this assessment did not indicate staff needed to provide or use lap straps for Mr A. We have therefore seen no indication of a failing in the Trust not using lap straps, as the Trust’s assessments did not identify a clinical need for one. Therefore, as we have not been able to identify a failing we take no further action on this point.
Nutrition
37. Mr A complains the Trust did not meet his nutrition needs and as a result he lost over two stone in weight during his admission (16 March to 22 April).
38. In considering the Trust’s account we note the nursing team acknowledged that Mr A’s appetite was reduced initially, and they tried to find alternative foods that would tempt him to eat. It recognised he needed encouragement to eat, and he was prescribed nutritional supplements.
39. We can see the Trust identified an improved appetite and he was eating well by the time of discharge. It said a change to environment and physical condition for a person is likely to result in weight changes and recognised he did initially lose some weight during his admission.
40. From the records and Trust response following the prescribed supplements his weight did improve. The dietician’s assessment documented Mr A’s weight at 84.3kg on admission and on 11 April as 83.4kg.
41. We discussed these concerns and reviewed Mr A’s medical records with our specialist nursing adviser to help us understand if the Trust’s nutrition support for Mr A fell below what should happen.
42. NICE QS124 ‘Nutrition support in adults’ guidance helps us understand what should happen here. Statement one of this guidance says people in care settings are screened for the risk of malnutrition using a validated screening tool.
43. The records do not evidence staff screened Mr A for the risk of malnutrition.
44. Statement two of the guidance says people who are malnourished or at risk of malnutrition have a management care plan that aims to meet their nutritional requirements.
45. Statement three of the guidance says all people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented and communicated in writing within and between settings.
46. In line with statement two and three above, the records evidence staff identified Mr A had poor oral intake, commenced food record charts and requested input from a dietician the day after his admission (17 March). The dietician noted a plan to encourage Mr A with eating and drinking, to continue the food record charts and to weigh him.
47. Records indicate the dietician assessed Mr A again on 21 March. The dietician noted Mr A was not meeting his nutritional requirements with his current oral intake and that this would likely result in weight loss. The dietician noted a plan for staff to offer Mr A regular snacks between meals, start Fortisip compact protein (nutritional supplement) and to weigh him as soon as possible.
48. On 28 March, the dietician assessed Mr A again. The dietician noted Mr A had good tolerance of the supplements but poor intake of meals resulting in a large nutritional deficit. The dietician recommended an additional supplement for Mr A.
49. The nursing notes indicate nurses regularly encouraged Mr A to eat his meals, snacks and nutritional supplements throughout his admission.
50. As such, whilst we cannot see the Trust screened Mr A for malnutrition on admission (16 March), the records evidence staff clearly identified his poor nutritional intake the day after his admission (17 March) and had input from a dietician who communicated the plan to all staff to aim to meet Mr A’s nutritional needs, this is in line with statement two and three of the NICE guidance.
51. To reach a full and impartial view, we contacted the Trust to discuss the lack of malnutrition screening and to better understand what happened. The Trust acknowledged it did not screen Mr A for malnutrition but also recognised staff completed all actions it would expect to arise from the screening, including referral to the dietician and nutritional supplements. It said due to the passage of time, staff would not be able to provide a meaningful recollection as to why staff did not complete a malnutrition screening. It apologised that it did not complete the malnutrition screening and recognise the confusion and distress this may have caused.
52. The Trust have therefore acknowledged it did not complete malnutrition screening for Mr A. This is not in line with statement one of the NICE QS24 guidance and is a failing. As such, we need to consider the impact this. Mrs A said because of the Trust not meeting Mr A’s nutrition needs he lost over two stone in weight. She told us she was shocked, when she was allowed to visit Mr A in hospital for the first time, as she thought he had lost a lot of weight.
53. Recognising this as a considerable and sudden weight loss, we spoke to our lead clinicians to better understand the weights recorded in Mr A’s records during admission.
54. Mr A’s weight on 14 March 2022 was 84.3kg and 83.2kg on 7 April, a weight loss of 1.1kg in three and a half weeks. There is a record on 22 April stating Mr A was 84kg but this seems to be an estimate as it is not noted elsewhere so we cannot say with certainty what Mr A’s weight on his discharge on 22 April. Similarly, we have not been presented with any further evidence from Mr A showing a weight recording of his discharge weight.
55. However, from discussing the records with lead clinicians we note there is recorded evidence that Mr A was eating and drinking adequately and taking dietary supplements. Therefore, on a balance of probability where something is more likely than not to have happened, we consider form our conversation with lead clinicians and the records that it is highly unlikely that Mr A would have lost a further 11kg in the following two weeks (until his discharge) in light of his satisfactory nutritional intake being achieved.
56. Mr A was admitted to the Trust in the evening on 16 March, around 5pm. On 17 March, the day after Mr A’s admission, we can see staff identified Mr A’s poor oral intake and requested input from a dietician. The dietician reviewed Mr A on 17 March at around 4.30pm, they documented a plan to monitor and aim to meet his nutritional needs in line with statements two and three of the NICE guidance. The above indicates there was possibly one day where staff were not supporting Mr A with his nutrition.
57. With an admission of a failing and a linked injustice, we have gone onto consider the severity of the injustice, using our severity of injustice scale, and what the Trust has done to remedy matters. We also refer to the Principles of Good Complaint Handling and Principles for Remedy, which state organisations should acknowledge mistakes and apologise where appropriate and provide fair, reasonable, and proportionate remedies. We further note it is for the Ombudsman to determine what is fair and reasonable.
58. As explained above, the Trust did not screen Mr A’s risk of malnutrition and so subsequently there is possibly one day where staff were not supporting Mr A with his nutrition. This is consistent with level one on our severity of injustice scale. This is because level one injustices include annoyance, frustration, worry or inconvenience, hardship arising from a single incidence of maladministration or service failure where the effect on the individual is of short duration, and where there are no other adverse effects or ongoing wider impact. We would generally consider an apology to be an appropriate remedy for level one injustice.
59. On this occasion, if we were to investigate this matter at a detailed investigation it is likely that we would ask the Trust to apologise.
60. As set out above, the Trust have apologised for the lack of malnutrition screening and the impact this had on Mr and Mrs A and we cannot link this to Mr A losing two stone in weight. Therefore, we consider the Trust has acted fair, reasonable and proportionate against our Principles for Remedy. For this reason, we do not consider the injustice is unremedied and there would be no practical value taking these matters to a detailed investigation to achieve any further outcome.
Hydration
61. Mr A complains the Trust did not meet his hydration needs and as a result this caused him suffering, to become dehydrated on many occasions.
62. We discussed these concerns and reviewed Mr A’s medical records with our specialist nursing adviser to help us understand whether the Trust’s hydration support for Mr A fell below what should happen.
63. NICE CG174 ‘Intravenous fluid therapy in adults in hospital’ helps us understand what should happen here. This guidance sets outs principles and protocols for intravenous fluid therapy. It says the assessment and management of patients’ fluid and electrolyte needs is fundamental to good patient care.
64. 1.1.1 of this guidance states ‘Assess and manage patients’ fluid and electrolyte needs as part of every ward review. Provide intravenous (IV – through a vein) fluid therapy only for patients whose needs cannot be met by oral or enteral routes, and stop as soon as possible.’
65. The records show Mr A arrived at the Trust at round 5pm on 16 March and staff commenced monitoring his food and fluid intake through daily record charts.
66. The fluid charts on 16 March show Mr A had 200ml of a cup of tea and around 50ml of water at 9pm.
67. We reviewed Mr A’s fluid intake through his admission. From this, we can see staff were regularly monitoring Mr A’s fluid intake an output. The records show Mr A had a good amount of fluid intake (typically ranging from one to two litres), apart from on 19 and 21 March only where the records indicate he had less than one litre.
68. On 24 March, the records indicate Mr A’s blood pressure went to 72 systolic (measure of the pressure within the arteries while the heart beats) and 82 diastolic (measure of the pressure within the arteries while the heart is resting in between heartbeats). Our nursing adviser explained this is significantly low.
69. The notes show the doctor thought this was likely due to Mr A being dehydrated and intervened to prescribe him fluids to be taken IV (intravenous though a vein) for six hours. Our nursing adviser explained dehydration can cause low blood pressure due to a decrease in blood volume, and so it was appropriate for the Trust to prescribe Mr A IV fluids at this point.
70. Following this, the records show Mr A continued to maintain a good fluid intake throughout the rest of his admission. Informed by the nursing advice, this is evidenced as the records show Mr A’s blood pressure readings remained within a more normal range for the rest of his admission.
71. Considering the above, we can clearly see staff were correctly monitoring Mr A’s fluid intake, through the use of fluid record charts and where he was showing signs of dehydration staff took appropriate action to resolve this, though from the records and advice taken have not seen their actions caused him to be dehydrated.
72. In line with 1.1.1. of the NICE guidance. As such, we have seen no indications anything has gone seriously wrong in terms of the Trust managing Mr A’s hydration needs. Therefore, without an indication of failing we will take no further action.
Mental health support
73. Mr A complains the Trust did not provide him with mental health support and he explains that as a result of this failing, his mental health declined during his admission, and he became depressed.
74. The Trust said at the time of Mr A’s admission it did not have a clinical psychologist as part of the stroke rehabilitation team, but following this complaint it has since employed one.
75. On 24 March, the clinical notes indicate the doctor spoke with Mrs A about Mr A’s care and treatment. The notes indicate there were concerns (unclear who raised the concerns) regarding Mr A’s mental health, Mr A experienced anxiety before his stroke and had struggled with his mental health after leaving his previous job. The doctor noted a plan to involve the mental health team after Mr A recovered from COVID-19.
76. The clinical notes on 25 March indicate the doctor discussed liaising with the mental health team which Mr A felt was a good idea.
77. The clinical notes show the doctor planned to request mental health input for Mr A on 1 April. On 4 April the notes indicate, following a discussion, the doctors felt a mental health review was unlikely to be beneficial and suggested conservative measures. The doctors also noted Mr A was already taking trazodone (antidepressant medication).
78. As such, we sought physician clinical advice to help us understand if the Trust’s decision not to request mental health support for Mr A was appropriate and in line with what should happen.
79. NICE CG162, ‘Stroke rehabilitation in adults’, helps us understand what should happen here. The guidance includes the recommendation that clinical psychologists form part of the core multidisciplinary stroke rehabilitation team.
80. Point 1.1.2 of the guidance says and an inpatient stroke rehabilitation service should consist of a dedicated stroke rehabilitation environment, a core multidisciplinary team who have the knowledge, skills and behaviours to work in partnership with people with stroke and their families and carers to manage their changes experienced as a result of stroke, and access to other services (for example, continence advice, dietetics, orthotics, wheelchair services).
81. Point 1.5.1 of the guidance says to assess emotional functioning in the context of cognitive difficulties in people after stroke. Any intervention chosen should take into consideration the type or complexity of the person's neuropsychological presentation and relevant personal history.
82. Point 1.5.2 says support and educate people after stroke and their families and carers, in relation to emotional adjustment to stroke, recognising that psychological needs may change over time and in different settings.
83. Point 1.5.3 says when new or persisting emotional difficulties are identified at the person's 6-month or annual stroke reviews, refer them to appropriate services for detailed assessment and treatment.
84. Point 1.5.4 states to manage depression or anxiety in people after stroke who have no cognitive impairment in line with recommendations in Depression in adults with a chronic physical health problem (NICE clinical guideline 91) and Generalised anxiety disorder (NICE clinical guideline 113).
85. The Trust said at the time of Mr A’s admission it did not have a clinical psychologist as part of the stroke rehabilitation team, but following this complaint it has since employed one. However, informed by the physician advice, we understand the assessment and interventions for psychological functioning involve the wider multidisciplinary team and is not the sole responsibility of a clinical psychologist, in line with 1.1.2 of the NICE guidance.
86. The records evidence the multidisciplinary team (including medical, nursing, occupational therapy, physiotherapy, dietetics and speech and language therapy staff) assessed Mr A’s psychological functioning including cognitive, emotional and communication factors. Additionally, the clinical records evidence nurses conducted daily assessments of Mr A’s mental health including comments about his cognition, mood and communication. This is in line with point 1.5.1 of the NICE guidance.
87. The medical records, mostly the nursing and multidisciplinary documentation regarding Mr A’s emotional functioning outlines no concerns, with descriptions of Mr A as ‘bright and chatty’, ‘good mood’, ‘calm and happy’. The records do not evidence staff had concerns about his sleep.
88. On occasion the records show staff noted him to be lonely. For example, on 27 March the nursing notes state Mr A reported feeling lonely and so the nurse spent some time chatting to him and called Mrs A for him.
89. The records show during the beginning of Mr A’s admission he was isolated due to COVID-19, which appears to be associated with visiting restrictions for his family, which were subsequently lifted.
90. The records show Mr A contacted his family frequently by phone, and the multidisciplinary team recognised the value of this for Mr A and encouraged him to contact family. Staff also frequently documented Mr A enjoyed listening to music.
91. The records show staff frequently contacted Mrs A to provide support and information regarding Mr A’s care and discharge planning, in line with 1.5.2 of the NICE guidance we have referred to above.
92. The staff noted Mr A’s background of dementia, anxiety and depression. The records show Mr A was prescribed medication use to treat anxiety and depression (trazodone) and dementia (donepezil) before this admission. Staff reviewed these medications and continued to prescribe these.
93. We recognise Mr and Mrs A’s concern about the lack of mental health support, and we do not wish to underestimate how distressing the admission was for both of them, given the seriousness of Mr A’s condition.
94. Considering the physician clinical advice and medical records, we can see staff correctly assessed Mr A’s psychological functioning, and this was performed regularly, in line with the NICE guidance. These assessments largely indicate staff reached a clinical view they did not have new concerns over Mr A’s mental health. For this reason, and informed by the physician clinical advice, the Trust did not need to review or change his treatment for mental health that was already in place before his admission.
95. On this basis, we have seen no indication anything went seriously wrong here.
96. We recognise these have been very upsetting and distressing times for Mr and Mrs A. In being an independent an impartial organisation, we must reach robust decisions based on our investigations and we hope our findings reassure Mr and Mrs A we have not identified any failings in the care complained about, other than the lack of nutritional screening which we consider the Trust have done enough to remedy this. This concludes our statement. We hope we have explained our decision clearly and we would like Mr A for bringing his complaint to us, with the help of Mrs A.