Testing at Hospital A and Mrs L’s discharge
23. In its complaint process, the Trust disputed the account Mr L gave about Mrs L not being able to walk at the time Hospital A’s staff discharged her from the ED around 6pm.
24. The Trust said staff X-rayed the hip she reported pain in following her fall, and this showed she had not broken anything. It added she had a full range of movement in that leg. Because staff saw no concerns with her mobility, and her X-ray showed no fracture, they considered they could safely send her home.
25. We found staff did not do all the tests they should have to investigate Mrs L’s suspected hip fracture and they failed to find it.
26. When Mrs L arrived at the ED, her records show staff asked radiologists to X-ray her right hip. This was because she fell at home and reported she injured her hip. ED staff noted they suspected a fracture.
27. Section 1.1.1 in NICE Guideline 124 says an X-ray is an appropriate test to do to check for a suspected hip fracture. If the X-ray does not show a fracture, but staff have clinical suspicion the patient may have one, they should do an MRI scan to check this. If MRI scan facilities are not available within 24 hours, or there is any other reason not to do an MRI scan, staff should consider doing a CT scan.
28. Based on Mrs L’s presentation, and staff suspecting a hip fracture, they acted in line with NICE Guideline 124 by asking radiologists to X-ray her hip.
29. Our radiologist reviewed her X-ray. They saw evidence of a fracture. However, this was not obvious from the image, and they said staff could easily have missed it.
30. Section four of the Radiology Discrepancy Guidance says radiology discrepancies can occur, and they are not all errors. It gives a range of causes for discrepancies. This can include how radiologists perceive images. It may be that a finding is identifiable from the image, but the radiologist missed it. The Radiology Discrepancy Guidance says there are no objective benchmarks for acceptable levels of observation.
31. Considering our radiologist’s advice, we recognise Mrs L’s fracture was difficult to see. The Radiology Discrepancy Guidance acknowledges events like this are not errors. For these reasons, we did not see the reporting of the Xray fell so far short of what should have happened that we considered it a failing.
32. That said, NICE Guideline 124 says staff need to do either an MRI or CT scan when an Xray does not show a fracture, but clinicians suspect one.
33. Our radiologist said the decision whether to do further scans on Mrs L should have been based on the suspicion clinical staff had about how likely a fracture was. The clinicians coordinating her care needed to decide what further tests to do to investigate her injury based on their assessments on her condition.
34. Good Medical Practice gives more guidance on how clinicians should assess patients. Section 15 says, to provide good care, if staff assess, diagnose, or treat patients, they must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations, or treatment where necessary.
35. Regarding taking account of a patient’s history and condition in the context of a fall, our ED adviser said, collectively, the BMJ Best Practice, the Oxford Handbook, and the BMJ Journals Guidance gives further instruction on what staff should do.
36. These guidelines say staff should obtain information about the circumstances of someone’s fall. They should consider whether any medical conditions or a patient’s medications influenced their fall.
37. Staff should try and find out whether they have a history of previous falls and any social circumstances that might contribute to a fall. Staff should ask about how the patient’s symptoms have progressed since their fall. For example, how any pain or swelling has progressed. Staff should ask about the patient’s ability to weight bear before and since their fall.
38. The history ED staff recorded in Mrs L’s ED records said, ‘fall injury at home, no head injury, rt (right) hip injury’. Staff also noted she tripped over a wire, and she did not collapse due to a specific medical condition. That said, we did not see staff gathered information about the factors we explained in paragraph 37.
39. As an older patient, the Holistic Assessment Guidance says staff should have done a holistic assessment on Mrs L to consider wider health factors that may have contributed to her fall.
40. Our ED adviser said this should have included an assessment of her cardio-respiratory system beyond the simple comment the doctor coordinating her care noted that she had ‘normal bp, pulse, res, sat’. This meant the doctor considered Mrs L had normal blood pressure, heart rate, breathing rate, and oxygen saturation levels at the time.
41. Our ED adviser said the doctor should have examined her neurological system beyond the comment they made that Mrs L was ‘alert orientated to her age’ when they saw her.
42. Regarding cardio-respiratory assessments, the Examination Guidance says the doctor should have looked and listened to Mrs L’s lungs to check for any respiratory distress. For example, any breathlessness at rest and when moving, and the ability to speak in full sentences. They should have checked her temperature.
43. Regarding neurological examinations, the Examination Guidance says the doctor should have examined her speech, cranial nerves, sensory system, and her motor system.
44. Regarding examining Mrs L’s hip injury, the guidelines we set out in paragraph 35 explain what staff should do to physically examine any limb injury. Staff should follow the ‘look, feel, move’ principles.
45. The doctor assessing Mrs L noted she had a full range of movement in her right hip, knee, and limbs. However, her notes do not record the doctor looked at her hip, for example, for any bruising or swelling. Her notes do not show they felt her hip for any tenderness.
46. When her X-ray results came back after their assessment, the doctor said her X-ray reported no fracture. On this basis, they decided to send her home with no further tests.
47. We also saw, elsewhere in Mrs L’s ED records, a nurse noted she was not able to fully weight bear since her fall. We consider this gives compelling evidence Mrs L was struggling to walk and could not fully bear her weight. The doctor’s entry contains no reference to this, or that they assessed this.
48. Our ED adviser said this factor, even though her X-ray reported no fracture, indicated staff should have considered further investigations to rule out an occult (hidden) fracture. The Occult Fracture Guidance says these kinds of fractures are not often visible on X-rays. Therefore, a patient may need more detailed imaging like an MRI scan to identify a fracture.
49. Our ED adviser said Mrs L’s inability to weight bear should have made the doctor consider the possibility of an occult fracture. Had they done an assessment in line with the guidelines we referred to in paragraphs 35 to 37, our ED adviser added the doctor was likely to have gathered more evidence to help them appreciate the full extent of her injury.
50. However, even with the limited assessment staff did, our ED adviser said there was clinical evidence suggesting an occult fracture which staff should have taken further action to investigate. As we explained in paragraph 32, in these circumstances, NICE Guideline 124 says staff should have arranged either an MRI scan, or failing that, a CT scan.
51. Had staff done these further scans, we concluded it is more likely than not they would have found the fracture.
52. Our radiologist saw evidence of the fracture from the X-ray. The Occult Fracture Guidance says X-rays are the type of images where fractures are most likely not visible. Where staff cannot see fractures in X-rays, MRI and CT scans can confirm a fracture.
53. So, had staff done the more detailed imaging tests to look for a fracture our radiologist saw in the X-ray, we considered it is likely they would have seen it in these further tests. On this basis, because staff did not do the tests these guidelines indicate, we concluded they should have found Mrs L’s hip fracture, and they failed to.
54. Moving on to the Trust’s assessment of Mrs L’s mobility and ability to cope at home, we found staff did not act in line with guidelines here.
55. As we have already explained, staff did not take all the steps they should have to assess her condition (and rule out an occult hip fracture) and what treatment and support she might need. Going further, sections 25 to 27 of the ED Patient Care Guidance emphasise staff need to give a holistic consideration to the discharge of a patient from the ED. Our ED adviser said this is particularly important in older patients.
56. The ED Patient Care Guidance says staff should assess a patient’s functional ability, and whether they need additional support at home. Mrs L’s records show no evidence of staff in the ED assessing these things. Our ED adviser said, given these omissions, the Trust’s discharge process was not in line with what they would expect to see.
57. Considering the above, we did not see staff assessed Mrs L’s mobility and ability to care for herself, and any support she needed at home for this when they discharged her.
58. Given staff recorded Mrs L could not fully weight bear, we consider this would have a significant impact on her functional ability at home. We saw how this meant, given the lack of support staff arranged, this made sending her home unsafe.
59. We appreciate Mr L described the impacts these events had. Chiefly, what happened because staff missed the opportunity to start treating his mother’s hip fracture. We considered this further from paragraph 102. This follows our consideration on whether staff at Hospital B acted in line with guidelines when they discharged Mrs L.
Mrs L’s discharge from Hospital B
60. In his complaint to the Trust, Mr L noted staff at Hospital B had to wheel Mrs L to the toilet and she could not mobilise alone during her admission. He disputed observations doctors made before her discharge she was using her walking frame on the ward.
61. Mr L added his mother’s bathroom at home was upstairs. As she lived alone, with only a stairlift to help her, she had to be mobile enough to cope with this before staff sent her home. Whether she was medically fit to leave hospital was separate to her mobility, which he said was the issue.
62. In its complaint process, the Trust said, on 13 March, cardiology staff assessed Mrs L as medically fit for discharge. Inpatient therapy staff assessed her mobility on 14 March. They noted she could mobilise ten meters on her walking frame, and she could move on and off a chair and the toilet. They noted she needed some support with bed transfers. Therefore, they ordered her a bed loop to use at home.
63. The Trust said staff did not do a stair assessment because Mrs L showed she could transfer from a chair to a standing position. Therefore, staff considered she would be able to use her stairlift. The Trust added, following a discussion with Mrs L, staff agreed to arrange for a local care provider to give her short-term support with daily living activities to help her after her discharge.
64. In comments it sent us during our investigation, after the therapist’s assessment on 14 March, the Trust said its nursing staff supported Mrs L with activities of daily living. Nurses did not see or raise concerns about her performing these activities.
65. The Trust said, while nurses should have documented these events, they did carry out ongoing reviews. It added staff would have escalated any concerns if they felt Mrs L’s abilities changed or they had concerns about her discharge before she went home.
66. We saw two parts to Mr L’s complaint on this matter. First, that the Trust’s staff did not properly assess Mrs L’s mobility and ability to care for herself at home. Second, that staff were wrong in deciding to send her home.
67. In both areas, we found staff did not act in line with guidelines. We explain this in more detail starting with how staff assessed Mrs L’s abilities and mobility in paragraphs 68 to 93. In paragraphs 94 to 101, we give our findings about the Trust’s decision to send Mrs L home.
68. Section one of CQC’s Transfer Guidance says effective transfers of care is more than discharging a patient from hospital in a timely way. Staff need to assess a patient’s needs so they arrange the right care to meet these needs. Staff need to work with other services to ensure when the patient moves out of a hospital setting, they have the right care in place to meet their needs.
69. Section three of the Trust’s Inpatient Discharge Guidance says hospital staff must assess a patient’s readiness for discharge and consider their physiological, social, functional, and psychological factors. Staff should do this in a multidisciplinary way.
70. Section 1.4 in NICE Guideline 27 also recommends multidisciplinary assessments like this which staff should document. At each shift handover and ward round, staff should review and update the patient’s progress towards their discharge from hospital.
71. To act in line with all this, our physician said they would expect medical or therapy staff to have assessed Mrs L’s ability to mobilise and perform daily living tasks during discharge planning. They would also expect staff to reassess her abilities daily during discharge planning up until the day staff discharged her.
72. As we set out in paragraph 62, Mrs L’s records show the Trust’s cardiologists reviewed her during her admission. They linked her collapse and hospital admission on 11 March to her taking her glyceryl trinitrate (GTN) spray (we explain what happened when she took her GTN spray in more detail in paragraph 113). On this basis, when the cardiologists saw her, they considered she was medically fit to go home.
73. Following that, the Trust did a physiotherapy assessment at 1.40pm on 14 March. We saw this assessment contained the observations we set out in paragraphs 62 and 63.
74. Our physician said this assessment noted how mobile Mrs L was at the time, and the physiotherapist considered the support she may need at home. Our physician said the physiotherapist assessed the factors the Trust’s Inpatient Discharge Guidance says they should have.
75. This included the physiological and functional assessments about her mobility and ability to do daily tasks like washing. The physiotherapist noted Mrs L engaged positively with the assessment.
76. They noted what she told them about her social situation. For example, about living alone, but having friends and family who were able to assist her with things at home when required. They also noted her description about her house and the equipment she already had in it. For example, her stairlift.
77. This assessment informed actions the physiotherapist then took regarding ordering equipment and the referrals they made.
78. From this point, our physician said staff did not reassess Mrs L’s ability to perform daily living tasks.
79. We saw the same physiotherapist saw Mrs L on 15 March. They documented the local care provider agreed to support her at home, and it would commence this support from the evening of 16 March. Therefore, the physiotherapist aimed to get Mrs L home when this support started.
80. They noted the equipment they ordered was due to arrive at her house earlier on 16 March. They also noted her neighbour could provide staff access to her house for the delivery. They said they made the Trust’s nursing staff and Mrs L aware of all this. The assessment did not reassess her abilities. The physiotherapist did not see Mrs L the next day.
81. Our physician said they would expect to see daily nursing and medical documentation where staff assessed Mrs L’s mobility during the days leading to her discharge. However, they could not see documentation like this in her records.
82. They added reassessing a patient’s abilities daily is important because they can fluctuate or deteriorate. This may mean their needs change.
83. We recognise the Trust told us staff reassessed Mrs L’s abilities, but they did not record their reviews on this. We appreciate Mr L considers staff did not properly assess her abilities. Noting these conflicting accounts and the lack of documentary evidence about what happened, we reviewed the other available evidence to reach a view on the balance of probabilities on whether staff reassessed Mrs L’s abilities after 14 March.
84. As we explain in further detail in paragraphs 119 to 122, in the care provider’s records, we saw staff documented their visits to Mrs L at home from 16 March. This recorded how immobile she was, that she could not complete transfers, and Mrs L said the Trust’s staff did not assess her mobility prior to discharging her from the ward.
85. We considered this is compelling documentary evidence from the time of the events indicating the Trust’s staff did not reassess her abilities. Given the evidence of Mrs L’s immobility so close to the time she had been in hospital, we consider, had staff reassessed her abilities after 14 March, they would have noticed this before her discharge.
86. We also saw a pressure ulcer risk assessment nursing staff did at 3.57am on 16 March. While not an assessment on her ability with daily living tasks and mobility, the Trust’s nurse recorded her mobility status at the time as part of their pressure ulcer assessment.
87. The nurse noted Mrs L needed the ‘help of another person to walk or move’. She spent ‘all or (the) majority of time in bed or (a) chair’. Regarding the frequency of her position changes, the nurse noted she moved ‘occasionally’. They also recorded the extent of her independent movement. They noted she could manage ‘slight position changes’ on her own.
88. We also noted the Trust’s account about what happened which we set out in paragraph 64 and 65 differed relative to what it said in its responses to Mr L’s complaint. During its complaint process, it said staff did no further reassessments because they considered Mrs L was independently mobile on 14 March.
89. The Trust’s account here is inconsistent. The evidence we referred to above suggests what it said during its complaint process is more accurate.
90. We also saw, in the Trust’s responses to Mr L’s complaint, despite the observations of its physiotherapist, it said there were times staff had to take Mrs L to the bathroom in a wheelchair at night. Our physician said this evidence of fluctuation/deterioration in her mobility should also have prompted staff to reassess her abilities.
91. Weighing this evidence, we considered it showed deterioration in Mrs L’s functions following her 14 March assessment, and staff did not reassess her abilities after that assessment and act on this deterioration.
92. On this basis, having reviewed the evidence and advice, we concluded staff did an initial assessment on Mrs L’s discharge readiness which considered the factors the guidelines we refer to recommend.
93. However, staff did not do the reassessments they should have in the days leading up to her discharge. This means, during the Trust’s discharge process, staff did not assess her mobility and ability to care for herself at home in line with guidelines.
94. We also found the Trust’s decision to send Mrs L home was not in line with guidelines.
95. Mrs L’s records from the time of her discharge, including her discharge summary, noted she was still in discomfort around the site of her hip injury following her fall on 11 March. Staff also noted her X-ray which did not show a break or fracture.
96. Our physician said these were unresolving clinical signs indicating a hip fracture. On this basis, staff should have suspected an injury like this despite the previous X-ray findings.
97. In these circumstances, section 1.1.1 in NICE Guideline 124 says staff should have conducted more detailed tests like an MRI or CT scan.
98. For the reasons we set out in paragraphs 51 to 53, we saw the more detailed tests would have identified her hip fracture. Had this happened, NICE Guideline 124 says staff should have considered surgery to treat the fracture either on the same day or the day after.
99. Notably, this happened from 21 March when staff readmitted Mrs L to hospital, and they did repeat tests to investigate her pain. However, our physician said staff should have done this during her 11 to 16 March admission. This would have meant, rather than going home on 16 March, she should have been in hospital recovering from surgery.
100. Having reviewed this evidence and advice, we found the Trust did not act in line with guidelines in deciding to send Mrs L home on 16 March. She should have remained in hospital to receive treatment for her hip fracture.
101. We hope we have clearly explained our findings and why staff did not act in line with guidelines. Below, we carefully considered the impacts Mr L said these events had.
Impacts
102. We found the impact Mr L described in paragraph three links to staff not doing the tests they should have to find Mrs L’s hip fracture.
103. Our physician said hip fractures are painful and uncomfortable for patients, even more so without treatment. Mrs L’s care records show she reported hip pain both while she was in hospital and when she was at home.
104. Had staff found Mrs L’s hip fracture, section 1.3 of NICE Guideline 124 says staff should have offered her pain medication to help manage pain associated with her fracture. Staff should have started with paracetamol. If this was not effective, staff should have offered her additional opioid pain medications. If she still reported pain, staff should have considered nerve blocks. Section 1.2 recommends surgery to aid a person’s mobility and pain.
105. Our physician said these treatments would have helped to manage Mrs L’s pain.
106. Mrs L’s records show the Trust’s staff started offering her paracetamol from 14 March. This was the pain medication they discharged her with on 16 March.
107. As we later set out in paragraph 127, her GP later prescribed an opioid pain medication (co-codamol). The care provider’s records show while this helped, she still experienced pain, and this got worse until she went back to hospital on 21 March.
108. As the Trust’s staff did not provide all the treatments we set out in paragraph 104, we consider Mrs L experienced pain which staff could have minimised until they started these treatments on 21 March. Because staff should have found her fracture on 11 March, this avoidable pain lasted ten days.
109. We found Mrs L’s collapse at home and reattendance at hospital on 11 March links to what went wrong in her discharge from the ED earlier that day.
110. The records made by the paramedics who attended her when she collapsed, and later entries from ED staff at Hospital B show she struggled to get from her son’s car into her house. When she got inside, she sat down and took her GTN spray to help with her shortness of breath after mobilising. She then lost consciousness.
111. This prompted her family to call an ambulance, and paramedics then taking Mrs L to Hospital B. Staff in its ED diagnosed myocardial infarction (NSTEMI). Our physician said this is a type of heart attack.
112. Our physician said sending Mrs L home from the ED with an undiagnosed and untreated hip fracture was likely to have caused her pain and discomfort when mobilising. They said this would have impaired her mobility and she would have had to exert herself more to move.
113. They said this exertion meant Mrs L needed to use her GTN spray. They said the spray caused the fall in her blood pressure paramedics and ED staff noted, and her low blood pressure triggered her loss of consciousness and collapse. Our physician added this may also have contributed to the heart attack staff diagnosed.
114. Having reviewed this information, we saw the decision staff made to send Mrs L home on 11 March started a chain of events which meant she collapsed, and paramedics needed to take her to hospital again.
115. Had she remained in hospital, and staff started the treatments NICE Guideline 124 recommends, we did not see she would have needed to exert herself to the point she needed to take her GTN spray. This would have avoided the problems taking the spray caused.
116. We also recognise Mrs L’s collapse and the urgent need to call paramedics would have been distressing for her and her family members. We do not underestimate how upsetting this must have been.
117. We found the omissions in the Trust’s discharge planning and its decision to discharge Mrs L on 16 March links to the impact we set out in paragraph five.
118. First, and most importantly, our physician said sending Mrs L home meant she did not receive the hip fracture treatment she needed. This is treatment staff provide in hospital. Instead, she was at home until 21 March when paramedics took her to hospital again.
119. The care provider’s records show, when its staff saw Mrs L at home the evening of 16 March, her abilities had changed since the Trust’s assessment on 14 March.
120. The member of staff who saw Mrs L noted they could not get her off her sofa without the help of other family members. They noted she could not walk, and her mobility meant it was not safe for her to use her commode without help. Mrs L also reported she had not been walking in hospital using a walking frame.
121. When the care provider’s staff saw Mrs L the next day, they also noted she was unable to complete transfers, for example, on and off seats. This included the seat of her stairlift. They noted she told them the Trust’s staff did not assess her mobility prior to discharging her from the ward.
122. We considered this is compelling evidence Mrs L’s abilities with daily tasks and her mobility deteriorated following the Trust’s 14 March assessment. Given staff did not reassess this, we concluded they missed these changes and did not plan what support she needed to manage them.
123. The care provider’s records show this meant Mrs L did not have the level of support she needed when she got home. Based on her low level of mobility, the member of staff who saw her on 16 March ‘doubled up’ her care.
124. Our physician said this meant Mrs L needed more care input than the care provider had planned based on the information it got from the Trust during its discharge process. Our physician added the care provider’s records showed the lack of reassessment and planning for her changing needs meant the Trust’s staff did not consider what equipment and home adaptations she needed for them.
125. Because Mrs L could not complete transfers, this meant she could not use her existing equipment to get to her bedroom. She could not transfer on and off the seat of her stairlift to get upstairs. Therefore, her family had to bring her bed downstairs.
126. Our physician said the increased level of input the care provider arranged meant it planned for two carers to visit her four times a day. This was the maximum level of support it could give her. Despite this, our physician said Mrs L’s family needed to provide additional input for her beyond this to support her daily living.
127. Mrs L’s GP records show her GP needed to do a pain medication review on 17 March as she reported pain which prevented her mobilising. She only had paracetamol to manage this. Her GP saw she needed stronger pain medication, and they prescribed her cocodamol.
128. Our physician said all this showed the Trust’s omissions in its discharge planning process meant staff did not identify and arrange the level of support for Mrs L’s needs. This was also in the context of staff sending her home when they should have been providing hospital level treatment to manage her hip fracture.
129. From the evidence set out from paragraph 119, we saw this meant Mrs L found it difficult to manage at home until she went back to hospital on 21 March. Members of her family, who were not registered carers, also needed to support her outside of the care provider’s visits.
130. We recognise this situation was difficult for Mrs L and the family members who supported her. The care provider’s staff also noted they were finding this difficult at the time. We do not underestimate how distressing this must have been for them.
131. We could not robustly link the delay in finding Mrs L’s hip fracture to her death. Having considered research and advice on this matter, we cannot know whether and to what extent this delay influenced her death.
132. Section 1.2.1 in NICE Guideline 124 recommends staff do surgery on a patient with a hip fracture on the day of or the day after their admission following their accident. In Mrs L’s case, the Trust delayed this by ten days.
133. The Impact of Surgery Review says up to 36% of older patients who suffer a hip fracture die within one year of the injury. Within the first three months of having surgery, there is an up to eightfold increase in the risk of dying. That said, it found patients who had surgery within 48 hours of fracturing their hip had a 20% lower risk of dying within a year.
134. Our physician said a hip fracture in an older patient with existing longterm conditions like Mrs L is a serious injury. Her records noted she had long-term conditions like atrial fibrillation, angina, high blood pressure, diabetes, and stage three kidney disease.
135. On this basis, our physician said there was a considerable risk she may have died even if she had the recommended surgery within a day of fracturing her hip. As set out in the Impact of Surgery Review, the surgery itself carried risk. Therefore, our physician said prompt surgery may not have changed what happened.
136. That said, as surgery can potentially help patients recover, they added the Trust’s delays in doing it may have contributed to Mrs L’s death. However, they could not be more definitive than that.
137. This leaves us with conflicting information about whether and how likely it was the treatment NICE Guideline 124 recommends would have prevented Mrs L’s death. We consider this information is finely balanced. Therefore, we could not conclude it is more likely than not she would have survived. That said, the research and advice indicate a possibility she may have.
138. This means, given Mrs L did not have surgery within a day of her injury, we can never know what might have happened and whether the outcome for her may have been different. We recognise this will leave Mr L with uncertainty on this matter, which understandably will be distressing for him and his family.
139. We hope we have clearly explained our findings about the impact of the events Mr L complains about. We hope our review on this assures him we gave this careful consideration.