Mid Yorkshire Teaching NHS Trust

6. Mrs C complains about aspects of the care and treatment her father, Mr D, received from the Trust from his admission to hospital on 14 January 2022 until his death on 9 March 2022. She also complains about the Trust’s administrative actions. She says: • Trust staff communication with her and her family was poor during Mr D’s inpatient admission, and the Trust delayed referring Mr D to the complex needs team.

• Trust staff failed to use Mr D’s CPAP machine during the initial part of his hospital admission, from 14-26 January 2022.

• The standard of nursing care was poor, and Mr D was neglected by Trust staff.

• The Trust delayed responding to Mrs C’s complaint, and its complaint response did not fully address her concerns.

7. Mrs C says the Trust’s delay in referring her father to the complex needs team left him without the support needed to meet his communication and care needs. Mrs C told us she believes this was distressing for her father, who had dementia and was left on his own in the hospital without the ability to understand what was happening.

8. Mrs C says the nursing care Mr D received from the Trust left him with a lack of dignity at the end of his life. She says he was left in discomfort, as he developed pressure sores. She believes the poor standard of nursing care caused Mr D to develop endocarditis, which was the cause of his death.

9. Mrs C also says the Trust’s communication and delay in referring her father to the complex needs team left her family unable to visit her father in hospital towards the end of his life. Mrs C says this has worsened her and her mothers’ bereavement. She also says the Trust’s communication and complaint handling added to her distress.

10. Mrs C would like the Trust to provide an apology, service improvements, and financial compensation as a resolution to her complaint.

11. Mr D was admitted to the Trust’s emergency department on 14 January 2022 after he experienced three ‘episodes’ in which he appeared ‘vacant’ and ‘unresponsive’. At the time of his admission, he was 86 years old and he had dementia, with fluctuating mental capacity. He needed support with communication and activities of daily living. He lived with his wife, Mrs D, who was his carer.

12. The Trust diagnosed Mr D with pneumonia, and staff suspected this was the cause of his ‘vacant’ episodes. They treated Mr D with meropenem (a type of antibiotic).

13. Mr D had a history of myelodysplasia (a condition in which a person does not have enough healthy red blood cells). This condition impacts a person’s immune system and leaves them more vulnerable to infections. He also had sleep apnoea, type 2 diabetes, and a metal heart valve. Mr D had regular blood transfusions, took a blood thinning medication, and used a CPAP machine every night.

14. When he was admitted for inpatient treatment, the Trust told Mr D’s family that he had a ‘guarded prognosis’. This means there was not enough information to know what the outcome of his illness would be. Trust staff also said there was a high risk that Mr D would not survive the ‘episodes’ he experienced because he was very frail.

15. Mr D’s infection responded to antibiotic treatment, and the Trust started to make plans to discharge him in early February.

16. Mr D became unwell again in February, which meant he could no longer go home. His blood tests from 10 February 2022 showed that he had an infection called ‘vancomycin resistant enterococcus’. The Trust diagnosed Mr D with endocarditis (an infection of the heart valve) on 17 February 2022.

17. Trust staff treated Mr D with antibiotics, and his heart scans from 22 February 2022 indicated that his endocarditis was responding to treatment.

18. On 22 February 2022, a member of the Trust’s complex needs team contacted Mrs C and her mother. They said Mr D should have been referred to their team when he was first admitted to hospital, and they started working with Mrs D to develop a personalised care ‘passport’ for him.

19. Although he showed signs of improvement in late February and early March, Mr D then deteriorated very quickly, and he died on 9 March 2022. The Trust’s medical examiner found that endocarditis was the primary cause of his death.

Communication and referral to complex needs team 23. Mrs C says Trust staff did not communicate well with her family, and that they delayed referring her father to the complex needs team.

24. To assess this part of Mrs C’s complaint, we reviewed what she told us about her experience with Trust staff. We also reviewed the Trust’s complaint file, as well as its medical and nursing records. We used our Principles of Good Administration to determine what should have happened.

25. The Trust’s complaint file shows that Mrs C contacted the complaints department to raise concerns about staff communication on 19 January, 26 January, 6 February, and 13 February 2022. She said staff did not: • update her or her mother about Mr D’s care • answer the phone on Mr D’s ward • respond to her or her mother’s requests to arrange virtual contact with Mr D • inform Mr D’s family when they moved him to a different hospital on 9 February 2022.

26. The Trust’s medical and nursing records reflect Mrs C’s concerns about staff communication. They show that staff forgot to respond to Mrs C’s requests for updates about Mr D’s care at the start of his admission, including on 20 January 2022. Trust records also show that on one occasion, staff turned Mrs C and her mother away when they tried to visit him on the ward. Mrs C says they tried to visit because they could not reach any staff on the phone.

27. Mrs C sent the Trust a formal written complaint about staff communication on 6 February 2022. She sent a further complaint after staff did not tell her or her mother about their decision to move Mr D to a different hospital on 9 February 2022.

28. The Trust responded to Mrs C’s complaints in April 2022. It explained that staff did not answer Mrs C’s calls or arrange virtual contact with Mr D due to ward clerk shortages. The Trust also acknowledged that it did not tell Mr D’s family about his hospital move. It said staff tried to call Mrs D on her home phone to tell her Mr D was moving hospitals, but she did not answer. Mrs C said there was no record of this call on her mother’s phone, and she asked why the Trust did not try her or her mother’s mobile phone instead. The Trust sent Mrs C a second complaint response in September 2022 in which it said staff did not see other phone numbers written down in Mr D’s records. It apologised for this oversight.

29. Based on this evidence, we find that aspects of the Trust’s communication with Mrs C and her mother fell short of our Principles of Good Administration, which say public bodies should communicate in a way that is sensitive to their needs.

30. The evidence we reviewed shows that the Trust’s communication caused Mrs C and her mother additional distress during a difficult time. We considered whether the Trust has done enough to address this.

31. The records we reviewed show that staff met with Mrs C’s mother, Mrs D, on 6 and 10 February 2022 to discuss concerns Mrs C and Mrs D raised about nursing care and communication. Following these discussions, staff agreed to let Mrs D visit her husband on the ward during mealtimes. We have also seen evidence that staff communication with Mr D’s family improved after he moved hospitals on 9 February 2022. The Trust’s records show that staff gave Mrs C and her mother regular updates about Mr D's care throughout February and March 2022. The Trust also acknowledged and apologised for the poor staff communication Mrs C and her mother experienced in its 7 April and 6 September 2022 complaint responses. We consider these actions to have addressed the impact that the Trust’s initial communication failings had on Mrs C and her mother.

32. In addition to her concerns about staff communication, Mrs C also complains that the Trust delayed referring her father to the complex needs team. We used the Trust’s Learning Disability and Autism Policy (Adults only) policy to assess this part of the complaint. Although Mr D did not have a learning disability or autism, the Trust told us this policy applied to him at the time of his hospitalisation because he had dementia.

33. The records we reviewed show that when Mr D was admitted to the emergency department on 14 January 2022, staff recorded that he needed support with communication and daily living activities due to his dementia. The Trust’s policy says this means he should have been referred to the complex needs team ‘as soon as possible after an admission.’ It also explains that emergency department staff should have contacted a ‘VIP team’ (the complex needs team) to determine whether Mr D needed additional nursing resources. The records we reviewed show that the complex needs team did not start working with Mr D’s family to identify which adjustments were needed to meet his support needs until 22 February 2022, which was almost 6 weeks later. This shows that the Trust failed to refer him to the complex needs team ‘as soon as possible’, as required under its policy.

34. Mrs C told us this delay caused her and her mother to lose opportunities to visit Mr D in the hospital towards the end of his life. The records we reviewed show that although Mrs C and her mother were allowed to visit Mr D at times, there was at least one occasion when Trust staff would not let them visit due to visiting restrictions on his ward. In its response to Mrs C’s complaint about this incident, the Trust confirmed that its visiting restrictions did not apply to the families of patients with complex needs. This means Mrs C and her mother should have been allowed to visit Mr D. We therefore consider it likely that Mrs C and her mother missed out on opportunities to visit him because of the Trust’s failure to follow its policy.

35. We recognise that this was upsetting for Mrs C and her mother, as Mr D was approaching the end of his life. We can see that the Trust acknowledged and apologised for this mistake in its complaint responses. The Trust also told us that since the events of Mrs C’s complaint, it has replaced its ‘Learning Disability and Autism Policy’ policy with a new ‘Complex needs’ plan, which explicitly includes people with dementia. This new policy says staff will now assess older adults for delirium and dementia within 72 hours of an inpatient hospital admission. It also says the Trust’s system will ‘flag’ patients with dementia who are assessed as needing extra support, and this will refer the patients to the complex needs team. The Trust also told us that after the events of Mrs C’s complaint, it provided ward staff with additional training on how to support patients with dementia, confusion, or delirium.

36. After careful consideration, we have decided that we do not uphold this part of Mrs C’s complaint. This is because we consider the policy change and apology enough to address the impact that its failings had on Mrs C and her mother.

Use of CPAP machine 37. Mrs C complains that Trust staff did not use her father’s CPAP machine towards the start of his hospital admission, from 14 - 26 January 2022. Mrs C says Mr D used his CPAP machine every night for over 20 years. She told us she was concerned that not using it in the hospital may have contributed to his deterioration and death.

38. To assess this part of Mrs C’s complaint, we reviewed the Trust’s records with our clinical adviser, a consultant in geriatric medicine. These records show that Mr D did not have CPAP support from 14 - 26 January 2022 because he was on a ward where staff were not trained to use CPAP machines. The Trust’s records show that the doctor responsible for Mr D’s care decided that he did not have an urgent need for CPAP support at this time. On 26 January 2022, Trust doctors decided to move Mr D to a ward where staff were trained to use the machines. The evidence we reviewed shows that staff helped Mr D use his CPAP for the rest of his admission, apart from a few nights when he refused it.

39. We reviewed the NICE Sleep Apnoea Guidelines and an NHS England Patient Safety Alert on Non-Invasive Ventilation (NIV) use to determine what should have happened. The NICE Guidelines recommend using CPAP machines (a type of non-invasive ventilation (NIV) machine) to manage patients with moderate-to-severe sleep apnoea, such as Mr D. This means Trust staff should have supported Mr D to use his CPAP machine during his inpatient admission. The NHS England patient safety alert also warns that patients face a risk of death if they use NIV machines around staff who are not trained to use them. It says this risk is particularly high for patients ‘with limited ability to summon help.’ Mr D was assessed as needing support to interact with staff. This indicates that there would have been significant risk associated with using his CPAP machine on a ward where staff were not trained in its use. Based on this information, we find that the Trust followed NICE and NHS England guidance when it decided not to use Mr D’s CPAP machine at the start of his admission.

40. Our adviser said that spending a few days without a CPAP machine would have had little impact on Mr D. This is reflected in the NICE Guidelines, which say patients with sleep apnoea will usually experience sleepiness if they do not use their machine. Our adviser said the Trust decided to move Mr D to a ward where he could use his CPAP machine after it became clear that he would be in the hospital for a longer time. This decision reflects NICE guidelines, which encourage patients with sleep apnoea to use their CPAP machines consistently.

41. We therefore do not uphold this part of Mrs C’s complaint, as the evidence we reviewed shows that the Trust followed the relevant guidelines on CPAP machine use.

Standard of Nursing Care 42. Mrs C says her father received a poor standard of nursing care. She says he had little support with his hygiene needs, and that he was left alone in a side room in an unhygienic condition without any stimulation or supervision. She told us this left him with a lack of dignity at the end of his life. Mr D developed skin damage and endocarditis during his hospitalisation, and Mrs C told us she believed this was a caused by the poor nursing care he received from the Trust.

43. To assess this part of Mrs C’s complaint, we reviewed the complaints she sent the Trust, the Trust’s responses, our conversations with Mrs C, and the Trust’s medical and nursing records. We used the NMC Code to determine what should have happened.

44. Mrs C sent the Trust a complaint on 6 February 2022 in which she said: • Mr D was left alone in his hospital bed without supervision or stimulation • he was not washed • rotting food was left around his bedside.

45. This is reflected in the Trust’s medical and nursing records. For example, nursing notes from 6 February 2022 say Mrs D told staff she found Mr D in soiled bedsheets when she visited him on the ward, as he had not been cleaned or changed after being incontinent of urine and faeces. The Trust acknowledged that there were shortcomings in Mr D’s nursing care in its 13 April 2022 complaint response. It recognised that there were ‘issues around food being left [around Mr C’s bed] after it had gone off, supporting him with his meals, cleaning under his nails, and cleaning his teeth.’ The Trust told Mrs C that following a meeting in which nursing staff met the family to discuss their concerns about Mr D's nursing care, ‘an email has been sent to all staff reiterating that the lack of basic care and communication is unacceptable and with not be tolerated.’

46. The NMC Code says nurses and nursing assistants must ‘deliver the fundamentals of care effectively.’ It explains that this includes ‘nutrition, hydration, bladder, and bowel care…[and] making sure that those receiving care are kept in clean and hygienic conditions.’ The evidence we reviewed shows that the Trust has already acknowledged that aspects of Mr D’s nursing care fell below these standards.

47. The Trust’s medical and nursing records also include the following information about skin damage Mr D developed during his inpatient admission: • SSKIN charts (documents used to record a patient’s skin conditions) filled out by Trust staff say Mr D did not have any skin damage on 27 or 28 January 2022, but that he developed a ‘moisture tear’ on his natal cleft (skin damage in between his buttocks) on 29 January 2022 • Trust pressure ulcer risk assessment documents say staff identified a ‘category 2’ pressure ulcer between Mr D’s buttocks on 11 February 2022 • our nursing adviser reviewed the Trust’s medical photography and told us it shows a moisture lesion between Mr D’s buttocks (a type of skin damage caused by too much moisture in an area, usually around skin folds).

48. Our nursing adviser said the Trust’s records indicate that staff incorrectly recorded Mr D’s moisture lesion as a ‘pressure sore’ (a different type of skin damage which occurs on a bony part of a patient’s body after they have been in a single position for a long period of time). This is a common misdiagnosis: NICE published a ‘clinical knowledge summary’ on pressure ulcers which says moisture lesions are a differential diagnosis for pressure ulcers. This means the two conditions share similar features.

49. We used the NICE Pressure ulcer guidelines to determine how the Trust should have responded to Mr D’s skin damage. It says staff should use barrier products ‘to prevent skin damage in adults who are at high risk of developing a moisture lesion or incontinence-associated dermatitis.’ Our nursing adviser said Mr D experienced increasing levels of urinary and faecal incontinence throughout his stay in the hospital. This indicates that staff should have used barrier products on his skin, as he was at risk of developing moisture lesions.

50. The records we reviewed show that Trust staff first identified Mr D’s moisture lesion on 29 January 2022. The records also show that at first, Trust staff followed NICE guidelines and applied barrier cream to the affected area.

51. We have also seen evidence that nursing staff stopped using barrier products on Mr D’s skin. Mr D’s SSKIN chart from 29 January 2022 says staff applied barrier creams every 3 hours. In contrast, his SSKIN chart from 16 February 2022 says no barrier products were being used. The records we reviewed show that in this period of time, Mr D’s skin damage became more severe, and ward staff asked a specialist Tissue Viability Nurse (TVN) for advice. The TVN assessed Mr D on 14 February 2022 and recommended using barrier products on Mr D. Despite this advice, the Trust’s records show that ward staff did not start using barrier products again until 24 February 2022, which was ten days after the TVN’s recommendation. Based on this evidence, we find that nursing staff failed to follow NICE Guidelines in their response to Mr D’s skin damage.

52. Mrs C told us she believes these failings caused Mr D to develop pressure sores. Based on the evidence we reviewed, we consider it more likely than not that Mr D developed skin damage as a result of the failings we have found in the nursing care he received from the Trust. Our nursing adviser agreed with this assessment. We acknowledge that Miss C says Mr D developed pressure sores, while our adviser says he developed a moisture lesion. The evidence we reviewed shows that this is because the Trust mislabelled Mr D’s skin damage, and Mrs C based her complaint on this incorrect information.

53. Mrs C told us her father’s skin damage caused him to experience a lack of dignity, and to ‘wince’ in pain. Based on the medical photography we reviewed, we agree that Mr D’s skin damage would likely have been painful. We also acknowledge that Mr D’s moisture lesion was in a sensitive area, which would have impacted his dignity. We recognise that it was very upsetting for Mrs C and her mother to see Mr D in this condition.

54. Mrs C told us she was concerned that the failings in Mr D’s nursing care may have caused him to develop endocarditis, which was his cause of death. We discussed this with one of our clinical advisers, a consultant in geriatric medicine. They said Mr D was very frail at the time of his admission, as he had a weakened immune system and a synthetic heart valve. This increased his risk of endocarditis. Our adviser said that because of these health factors, they could not link Mr D’s endocarditis to the failings we have found in his nursing care.

55. We recognise that the Trust acknowledged and apologised for some aspects of Mr D’s nursing care in its 13 April 2022 complaint response. Specifically, the Trust apologised for the fact that Mr D was left alone in a side room with rotting food near him, and it recognised that he did not receive enough support with his hygiene needs.

56. We have also seen evidence that the Trust took steps to address these failings. The records we have reviewed show that Mr D’s nursing care improved after he moved to a different hospital ward and received input from the complex needs team.

57. We have not seen evidence that the Trust has acknowledged a link between its nursing care and the skin damage Mr D developed, or the impact this had on Mr D. We also have not seen evidence that the Trust acknowledged the impact that witnessing this had on Mrs C and her mother. We therefore partly uphold this part of Mrs C’s complaint.

Complaint handling 58. Mrs C says the Trust delayed responding to her complaint, and that its responses did not fully address her concerns.

59. Ms C raised concerns about staff communication and her father’s nursing care with the Trust’s complaints department throughout January and February 2022. The Trust formally responded to Mrs C’s complaint on 13 April 2022. Mrs C was not happy with this response, and she told us she phoned the Trust to try to discuss her concerns in more detail, but nobody returned her calls. This is reflected in the Trust’s complaint file. Mrs C sent the Trust a written follow-up complaint on 5 June 2022 in which she raised further concerns about clinical care and communication. She also asked the Trust to explain how her father died from endocarditis when he had been admitted with pneumonia. The Trust responded on 6 September 2022 and offered further apologies for its communication. It did not explain how Mr D developed endocarditis.

60. Our NHS Complaint Standards say organisations should ‘openly welcome complaints so they can identify and resolve issues quickly.’ Our standards also explain that staff responsible for complaint handling should ‘make sure people are being listened to.’ They add that complaint responses should clearly explain what happened in a complaint.

61. We consider the Trust’s complaint handling to have fallen short of our standards. The Trust’s records show that staff did not return Mrs C’s calls. This means they missed opportunities to help her feel listened to and resolve her concerns. Furthermore, the Trust’s second complaint response does not answer Mrs C’s questions about her father’s cause of death. This shows that the Trust failed to follow our standards’ requirement to clearly explain what happened in her complaint.

62. Mrs C told us that these failings prevented her from resolving her concerns about her father’s care in a timely manner, which prolonged her distress. We recognise that the Trust’s complaint handling caused Mrs C further distress during an already upsetting time. We therefore uphold this part of her complaint.

1. Mrs C complains about aspects of the care and treatment her father, Mr D, received from Mid Yorkshire Teaching NHS Trust (the Trust) from January to March 2022. She also complains about the Trust’s communication and complaint handling.

2. We partly uphold Mrs C’s complaint about the nursing care her father received from the Trust. The evidence we reviewed shows that there were failings in the Trust’s nursing care which caused Mr D to experience pain, discomfort, and a lack of dignity at the end of his life. We recognise that this was very upsetting for his family to witness. The evidence we reviewed did not show a link between these nursing failings and Mr D’s death from endocarditis in March 2022.

3. We do not uphold Mrs C’s complaint about the Trust’s use of Mr D’s CPAP machine (continuous positive airway pressure - a breathing support machine) because we did not find any failings in this part of the care he received from the Trust. We also do not uphold Mrs C’s complaint about the Trust’s communication. This is because although we found some failings in the Trust’s communication with Mrs C and her mother, the evidence we reviewed shows that the Trust has already done enough to address them.

4. We uphold Mrs C’s complaint about the Trust’s complaint handling. We found that the Trust’s complaint handling fell short of our NHS complaint standards, and that this added to Mrs C’s distress during an already difficult time.

5. As a remedy to Mrs C’s complaint, we recommend that the Trust: • send Mrs C a written acknowledgement and apology for the failings we found in Mr D’s nursing care and the Trust’s complaint handling.

• explain what it has done, or will do, to address these failings.

• pay a financial remedy of £750 to recognise the distress Mrs C experienced as a result of the failings we found.

63. In considering our recommendations, we have referred to the ‘NHS complaint standards.’ The Complaint Standards support organisations to provide a quicker, simpler and more streamlined complaint handling service. They have a strong focus on: • early resolution by empowered and well-trained people • all staff, particularly senior staff, regularly reviewing what learning can be taken from complaints • how all staff, particularly senior staff, should use this learning to improve services.

64. In line with these standards, we recommend the Trust: • write to Mrs C within one month this report to acknowledge and apologise for the failings we found in the Trust’s nursing care and complaint handling, as well as the impact that these failings had on Mrs C and her family.

• explain what it has done to prevent these failings from happening again. The Trust should share evidence of this with us, Mrs C, and the CQC within 3 months of this report.

65. We also recommend financial compensation in recognition of the impact that the failings in the Trust’s nursing care and complaint-handling had on Mrs C and her family. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that the Trust should pay Mrs C £750 within one month of this report.