Discharge and care package
17. Mrs V said her mother’s discharge on 4 March was unsafe and the appropriate care package was not in place following discharge. Mrs V said her mother was discharged with COVID-19 and should have had a palliative care package and not a rehabilitative care package. Mrs V said her mother was very unwell when she arrived home and had to be readmitted to the Trust the same day. Mrs V said the Trust has since changed its process to ensure patients are seen by a doctor on the day of their discharge.
18. From the records we can see on 17 February the Trust documented it would aim for Mrs E to be discharged the next day if she improved. On 18 February the Trust documented Mrs E wanted to go home. We can see the Trust requested a PT (physiotherapist) and OT (occupational therapy) assessment. The Trust also noted Mrs E may potentially require a palliative discharge.
19. On 21 February we can see the Trust documented Mrs E reported being uncomfortable in the bed and was very keen to go home. We can see the Trust completed a referral to the palliative care team to assess Mrs E at 11.40am. At 1.50pm the palliative care team reviewed Mrs E and noted she did not have any specialist palliative care needs and for staff to contact them if this changed.
20. We can see a PT assessment took place on 22 and 23 February to assess Mrs E’s mobility. On 23 February we can see the Trust noted Mrs E was medically fit for discharge and a package of care was being put into place. We can see the OT contacted Mrs V on 25 February due to Mrs E declining an assessment.
21. The OT documented they discussed the package of care with Mrs V and documented they would order a hospital bed, pressure relief mattress, sarasteady (an aid to help the patient sit down and stand up), and slide sheets. We can see this equipment was ordered on 28 February and was due to be delivered on 2 March. A package of care had also been arranged with two carers visiting four times a day.
22. We can see Mrs E was reviewed by a doctor on 1, 2 and 3 March and it was documented on each occasion that she wanted to go home. On 2 March we can see the consultant completed a CMC referral which is a Coordinate My Care plan. In the CMC referral the Trust noted Mrs E would require a pain team review in the community and TVN (tissue viability nurse) input in the community.
23. On 3 March we can see the doctor documented Mrs E was lying comfortably in bed. We have not seen any concerns noted and the doctor requested for discharge planning to continue. We can see Mrs E’s NEWS2 scores were zero on this date. NEWS2 is a tool used to detect clinical deterioration. A score of zero would indicate there are no signs of clinical deterioration.
24. Mrs E was discharged at approximately 10.40am on 4 March. The Trust documented she had a NEWS2 score of zero prior to her discharge.
25. We have first considered whether there were any failings in when Mrs E was discharged.
26. The Government discharge policy says discharge will be organised as soon as clinically appropriate. It also says people will not be able to stay in a bed after the point where this is clinically necessary. The Government discharge policy lists the criteria to reside in hospital as:
• requiring intensive care (ICU) or the high dependency unit (HDU) • requiring oxygen therapy • NEWS2 score of 3 and above • Diminished level of consciousness • Undergone an invasive procedure or limb surgery within 24 to 72 hours
27. The UKHSA guidance on discharging COVID-19 patients says a COVID-19 patient can be discharged to their own home once their clinical status is appropriate for discharge.
28. From the evidence we have seen, we have found the Trust acted in line with the Government discharge policy and the UKHSA guidance. We can see Mrs E did not meet the criteria, as set out above, to remain as an inpatient and she was deemed medically fit for discharge. In line with the UKHSA guidance on discharging COVID-19 patients this meant she was able to be discharged to her home despite having COVID-19.
29. We can see Mrs E’s NEWS2 score was zero on the morning of her discharge. We have not seen any evidence that would suggest Mrs E had a diminished level of consciousness or that she required a higher level of care such as ICU or HDU. Our adviser said Mrs E appeared clinically stable and fit for discharge on the 4 March.
30. We have found the Trust acted in line with the Government policy on discharge and discharged Mrs E as soon as was clinically appropriate. We have found Mrs E’s discharge was not unsafe and she had been assessed as medically fit.
31. We understand Mrs E’s discharge and subsequent readmission later that day was upsetting for Mrs V. We hope the reassurance that the Trust did not discharge Mrs E unsafely will be of some comfort.
32. We will next look at the care package that the Trust discharged Mrs E with. Mrs V’s concern here is that Mrs E was discharged with a rehabilitation care package, rather than a palliative care package.
33. NICE guidance on discharge planning says many patients who are discharged from hospital will have ongoing care needs. It says this may include the use of specialised equipment at home such as a hospital type-bed. It also says this may include daily support from carers to complete activities of daily living, or regular visits from district nurses to administer medication.
34. Lastly, it says discharge needs to be planned in advance of the patient’s return home. It explains this is to ensure that there is no gap in the provision of care between the discharge from hospital and the initiation of community services.
35. From the evidence we have seen, we have found the Trust has acted in line with NICE guidance on discharge planning. We can see the Trust noted Mrs E required a bed, mattress, slide sheets and an aid to help her to stand and sit on her discharge. We can see this was delivered and in place prior to her discharge.
36. We can also see the Trust had arranged for carers to visit Mrs E four times a day. The Trust had also referred Mrs E to the tissue viability nurse and pain team to be reviewed in the community. Based on this we have found the package of care the Trust provided to Mrs E was in line with NICE guidance.
37. NMC the Code says nurses should make a timely referral to another practitioner when any action, care or treatment is required.
38. From the evidence we have seen, we have found the Trust has acted in line with NMC the Code. We can see the Trust noted Mrs E may require palliative care on her discharge. We can see the Trust referred Mrs E to the palliative care team for a review. Following review, the palliative care team documented Mrs E did not have palliative care needs and advised staff to re-refer her if needed. We have found this is in line with NMC the Code which says to refer patients to another practitioner when required.
39. Mrs V told us her mother should have been discharged with palliative input and we can understand why she thought this. We recognise there are contradictions within the medical records and the Trust’s complaint responses which imply Mrs E would receive palliative care on her discharge. We understand why this would be confusing and concerning for Mrs V when this was not then provided.
40. As explained above, Mrs E was reviewed by the palliative team who stated she did not have palliative care needs. Therefore, we think it was reasonable the Trust discharged Mrs E without palliative input. Our adviser also confirmed there was no evidence Mrs E required a palliative care package on her discharge. We have found the Trust acted in line with NICE guidance on discharge planning and NMC the Code in the referrals it completed for Mrs E.
Pressure Ulcers
41. Mrs V said her mother developed pressure ulcers to her right foot whilst an inpatient at the Trust.
42. The Trust said the Tissue Viability Nurse (TVN) reviewed Mrs E on three occasions during her inpatient stay. The Trust said the first review took place on 17 February and it was documented there was skin damage to Mrs E’s right heel. The Trust said it implemented a care plan to treat Mrs E’s heel.
43. NICE guidance on pressure ulcers says clinicians should carry out and document an assessment of pressure ulcer risk. It says if a patient has been assessed as being at risk of a pressure ulcer, then a skin assessment should be conducted.
44. It also says if a patient has been assessed at risk of developing a pressure ulcer to change their position frequently and at least every six hours. It also says to use a high specification foam mattress. It says if this is not sufficient to redistribute pressure, consider the use of a dynamic support mattress (air mattress).
45. From the records we can see the Trust used the Braden Scale, which is a tool used to predict the risk of pressure ulcers, on 13 February. Mrs E had a score of 13 which meant she was at moderate risk of developing a pressure ulcer. We can see the Trust then completed a body map the same day and noted Mrs E’s skin was intact with oedema in her legs (fluid build-up).
46. The Trust re-assessed Mrs E’s risk using the Braden Scale and body map the next day and documented Mrs E’s skin was intact but noted callouses had developed on her right heel. On 15 February we can see the Trust noted a dynamic mattress had been provided to Mrs E and it had provided pillows to elevate her feet due to the oedema.
47. On 16 February we can see the Trust documented it had identified a blister on Mrs E’s heel and the nurse in charge was made aware of this.
48. We can see the TVN performed an assessment on 17 February and documented Mrs E’s left heel was intact, but her right heel had pressure damage. It documented there was purple discolouration to the heel which was non-blanching (does not lose colour when pressed), dry and fragile. The TVN noted Mrs E’s heel would need to be kept elevated and provided repose boots. Repose boots are inflatable boots to reduce pressure damage.
49. On the 18 February we can see the Trust documented there was a DTI (deep tissue injury) to Mrs E’s right heel.
50. PMC research says DTI pressure ulcers are defined as purple or maroon localised areas of discoloured intact skin or a blood-filled blister. It says this is due to damage of underlying soft tissue from pressure. It says a DTI can occur about 24 to 72 hours between the pressure event and the onset of purple or maroon skin, with the most common timeframe of 48 hours.
51. From the evidence we have seen, we have found the Trust acted in line with NICE guidance on pressure ulcers. We can see on Mrs E’s admission to the Trust it performed a pressure ulcer risk assessment and a skin assessment. We can see the Trust noted on 13 February Mrs E’s skin was intact. We have found the Trust acted in line with NICE guidance on pressure ulcers in its assessment of Mrs E.
52. It is difficult to say whether Mrs E was admitted with pressure damage to her heel or if this occurred whilst she was an inpatient. Our adviser said the wound being classed as a DTI on 18 February would suggest the tissue damage could have occurred prior to Mrs E’s admittance.
53. The PMC research says DTIs can take up to 72 hours to develop from the pressure event. We can see on 14 February it was noted a callous had appeared on Mrs E’s heel which then developed into a blister on the 16 February, which is approximately 72 hours after her admittance. Due to this we are not able to say when the pressure damage that caused the DTI occurred.
54. We have looked at what the Trust did to reduce the risk of Mrs E developing a pressure ulcer and whether this was in line guidance. We can see the Trust was filling in daily comfort round and skin care documentation throughout Mrs E’s admission which showed it was repositioning Mrs E approximately every two hours. We have also seen the Trust provided a foam mattress on Mrs E’s admittance and pillows for her to keep her feet elevated on 15 February.
55. We can see the Trust changed Mrs E’s mattress from a foam mattress to an air mattress on 15 February. After Mrs E developed a pressure ulcer to her right ankle, we can see the Trust provided repose boots on 18 February. These are inflatable boots to reduce pressure damage. We have found this was in line with NICE guidance on pressure ulcers.
56. We understand Mrs V has raised concerns that her mother developed a pressure ulcer due to a failing in the care provided by the Trust. We can see the first instance of the pressure ulcer developing on Mrs E’s heel was reported on 15 February when the Trust noted there appeared to be ‘callouses’. We understand why this would cause Mrs V to believe the pressure damage event occurred in the Trust as this was 48 hours after her mother’s admittance.
57. As explained above, the PMC research says DTIs can take up to 72 hours to develop. This then makes it difficult for us to say when the pressure event occurred. We understand this will leave Mrs V with uncertainty on when the pressure damage occurred. We hope our findings can offer reassurance that the Trust had identified Mrs E’s risk of pressure ulcers and took the correct steps in line with guidance to reduce this risk. We understand it would have been upsetting for Mrs V to discover her mother had developed a pressure ulcer so soon into her admittance.
Moisture damage, Hygiene and Catheter
58. Mrs V said on previous admissions, the Trust had fitted her mother with a catheter. Mrs V said the Trust should have also fitted a catheter on this occasion. Mrs V has raised concerns about hygiene related issues. She said the Trust were not changing Mrs E and leaving her ‘wet’ which was not meeting her hygiene needs and caused moisture damage to her vagina.
59. The Trust said the surgical team had requested a catheter be fitted and it apologised this did not happen, and for any distress this caused. The Trust said Mrs E also developed moisture damage to her sacrum and groin. It said this can occur due to prolonged exposure to moisture such as stool, urine and sweat.
60. NMC the Code says nurses should make sure they deliver the fundamentals of care effectively and that it is delivered without undue delay.
61. We can see on Mrs E’s admission documentation dated 13 February the Trust noted she was incontinent.
62. On 15 February at 6.15am we can see the Trust noted Mrs E was given a wash in bed. At 9.15pm the Trust noted Mrs E was incontinent of urine and it had provided personal care.
63. On 16 February the Trust reported all Mrs E’s care needs had been met and she was regularly checked and repositioned. The next day we can see it was noted Mrs E’s hygiene needs were met, and the Trust had changed Mrs E’s pad due to her opening her bowels.
64. We can see on 18 February the Trust documented there was a small amount of bowel movement and Mrs E had been washed and changed. On 22 February we can see the Trust noted it changed Mrs E’s pad and washed her.
65. On 27 February the Trust documented Mrs E was incontinent and she had opened her bowels and passed urine. The Trust noted it had changed Mrs E. On 28 February, 1 March and 2 March we can see it was documented the Trust washed Mrs E.
66. We would like to make the clear the above is not an exhaustive list, but a selection of information from the records. This is to demonstrate whether the Trust was meeting Mrs E’s hygiene needs.
67. We can also see the Trust completed comfort round and skin care documentation for each day of Mrs E’s admittance. We can see the Trust noted Mrs E’s toilet needs were checked approximately every two hours, alongside checking Mrs E’s skin.
68. From the evidence we have seen, we have found the Trust acted in line with NMC the Code in the care it provided to Mrs E in relation to her hygiene needs. We can see the Trust checked Mrs E’s toilet needs approximately every two hours and it was regularly documented within the medical records when it changed her pad and provided her with an opportunity for a wash. We have found this is in line with NMC the Code which says nurses should deliver the fundamentals of care effectively and without delay.
69. We will next look at whether Mrs E should have had a catheter fitted.
70. NICE guidance on infection prevention says catheterisation should be used only after considering alternative methods of management. It says the person's clinical need for catheterisation should be reviewed regularly.
71. Our adviser said urinary catheters can assist in monitoring a patient’s fluid balance whilst receiving IV fluids. We can see on Mrs E’s presentation to the Trust she was provided IV fluids.
72. We can see on the 13 February during a doctor’s review the Trust noted it planned to insert a urinary catheter. There is no other documentation relating to a catheter.
73. We can see on 14 February the medical team reviewed Mrs E. We can see the medical team did not document the need for a catheter. Mrs E was reviewed by the medical team multiple times throughout her stay and a catheter was not documented as being required.
74. Our adviser said as the catheter had not been requested again it would indicate it was no longer necessary. Our adviser explained that whilst Mrs E was incontinent of urine on her admission to hospital that alone is not a valid reason to insert a catheter. This is because a catheter would increase Mrs E’s risk of developing a catheter associated urinary tract infection. Our adviser confirmed there was no clinical indication Mrs E required a catheter to be inserted.
75. From the evidence we have seen, we have found the Trust has acted in line with NICE guidance on infection prevention. We can see that whilst the Trust did initially plan to insert a catheter this was later deemed no longer necessary. This is in line with NICE guidance which says the need for catheterisation should be reviewed regularly.
76. We understand Mrs V is concerned that by not inserting a catheter the Trust allowed Mrs E to develop moisture damage. We will next look at the moisture damage to Mrs E’s skin and whether a catheter being inserted could have prevented this.
77. NICE guidance on pressure ulcers says when conducting a skin assessment to check for moisture that could be caused by incontinence.
78. Our adviser explained moisture lesions are caused by exposure to excessive moisture for a long period of time. They said the four main causes of moisture damage are incontinence, faecal incontinence, leaking wounds and excessive sweat.
79. As explained in paragraph 45, Mrs E scored 13 on the Braden Scale on 13 February. One of the categories within the Braden Scale checks for moisture and we can see Mrs E scored two for moisture. This identified that Mrs E’s skin was often, but not always moist. We can see the Trust checked Mrs E for moisture on each skin assessment it performed daily, and she consistently scored two.
80. We can see Mrs E did not have moisture damage documented until the 18 February when the Trust documented moisture damage to her vagina. We can see the TVN completed a care plan and advised staff to use a Tena wash cream which would cleanse, moisturise and protect the skin. The TVN documented the area should be kept clean and dry, to promote healing.
81. We have seen the Trust checked Mrs E approximately every two hours and this has been documented on the daily comfort round and skin care documentation.
82. From the evidence we have seen, we have found the Trust has acted in line with NICE guidance on pressure ulcers. We can see the Trust checked Mrs E daily for signs of moisture damage and was checking her toilet needs approximately every two hours. This is in line with NICE guidance on pressure ulcers which says to check patients for signs of moisture damage caused by incontinence.
83. We understand Mrs V has told us the moisture damage occurred due to the Trust not regularly changing her mother’s pad. We understand why Mrs V would feel this way as incontinence is a cause of moisture damage. From the records, we have not seen any evidence that would suggest the Trust was not regularly checking and changing Mrs E’s pads. Our adviser also explained that even if Mrs E had been catheterised, it is likely she would have still developed the moisture lesions due to also being faecally incontinent.
84. We understand Mrs V does not agree that her mother had faecal incontinence and has told us her mother only had urine incontinence. We have seen numerous references throughout the records that would suggest Mrs E also had faecal incontinence while she was an inpatient. Our adviser said being doubly incontinent is a key contributor to moisture lesions. Our adviser said the moisture lesion was possibly present on Mrs E’s admission and could have been caused or exacerbated by her double incontinence whilst an inpatient.
85. We acknowledge how distressing it must have been for Mrs V to learn Mrs E had developed the moisture lesion. We can understand why she has been concerned this was due to a failing by the Trust, given the care Mrs V has told us Mrs E had received.
86. It is possible Mrs E developed the moisture lesion whilst an impatient despite the Trust acting in line with NICE guidance on pressure ulcers. We have seen the Trust was regularly checking and changing Mrs E to promote healing and to keep the area dry. We have found the moisture damage to Mrs E was not due to a failing by the Trust.
87. We understand this is not the decision Mrs V was hoping for. We hope this provides reassurance to Mrs V that the Trust was actively checking for damage, and then looking after and managing the moisture damage that had occurred. We also hope it provides reassurance that this could not have been prevented by the insertion of a catheter and was likely due to her double incontinence.
COVID-19 Ward
88. Mrs V said the Trust placed her mother on a COVID-19 ward despite her not having COVID-19. Mrs V said on 15 February there was a board blocking the entrance to the ward, and on 17 February there was a sign saying the ward had been closed due to an outbreak of infection. Mrs V said the Trust placing her mother on a COVID-19 ward led to her mother contracting COVID-19 and they were unable to visit her.
89. The Trust explained Clementine B ward, where Mrs E was placed, was closed on 7 February due to six patients testing positive. The Trust said on 14 February it was experiencing extreme bed pressures due to a high number of patients within the emergency department requiring admission. It said it re-opened 2 bays within the ward at 5pm for new admissions and these bays had dedicated staff to reduce the risk of transmission. The Trust said patients with COVID-19 on this ward were kept isolated in bays and side rooms.
90. NHS COVID-19 guidance for times of extreme bed pressure says organisations can consider using the vaccination status of patients to triage new admissions into a closed ward. It says to start by using the non-contact bays (bays where the patients are not a contact of COVID-19) and then move on to the contact bays where the patients are nearest the end of their quarantine period.
91. From the records we can see Mrs E was transferred to Clementine B ward at approximately 11.50pm on 14 February, approximately five hours after the ward had been re-opened. We can see a COVID-19 test was completed the same day and the result was negative.
92. We can see in the early hours of 15 February, a nurse contacted Mrs V to advise Mrs E had been placed on Clementine B ward. The nurse documented Mrs V was not happy with this due to her mother being high risk. We can see the nurse escalated Mrs V’s concerns to both the bed manager and their own manager and Mrs E was moved to a side room.
93. From the evidence we have seen, we have found the Trust acted in line with the NHS COVID-19 guidance for times of extreme bed pressure. We can see the Trust placed Mrs E in a bay with other patients. This is in line with the NHS guidance which says new admissions can be placed with other patients who are either not a contact of COVID-19 or who are reaching the end of their quarantine period. The Trust has confirmed that patients with COVID-19 were kept isolated from the new admissions.
94. We can see the Trust also moved Mrs E to a side room as soon as Mrs V raised concerns that her mother was high risk. Mrs E also told us the Trust contacted her at approximately 10pm on 14 February to check Mrs E’s COVID-19 vaccination and booster dates. We have found the Trust acted in line with NHS COVID-19 guidance for times of extreme bed pressure which says it can use the vaccination status of patients to triage new admissions to closed wards.
95. We recognise this is not the decision Mrs V was hoping for, especially as Mrs V believes the actions of the Trust caused her mother to contract COVID-19. We understand how worrying it must have been for Mrs V when Mrs E tested positive for COVID-19. Our decision is in no way intended to detract from the difficult time Mrs V has experienced.
Hearing Aid
96. Mrs V said on 17 February she identified her mother’s right hearing aid was lost and the Trust did not conduct a thorough search to locate it. Mrs V said when she was allowed to visit on 21 February, she found the missing hearing aid in her mother’s cardigan and the Trust had not checked this.
97. The Trust said when Mrs E’s hearing aid was reported lost, it conducted a full search and identified she was admitted with only one hearing aid to her left ear. During the local resolution process, the Trust advised Mrs V it had changed its process from weekly property checks to daily property check lists.
98. The Trust’s patient’s property policy says all healthcare professionals are responsible for ensuring the patient’s property is listed and documented. It also says special attention must be given to personal items that the patient needs to keep with them such as hearing aids.
99. From the records, we can see the Trust completed a property list for Mrs E. We can see next to hearing aids the letter ‘L’ was handwritten. We can see the Trust circled yes to hearing aids on 13 February and on 14 February we can see the Trust circled yes and wrote left.
100. On 17 February we can see the Trust noted Mrs E reported she had lost her hearing aid and on observation she only had a hearing aid on her left ear.
101. From the evidence we have seen, we have found the Trust has acted in line with its patient’s property policy. We can see the Trust completed the property form whilst Mrs E was in the emergency department and circled yes to hearing aids. This is in line with the Trust’s patient’s property policy which says property should be listed and special attention given to hearing aids.
102. It is difficult for us to form a view on what happened to Mrs E’s right hearing aid. We can see the Trust did record Mrs E had hearing aids on 13 February, but it is unclear how many and if one was missing. This is because we can see the letter ‘L’ had been handwritten next to hearing aids and we do not know at what time this was added. We can see that as early as 14 February the Trust noted Mrs E only had a left hearing aid.
103. We understand Mrs V has told us her mother had both hearing aids on her admission to the Trust. We do not doubt Mrs V’s version of events and Mrs V has told us she found the right hearing aid on 21 February in her mother’s cardigan.
104. We acknowledge that it was distressing for both Mrs V and Mrs E when Mrs E was unable to use one of her hearing aids. We can understand how this left Mrs E feeling isolated, particularly given she was unable to have visitors due to the COVID-19 visiting restrictions. We can appreciate how distressing this time was for both Mrs V and Mrs E.
105. We are not able to say that Mrs E’s hearing aid was lost or went missing due to a failing of the Trust. This is because we do not know at what point the hearing aid went missing and who, if anyone, from the Trust was involved. We have found the Trust acted in line with the Trust’s patient’s property policy as we can see the Trust did document Mrs E’s property including her hearing aids.