Warfarin
23. Mrs F says after Mr G’s fall on 14 October, the Trust stopped prescribing warfarin and then after six days, a respiratory consultant prescribed too high a dose. Mrs F says Mr G went from not having any warfarin between 14 and 19 October, to suddenly having too much. She said this happened at a time when Mr G was already bleeding on the brain and the sudden high dose of warfarin made the bleed worse.
24. The NICE guideline for warfarin sets out key information about prescribing this drug. It says a starting dose is between 5 and 10mg, and subsequent doses will be dependent on the time it takes for the individual’s blood to clot. This is measured as the ‘Internationalised Normalised Ratio’ (INR), a laboratory measurement that indicates how long it takes for blood to clot. The lower the INR, the quicker the blood clots. A person who is at risk of blood clots will be given a target INR range.
25. Our adviser could see from the records Mr G was at particular risk of blood clots because he had a metal heart valve. They explained without warfarin, Mr G was at a high risk of developing a life-threatening blood clot in his heart.
26. Mr G was admitted back to the Trust having restarted a daily dose of 3mg of warfarin. The discharge instructions from University Hospital Southampton NHS Foundation Trust set out that Mr G’s target INR was between 3 and 4, and warfarin should be ‘titrated accordingly’ (the dosage increased over time as needed to reach the target INR).
27. The records do not show why the doctor decided to stop giving Mr G warfarin on 14 October. We can see warfarin has been crossed off Mr G’s prescription chart between 14 October and 19 October. Mr G’s discharge summary says ‘the warfarin was temporarily held’ after Mr G had his fall. In its complaint response, the Trust said it took Mr G off warfarin temporarily as he was being monitored for signs of a bleed.
28. Mr G’s fall on 14 October was unwitnessed and doctors did not know if he had hit his head. As we know, Mr G was recovering from burr hole surgery and there was an increased risk of bleeding once he restarted warfarin. There was a possibility if he had hit his head, this could have caused a further bleed on his brain. As warfarin could increase this risk further, we think it likely the doctor stopped giving Mr G warfarin because of this risk.
29. The NICE guideline says warfarin is potentially not safe to prescribe to a person who has had ‘recent trauma’ to the head or spine. So, even though we cannot be sure of the doctor’s reason for withholding warfarin, we consider they managed the risk of Mr G having a further bleed in accordance with these guidelines. Our adviser said it was appropriate for the doctor to stop giving Mr G warfarin temporarily.
30. The Trust measured Mr G’s INR at 1.6 on 19 October. We can see it reintroduced warfarin at a dose of 6mg, which is within the range set out in the NICE guideline. Our adviser said it would have been Mr G’s target INR that determined the amount of warfarin the Trust needed to give him at this time. They explained Mr G was given the level of warfarin he needed to get his INR to the target range and therefore reduce his risk of a life-threatening blood clot in his heart.
31. Our adviser explained the way the body processes warfarin depends on lots of factors including other medication, diet, and bowel absorption. They said it can take two to three days to be effective. They explained if an individual’s INR is low, it is appropriate for doctors to give a larger dose of warfarin to help reach the target INR more rapidly.
32. We have not seen evidence that the Trust suddenly gave Mr G too much warfarin. The evidence shows at all times, the Trust was balancing Mr G’s high risk of developing a blood clot with the risk of bleeding on his brain. We consider the Trust prescribed warfarin in line with the NICE guideline.
33. We have not seen a failing for this part of Mrs F’s complaint. We understand how distressing it would have been for Mrs F and her family to believe Mr G was not being treated with warfarin in a safe way.
CT scan
34. The Trust’s fall policy says when a patient’s fall is unwitnessed, it should be ‘assumed’ they have suffered a head injury. The policy says nurses should therefore arrange for a patient who has suffered a fall to have an urgent medical review and neurological observations. These include an assessment of a person’s level of consciousness, how their eyes react to light, as well as monitoring their vital signs, including blood pressure and heart rate.
35. The records show Mr G fell at some point between a conversation with his daughter at 19:00 and about 21:00 when he was found by either a nurse or a healthcare assistant. His fall was not witnessed but the records say nurses reported he was ‘found next to bed – suspect he slipped off bed onto floor.’ The nursing notes say Mr G told his daughter on the phone that he had tried to ‘walk on his own and slipped’.
36. Mrs F’s account of what happened differs slightly to the Trust’s. She told us Mr G climbed over the bed rails, fell from the bed, and lay on the floor unable to move for up to two hours. She explained she does not know if Mr G called for help but she said he would not have been seen or heard by nurses due to the layout of his room. Mrs F told us he was discovered at approximately 9pm.
37. The records show a doctor reviewed Mr G on the evening of his fall. The doctor noted Mr G said he was not experiencing any head or neck injury or pain. The doctor noted there was no evidence Mr G had suffered a head injury and his neurological observations were stable.
38. A doctor examined Mr G again the following day. They noted Mr G remembered the fall and was able to describe what had happened. The records show the doctor examined Mr G and noted he did not have a head injury or any bruising. The doctor noted Mr G’s neurological observations remained stable.
39. We can see the Trust followed its falls policy by assuming Mr G had suffered a head injury and arranging a medical review with this in mind.
40. We also looked at the GMC ‘Good Medical Practice’ guidance. This guidance sets out the duties of doctors and tells them what they must do to provide good clinical care. The guidance says in providing clinical care, doctors must ‘adequately assess the patient’s conditions’, take account of their ‘history’ and ‘symptoms’ and ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
41. Our adviser said the doctor acted in line with GMC guidance because they made their decision not to offer a CT scan based on Mr G’s clinical need at the time. They said it is clear the doctor did not arrange a CT scan on 14 October because their examination showed it was not necessary.
42. We understand how worried Mrs F and her sisters were about Mr G during his time in hospital, particularly after his fall. Our adviser highlighted CT scans should not be given as a precautionary measure. They explained NHS Trusts need to balance the needs of the patient with the risk of the radiation dose from a CT scan, the availability, and the importance of using resources in a sustainable way.
43. Our adviser said the first sign of a clear change in Mr G’s neurological observations was on 21 October. The records show a physiotherapist noted Mr G had ‘swallowing difficulties’, ‘left sided weakness’, was ‘slightly confused’, and was ‘drowsy, weak, and not engaging’. We can see a doctor assessed Mr G and, as we know, arranged a CT scan straight away.
44. Our adviser said the doctor acted in line with GMC guidance by promptly arranging the CT scan after Mr G started to show signs of acute deterioration.
45. In summary, the Trust did wait until 21 October to offer Mr G a CT scan, but for good reason. The evidence shows the Trust arranged for Mr G to have a CT scan as soon as there was a clinical indication he should have one.
46. We do not wish to underestimate how worried Mrs F and her family were after Mr G fell. We are satisfied the Trust acted within the guidelines and arranged the CT scan as soon as it was clinically necessary.
Service improvements
47. Mrs F complains the Trust has not made service improvements since the coroner issued the prevention of future deaths report. She says the service improvements it suggested did not address the failings which led to Mr G’s fall on 14 October 2020.
48. The Royal College of Physicians audit of falls in hospitals looks at the care inpatients have received before a fall. It says there is no single thing a Trust can do to reduce the risk of falling. It says ‘multifactorial interventions’ can reduce falls by between ‘20% and 30%’. This standard recognises how falls can be caused many different factors, and there are many different factors needed to reduce the risk of a fall.
49. This means it is not possible to say there was a single factor that caused Mr G to fall. We have therefore looked at what relevant guidance tells us about what the Trust should have done to reduce the risk of Mr G falling.
50. The Trust’s falls policy says ‘a multifactorial falls risk assessment’ (an assessment that identifies the factors that put an individual at risk of falling) will be completed within six hours of a patient’s admission. The Trust’s falls policy says it should complete a falls care plan for all patients aged over 65 or older. Falls care planning is intended to identify a patient’s individual risk factors that can be treated, improved, or managed during their hospital stay. For example, falls care planning might identify that a patient needs special equipment to help prevent or help reduce the impact of a fall.
51. Mr G’s records show the Trust did not complete a multifactorial falls risk assessment until after his fall on 14 October, over 24 hours after his admission. The care plan section of the form was left blank. It is clear from this evidence that the Trust missed an opportunity to reduce the risk of Mr G falling on 14 October.
52. This was recognised by the coroner. As we have explained, at the end of the inquest the coroner issued a prevention of future deaths report to instruct the Trust to take action to address this.
53. In its response to the coroner, the Trust said it was transitioning its patient record system from paper-based to electronic. It said it had also recently reviewed its programme for training newly registered nursing staff and health care support workers (HCSW). It said this includes a ‘comprehensive overview’ of documentation. The Trust sent this information to the coroner. Mrs F has also seen its reply.
54. The coroner asked the Trust to take action to address their concerns, not Mrs F’s. It is therefore understandable that she feels the Trust has not made service improvements which address her specific concerns about what led to Mr G’s fall.
55. We began our assessment of Mrs F’s complaint shortly after the coroner issued the prevention of future deaths report. We think these circumstances and the coroner’s process mean she has not had the opportunity to have been kept informed of the service improvements through the Trust’s complaint process. This is not to say Mrs F could have done anything differently to get the answers she needed.
56. Our principles outline how public bodies (including NHS Trusts) should respond when things go wrong. Our principles say when something has gone wrong, public organisations should make changes to staff training and systems to make sure poor service is not repeated.
57. As we know, at the time of Mr G’s fall, nursing staff at the Trust completed written falls risk assessments and care plans. The Trust told us it has since moved to only using electronic records. It explained one of the benefits of using electronic records is automatic prompts. This means if a patient has a particular risk factor, for instance they are older than 65, the system will automatically identify that that a falls risk assessment must be completed.
58. We looked at what relevant guidance tells us about the use of electronic records. In June 2022, the government published its digital health plan for the NHS in England. One of its main aims is to ensure most health and social care services are using electronic records by March 2025. The plan recognises that electronic records can help health care services ‘improve the quality of their care’ by reducing errors associated with manual record-keeping, allowing clinicians access to a patient’s information where and when they need it, and automatically alerting clinicians to risks.
59. The Trust also told us since Mrs F raised her complaint it has made improvements to how it supports and trains new nurses. It said its induction for new nurses and HCSWs now begins on their first day, before they start caring for patients on the ward. The Trust explained its induction process specifically covers training on falls.
60. We have not seen a failing for this part of the complaint. It is clear to us that the Trust has made service improvements since the coroner issued the prevention of future deaths report. We can see these changes are in line with our Principles, and with national policy. We consider the circumstances that Mrs F feels led to Mr G’s fall are less likely to occur now the Trust has made these improvements.
61. Potentially, the Trust might have resolved this part of Mrs F’s complaint had it written to her to explain these improvements. However, as this is not part of the coroner’s process, and we were looking at the complaint already, we are not critical that it did not do this.
62. We recognise how upsetting it has been for Mrs F to feel the Trust had not done anything to improve its services. We fully empathise with how Mrs F and her family’s life has been affected by Mr G’s sad death and thank her for sharing her experience with us.