Fall
19. Mr O complains his fall could have been prevented. Mr O says he was given a permanent catheter, despite his wife warning staff it was a trip hazard as he suffered from Parkinson’s disease. Three days later he fell and required a brain scan.
20. Within the Trust’s May 2024 complaint response, it said this was an unwitnessed fall and it informed Mrs O at the time. Mr O said he lost his balance on his way to speak to another patient on the ward and fell on his back. Doctors assessed Mr O, there was no injury. It carried out a CT scan and vetted with nil concerns.
21. Mr O’s records show he fell (unwitnessed), losing balance, while mobilising to another patient’s bed to talk to them, at 11.45am on 18 May.
22. The relevant guidance is NICE CG161, which says clinicians should regard all patients aged 65 or older as being at risk of falling in hospital. They should consider multifactorial assessments and interventions, ensuring the assessment ‘identifies the patient's individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay.’
23. The guidance also says that all patients over 65 should have a multifactorial falls risk assessment on admission to hospital. Mr O was 78 at the time of his admission.
24. Mr O had capacity to make his own decisions. He informed staff on admission he was independently mobile. The records show he had no history of falls. It is recorded he understood the use of the call bell if he needed assistance and was physically able to use it. Our nurse adviser said Mr O therefore understood the risk of mobilising around the ward and the assistance needed if he required it.
25. Staff completed a multifactorial falls risk assessment within one hour of Mr O’s admission in line with NICE guidance, which says falls risk assessment should be completed within four hours of admission to hospital.
26. Our nurse adviser said the records show the Trust completed a care plan for Mr O due to a decline in his mobility, in line with NICE guidance. This contained interventions such as ensuring slip/trip/fall hazards are managed at the bedside and ward area, appropriate footwear is worn, and call bell is in reach and explained.
27. The Trust completed a falls risk intervention in line with 1.2.2.4 of NICE guidelines, which says clinicians should ‘promptly addresses the patient's identified individual risk factors for falling in hospital and takes into account whether the risk factors can be treated, improved or managed during the patient's expected stay.’
28. The records show the Trust followed NICE guidance regarding completing a multifactorial risk assessment/intervention and care plan to reduce the risk of Mr O falling during admission.
29. Our nurse adviser said there is no evidence Mr O fell because of lack of care by the Trust or by tripping over any trip hazards, for example wires or tubes (catheter).
30. We are sorry to learn about Mr O falling during his admission in May 2023. We recognise his and his wife’s concerns on whether his fall could have been prevented.
31. The Trust completed relevant assessments/interventions and care plans to reduce the risk of Mr O falling during admission, in line with NICE [CG61] guidance. There is no evidence he fell because of a lack of care by the Trust.
Rehabilitation care plan
32. Mr O complains the Trust delayed arranging a rehabilitation plan following his discharge. Mr O says there was no rehabilitation plan for several months following his discharge and when it arranged this, it was only on the insistence of his wife.
33. As there was no rehabilitation plan in place after three months, he says his wife arranged for private physiotherapy (PT) and occupational therapy (OT) assessments and employed someone to assist with daily exercises.
34. The Trust said it planned for Mr O to have medical therapy with no further intervention wanted by him or his relatives. It said as per the cardiac care pathway, a specialist nurse from its Cardiac Rehabilitation Team (CRT) contacted him by telephone within two weeks of discharge on 1 June 2023. General exercise advice was given including avoiding being inactive, to walk around the garden, and continue seated exercises.
35. The Trust said the CRT rang him again on 21 June, 14 and 24 July, and 31 August. It explained Mr O’s mobility was slowly improving at home and he was beginning to be able to exercise with the support of the community and private PT.
36. The Trust said Mr O was due to be followed up by the CRT post discharge to arrange cardiac rehabilitation and so there was no indication at the time for community PT follow up. It said it was appropriate for Mr O to be referred to community PT by the GP when it was determined his mobility was not improving at home.
37. It said Mrs O said the falls at home were due to his BP being low and so this would not have been prevented by having community PT.
38. Our PT adviser said as Mr O was over 65 at the time, has Parkinson’s (which can affect mobility) and had a cardiac event (reason for admission), he was at risk of falls.
39. The Trust recorded that prior to admission, Mr O could walk independently. During his admission, staff recorded he needed the assistance of one to mobilise. Therefore, his mobility was not the same as it was prior to his admission.
40. On 15 May, staff record Mr O’s mobility of ‘assistance 1/2’ (assistance from one person) and no decline in mobility, however a decline in mobility was ticked in the care plan. The rehabilitation practitioner who assessed Mr O on 16 May took Mr O’s medical history from his wife and noted that prior to admission Mr O was independently mobile, despite having Parkinson’s and had just bought a walking stick.
41. The rehabilitation team assessed and reviewed Mr O on 18 May at 9.50am prior to his fall at 11.45am. The notes record he fell after he lost his balance when walking to speak to another patient. As a plan, staff recorded PT/OT to review. However, this plan was not ticked to say it was completed.
42. The rehabilitation practitioner saw Mr O the following day (19 May – day of discharge). Our PT adviser said there is no reference to his fall, and no clear reassessment of balance or strength.
43. Again, his mobility was recorded as requiring assistance of one to rise to stand, and assistance of one using a wheeled zimmer frame. There is no documentary evidence seen to indicate why he needed assistance of one to rise to stand or to walk, and whether his strength and balance was assessed.
44. In line with NICE [CG161] guidance (1.1.2.2), following Mr O’s fall, our PT adviser said the Trust should have carried out a multifactorial assessment. This should have included a further assessment and review of his mobility, balance and gait, either before he was discharged or at home soon after his discharge. It was important this was carried out, not just because Mr O had a fall during admission, but he also had complex co-morbidities, including cardiac event, and Parkinson’s, which can affect mobility.
45. The rehabilitation team should have also made a rehabilitation plan to assess Mr O’s strength and balance and equipment at home, following his discharge.
46. There is no evidence the Trust’s PT Team did a therapy review and assessment or put in place a rehabilitation plan following his fall. This was a missed opportunity by its Therapy Team.
47. Our PT adviser said the CRT completed its own rehabilitation plan prior to and following Mr O’s discharge, in line with guidance NICE [NG185]. The Trust made a referral to the community cardiac rehabilitation for follow up on 18 May, prior to discharging him home on 19 May.
48. Cardiac rehabilitation and physiotherapy rehabilitation (following a fall) are different. Cardiac rehabilitation is a personalised program of education and exercise designed to improve the health of those who have had a cardiac event – as in Mr O’s case. Our PT adviser said the cardiac rehabilitation team carried out telephone and one to one assessment because of Mr O’s comorbidities, in line with guidance NICE [NG185], section 1.8.
49. Following Mr O’s fall, the PT therapy would have focused on his confidence, balance and strength, because of his fall and reduced mobility.
50. Mr O’s GP referred him in July 2023 to the Trust’s community PT rehabilitation team. Informed by clinical advice, the community PT carried out an assessment on 19 July, in line with NICE [CG161] guidance. The Trust should have made this referral prior to or after it discharged Mr O on 19 May. There is no evidence it did so. This is an indication of a failing.
Impact
51. The lack of PT assessment following Mr O’s fall led to a two-month delay in a PT referral and assessment being made. Mr O says the delay in arranging a rehabilitation plan caused him to lose confidence in walking unaided. He says the delay in the Trust providing rehabilitation following discharge, resulted in him falling at home twice and breaking his ribs.
52. Our PT adviser said a multifactorial falls assessment would have identified his risks of further falls, such as a decrease in mobility confidence and a fear of falling. Unfortunately, we cannot say it would have prevented Mr O from falling at home and breaking his ribs.
53. This is because NICE [CG161] guidance acknowledges that falls cannot always be prevented. It may have reduced his chances of falling, but we could never say it would have prevented it entirely.
54. Our PT adviser agreed that Mr O’s confidence in walking may have improved if he had a therapy assessment and rehabilitation following his fall, but we cannot say for certain. The delayed PT assessment caused Mr and Mrs O frustration and distress.
55. We have resolved this complaint, and this is explained at the end of this report.
Treatment for BP
56. Mr O complains the Trust incorrectly treated him for high BP instead of low BP.
57. The Trust said Mr O’s BP readings on the ward were consistently high. It discharged him on anti-anginal medication. It said it has reviewed the medications, and they are all correct and according to all the recognised national and international guidelines.
58. The relevant guidance is:
• NICE [NG136]: Hypertension in adults: diagnosis and management • American Heart Foundation (AHA): Hypertension:2020 International Society of Hypertension Global Hypertension Practice Guidelines.
59. Our cardiologist adviser said Mr O’s initial BP on attendance at the ED on 15 May 2023 was 118/76 lying and 86/60 standing, which should have raised an alert for adding antihypertensive medications (medicines that lower BP) in the presence of Parkinson’s disease.
60. During Mr O’s admission there are several high BP readings recorded, for example, lying BP 147/88mmHg, standing BP 182/85 on 16 May and 138/71mmHg on lying BP, 149/90mmHg on 19 May 2023 - the day of Mr O’s discharge.
61. Our cardiologist adviser said according to NICE [NG136] and AHA guidelines, the above BP readings are high and need to be treated to bring into normal range.
62. During Mr O’s admission, he was given Amlodipine medication to lower his BP. Our cardiologist adviser said regardless of whether Mr O was on this medication at the time of the high BP readings, the Trust did follow guidelines in treating his high BP, by administering him with medication to lower his BP.
63. Because Mr O has Parkinson’s and was receiving treatment for this, the clinicians may have considered waiting and monitoring his BP for a little longer before administering medication to lower it (as Parkinson’s can lower BP). His BP may have lowered without treatment, but we will never know for certain.
64. Our cardiologist adviser confirmed that in line with relevant guidelines, Mr O’s BP readings were at times high. The Trust followed guidelines in treating the high BP during his admission and in the take home medication. The guidelines do not say anything about treating patients with Parkinson’s differently.
65. We understand Mr O questioning whether the Trust treated his high BP correctly. The medical records show his BP readings were at times high during his admission, including on the day of his discharge. Informed by clinical advice, the Trust treated his high BP with medication in line with relevant guidelines, including medication on discharge.
Accuracy of medical records/complaint response/complaint handling
66. Mr O complains the Trust wrote inaccurate information in his medical records and/or complaint response and delay in responding to his complaint. We will address Mr O’s complaints separately below:
Further intervention and patient mobility
67. Mr O complains that at no time did he, his wife or family ever say; ‘no further intervention was wanted by him or any of his relatives.’ [contained in Trust’s complaint response] and disputes his mobility had improved, despite what the Trust said in its complaint response.
68. The NHS Complaint Standards says:
‘Staff who carry out investigations will give a clear and balanced explanation of what happened..’
69. Our Principles says, ‘Investigate complaints…basing [the] decision on the available facts and evidence.’
70. We have viewed Mr O’s medical records and can see the Trust’s complaint response was based on the information contained in those records. Its responses were in accordance with the medical records and in line with above quoted guidance on complaint handling.
71. If Mr O wants to dispute the accuracy of his medical records, he can raise a complaint with the Information Commissioner’s Office (ICO).
Complaint handling
72. Mr O complains the Trust delayed in responding to his complaint.
73. Regulations 2009 says the organisation (NHS in this case) ‘must acknowledge the complaint not later than 3 working days after the day on which it receives the notification…’ and keep the complainant updated.
74. The Trust acknowledged Mr and Mrs O’s initial complaint within three working days. It explained in most cases it aims to investigate and respond to complaints within 40 working days. It said it would keep Mr and Mrs O informed if there are any delays in the investigation.
75. The Trust responded to Mrs O’s complaint 101 working days after receiving it.
76. Mrs O responded to the Trust’s letter, and it acknowledged this within three working days. It reiterated it aimed to investigate and respond within 40 working days, and would keep her updated of any delays. It sent Mrs O its final response 42 working days after acknowledging it.
77. The evidence shows the Trust acknowledged receipt of Mr and Mrs O’s complaints in line with Regulations 2009. However, there was a lengthy delay following receipt of Mrs O’s initial complaint, and then a very short further delay in responding to the second complaint. The Trust also did not update Mr and Mrs O about the delays. We consider the Trust did not respond to the complaint in line with Regulations 2009 and we understand this caused Mr and Mrs O frustration and distress.
78. The Trust has acknowledged what went wrong and apologised for the distress caused. However, we cannot see any action to improve its complaint services to minimise the risk of this happening again.
79. We have resolved this complaint and explain this at the end of this report.
Cardiac Rehabilitation summary and Communication with other departments
80. Mr O complains the Trust’s Cardiac Rehabilitation (CR) summary dated 22 March 2024 says there were 12 phone calls made to him. He says there were only five with his wife, as he has difficulty with phone calls. He also complains the CR summary says he is ‘an ex-smoker 14 years.’ He says this should read 40 years.
81. Mr O also complains the Trust did not inform other departments, whose care he was under, about his admission.
82. In health cases, section 4(4) and (5) of the HSC Act prevents us from investigating unless we are satisfied the complaints process has been used and exhausted, or it was not reasonable to expect the complainant to have done so.
83. We cannot investigate these aspects of Mr O’s complaint because there is no evidence he raised these issues with the Trust.
84. Even if he raised this with the Trust now, his complaint would be out of time for the Trust and for us to investigate, in line with Regulations 2009 and the HSC Act, which says that complaints must be made within 12 months of the person being aware of the problem.
85. We cannot investigate this complaint any further.
Summary
86. We have seen the following indications of failings:
• no assessment or rehabilitation plan put in place by the Trust’s Therapy Team following Mr O’s fall on 18 May • poor complaint handling.
87. If the Trust’s PT team had carried out an assessment/review and rehabilitation plan following Mr O’s fall, it may have reduced his chances of falling at home, but we could never say it would have been prevented. Mr O’s confidence in walking may have improved if he had a therapy assessment and rehabilitation following his fall, but we cannot say for certain.
88. We recognise the Trust’s actions caused Mr and Mrs O, frustration and distress.
Agreed resolution
89. Having identified indications of failings, we asked the Trust what it would do to put this right. It agreed to:
• acknowledge what went wrong • apologise for the distress and upset caused • make service improvements to minimise the risk of this happening again.
90. Mrs O agreed this resolved their complaint.
91. We are sorry to learn of Mr O’s complaint about the Trust and the impact this has had on him and his wife. Our primary investigation decision is not made without recognition of the impact this has had. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for them.