Physiotherapy 16. Miss A says the Trust failed to provide appropriate physiotherapy to her sister between 14 April and 13 June 2023.
17. The NICE CG83 guidance explains clinicians should start rehabilitation on patients following a critical illness as early as clinically possible. For patients at risk of physical health conditions (such as Mrs C as she had a history of a long previous admission and obvious injury) they should carry out a comprehensive clinical assessment to identify their rehabilitation needs. This should include a family member if necessary and be developed by a multidisciplinary team.
18. The NICE CG83 guidance further explains a rehabilitation plan should include measures to prevent avoidable physical and non-physical deteriorations in the patient’s condition, and an individualised, structured rehabilitation programme. It also explains that before a patient is discharged into another care setting, discharge arrangements including appropriate referrals for the necessary ongoing care, should be in place before completing the discharge.
19. The clinical study recommends early rehabilitation, including bed exercises to provide significant benefits for functional recovery in patients who are immobile due to severe illness or surgery.
20. The clinical records show the Trust provided regular physiotherapy input during Mrs C’s admission. An initial physiotherapy assessment was carried when she was admitted on 14 April, it was felt further medical information was required to enable physiotherapists to carry out a full mobility and transfer assessment on Mrs C at this time. We can see the physiotherapy department contacted the fracture clinic and the orthopaedic team at her previous hospital on 17 and 18 April to clarify details regarding Mrs C’s previous fractures and weight-bearing status.
21. Once this information was obtained, the Trust’s physiotherapy team carried out a comprehensive assessment in collaboration with the occupational therapist and Mrs C’s sister on 18 April. During this session, the records show a discussion took place with Miss A to address the challenges to Mrs C’s rehabilitation. These were attributed to her cognitive impairments and complex physical presentation, which included her history of suffering a pelvic fracture, skin damage and limited mobility.
22. We hope to assure Miss A this was full and comprehensive. We consider this assessment was in line with the NICE CG83 guidance as the Trust took a multidisciplinary approach to Mrs C’s care, including different specialists and family members to identify her rehabilitation needs.
23. Given her limited mobility, the records show the rehabilitation programme focused on therapeutic interventions with ongoing attempts to engage Mrs C in bed exercises and attempts to assist her with sitting on the edge of the bed, despite her having a limited potential for recovery. Our physio adviser explains this approach includes a passive range of motion and muscle strengthening exercises which helps prevent the complications associated with immobility and prepares patients for eventual mobilisation. We consider this is in line with the NICE CG83 guidance on creating a rehabilitation plan to prevent avoidable physical and non-physical deteriorations in a patient’s condition, and our clinical advice supports this view.
24. The records show the Trust carried out a subsequent physiotherapy review on 20 April. Mrs C declined attempts to involve her in physiotherapy on 21 April and 24 April. She then had regular follow-up sessions from 25 April until she was discharged on 13 June. These sessions focused on offering therapeutic interventions, with ongoing attempts to engage Mrs C in the prescribed bed exercises and attempts to assist with sitting on the edge of the bed. We consider this is in line with the recommendations outlined by the clinical study of bed exercise for patients who are immobile, such as Mrs C.
25. The records show on 6 June the Trust also arranged for a referral to the community therapy team to review her sitting ability when she was discharged to the care home. We consider this is in line with NICE CG83 guidance on making appropriate referrals to ensure ongoing care is in place before the discharge.
26. Overall our physio adviser explains the evidence shows the Trust provided an appropriate level of physiotherapy input during Mrs C’s admission, given the challenges associated with her complex physical condition and poor cognitive function.
27. We recognise the concern Miss A has with this aspect of her sister’s care and how hard it was seeing her sister in bed during the admission. We hope we can assure her the Trust provided Mrs C with appropriate physiotherapy during her admission, which was in line with the relevant guidance, and our clinical advice supports this view.
Skin care 28. Miss A says the Trust failed to provide appropriate skin care to her sister during her admission.
29. The NICE CG179 guidance recommends healthcare practitioners should carry out an assessment of pressure ulcer risk for adults with either significantly limited mobility, a previous pressure ulcer or the inability to reposition themselves. They should use a validated scale to support the clinical judgement of the skin damage (such as a Waterlow score) to assess pressure ulcer risk. It explains healthcare practitioners should encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every six hours. For patients who are high risk, this should be done every four hours.
30. The NICE CG179 guidance also says if they are unable to reposition themselves, healthcare practitioners should offer help to do so, using appropriate equipment if needed, and document the frequency of repositioning required. For further prevention and management, they should also use pressure redistributing devices (such as mattresses), use barrier cream if necessary, offer debridement of the pressure ulcer, use antibiotics and antiseptic cream and use dressings.
31. Mrs C was transferred to the Trust for rehabilitation directly from another hospital where she had been treated for a broken pelvis and had deep tissue damage following a fall at home and a long lie. Our nursing adviser explains it is challenging when a patient has suffered a long lie at home, as the depth and development of any pressure damage is not always initially clear. Mrs C was catheterised and incontinent of faeces.
32. When the Trust admitted her it completed a Waterlow pressure ulcer risk assessment. This identified her as having a skin tear to her right wrist, a skin tear to her left elbow which was healing, deep tissue damage to her sacrum/natal cleft and a category two pressure ulcer to her right buttocks. She had an overall Waterlow score of 14. This means Mrs C was at risk of pressure damage at the time of her admission (a score between 10 and 14 means a patient is at risk of pressure damage). We consider the Trust carried out an appropriate pressure ulcer risk assessment on Mrs C following her admission in line with the NICE CG179 guidance.
33. The records show the Trust created a repositioning plan of ensuring she was moved on average every two hours. The records show this was challenging as Mrs C was quite rigid and scared at times. This must have been very upsetting for Mrs C and we are pleased to see the Trust provided her with reassurance in response to this. From reviewing the clinical records, we can see the Trust has maintained sufficient records which detail the frequency Mrs C was repositioned. The records also document throughout the admission, Mrs C was repositioned on average every two hours.
34. We consider the Trust created an appropriate repositioning plan for Mrs C, which was in line with the NICE CG179 guidance on ensuring repositioning every four to six hours, considering her risk.
35. The records show the Trust reviewed her pressure sore throughout the admission and photographed the pressure wounds to document their progression. The Trust dressed the pressure sore upon her admission on 14 April. The Trust also placed Mrs C on a ‘PRO matt plus’ mattress at this time to try to prevent her from further skin damage. This type of mattress maintains optimal air pressure to provide equal pressure redistribution for the user.
36. Our nursing adviser explains this type of mattress is suitable for the treatment of uncomplicated pressure ulcers (like Mrs C had upon admission), and therefore appropriate for Mrs C at this time.
37. We can see Mrs C was catheterised and incontinent of faeces which our nursing adviser explains meant she was at further risk of infection. The Trust appropriately used barrier cream to try to prevent a further breakdown of her skin. As the pressure sore continued to deteriorate, on 19 April, the Trust changed her dressing to a waterproof dressing.
38. On 20 April Mrs C had a rising temperature so the Trust prescribed oral antibiotics. Her temperature continued to increase and the Trust administered IV antibiotics on 21 April. On 25 April Mrs C’s mattress was upgraded to a Dolphin mattress, which creates a simulated fluid environment for the patient to significantly reduce pressure. Our nursing adviser explains this is suitable for patients with pressure related tissue damage and prevention of skin breakdown in the most vulnerable patients.
39. Sadly Mrs C’s pressure sore continued to evolve and on 11 May it became a large cavity. On 18 May she was referred to the tissue viability team for more specialist input. The tissue viability team provided regular debridement of the pressure sore (removing the damaged tissue) for the remainder of her admission to attempt to manage this and prevent her skin from breaking down further.
40. Our nursing adviser explains as the deep tissue damage was already present at the time Mrs C was admitted to the Trust, the process of debriding the damaged tissue is part of the development of the wound. The removal of the damaged tissue from the wound then reveals the cavity, which may make the wound look worse. This is part of the evolution process of the wound.
41. Miss A told us how difficult it was to see her sister’s pressure sore and skin deteriorate to this extent and we recognise how distressing this must have been for her. We understand how important this element of the complaint is for her and how she continues to be impacted by this.
42. We can see throughout the admission the Trust provided Mrs C with pressure relieving equipment to try to prevent a further breakdown of her pressure sore. It provided her with barrier cream as she was catheterised and incontinent, it provided her with oral and IV antibiotics and offered regular debridement of the pressure sore. Our nursing adviser explains the Trust created a preventative plan and provided regular wound management to Mrs C during the admission, with input from a specialist tissue viability team. As the pressure sore condition to deteriorate the Trust changed her treatment plans accordingly to recognise her wound care needs.
43. We consider the Trust’s management of Mrs C’s pressure sore and skin was in line with the NICE CG179 guidance on using pressure redistributing devices (such as mattresses), barrier cream, debridement, antibiotics and antiseptic cream and dressings to prevent and manage the breakdown of skin. Sadly, Mrs C’s sore continued to deteriorate, despite the appropriate care and treatment.
44. Overall we consider there are no failings in respect of the care and treatment provided to Mrs C during her admission. We do not underestimate how much of an impact losing her sister has had on Miss A. We hope our findings will provide her with the explanation she seeks, and reassurance about the care and treatment provided by the Trust.