Nutrition and hydration
13. Mrs I says staff did not provide adequate nutrition and hydration to Mr I during his admission to hospital from 24 August 2022 to 15 September 2022. Mrs I believes staff did not record nutrition correctly as she knows he was not eating as much as they said he was. Mrs I does not think Mr I was encouraged or helped to eat.
14. Mrs I says Mr I had visibly lost a lot of weight, so much so on his return to the care home, the care home staff commented on his appearance.
15. The Trust said Mr I was eating the majority of his meals between half and all of each. It said there were some occasions where Mr I refused meals. It said staff would have encouraged Mr I to eat but if he declined they would not have been able to give him more.
16. The Trust told us Mr I’s appetite was very up and down. Although he showed no clinical signs of malnutrition or dehydration, it would have been appropriate to offer nutritional drinks at regular intervals to supplement him.
17. The Trust said Mr I was not showing signs of dehydration. He had a small appetite and fluid intake, and this was being monitored by staff. It said Mr I was encouraged to take fluids regularly every day.
18. Nutrition guidance states: ‘people in care settings should be screened for the risk of malnutrition using a validated screening tool.’ MUST is a five-step screening tool to identify adults who are malnourished, at risk of malnutrition or obese. It includes management guidelines which can be used to develop a care plan. It is used in hospitals, community and other care settings and can be used by all care workers.
19. The five MUST steps are:
1 – measure height and weight to get a BMI score 2 – note percentage unplanned weight loss and score 3 – establish acute disease effect and score 4 – add scores from steps 1, 2 and 3 to obtain overall risk of malnutrition 5 – use management guidelines and/or local policy to develop a care plan
20. MUST guidance states a care plan should contain the following:
1 - set aims and objectives of treatment 2 - treat any underlying conditions 3 - treat malnutrition with food and/or oral nutritional supplements (ONS) 4 - monitor and review nutritional intervention and care plan 5 - reassess subjects identified at nutritional risk as they move through care settings
21. On admission to hospital on 21 August, Mr I was initially treated for covid-19 with intravenous fluids.
22. On 22 August it was recorded in a nutrition care plan there was a risk of malnutrition due to Mr I’s confused state. The goals were to detect signs of malnutrition promptly and maintain patient body condition by ensuring no reduction in weight during admission.
23. The nutrition care plan stated the interventions to achieve these goals included nutrition screening on admission, food charts to be completed daily, to weigh Mr I on admission and then again weekly and staff to assist Mr I with feeding.
24. Although a nutritional care plan was commenced on the day of admission, this was inaccurate as it was ticked Mr I had been weighed and also been referred to a dietician. There is no evidence in the records Mr I was weighed at any point during his stay. The records show Mr I was not referred to a dietician on admission.
25. Nutrition in dementia guidance states ‘as dementia progresses into the later stages, patients can begin to refuse meals and lose weight. The calorie content of food and drink is not of prime importance at this stage and is unlikely to increase a person’s length of life. Weight loss is normal, and quality of life takes priority. Enforced feeding can cause discomfort, stress and anxiety to the patient. This includes the use of prescribed oral nutritional supplements which should not be requested or provided at this stage.’
26. Nursing staff recorded Mr I’s oral intake on daily food charts. The records document nursing staff encouraged Mr I to eat and drink every day, but his appetite was poor.
27. Mr I was assessed by the SALT team on 5 September after concerns were raised by nursing staff about his ability to swallow. The SALT team recommended a diet of soft and smooth food and thin fluid.
28. The records show Mr I was offered the following foods after the SALT assessment recommended soft and smooth foods on 5 September: shepherd’s pie (declined), chicken casserole (declined) yogurt (ate ¾) jelly (ate ¾), porridge (ate all), minced lamb (ate ½) yogurt (ate all) custard (ate all), hotpot (ate ¾) yogurt (ate all) cottage pie (declined) custard (ate ½) yogurt (ate all), ice cream (ate ¼) cottage pie (declined), porridge, hot pot (ate all), yogurt (ate all).
29. The NMC code of Practice says, ‘keep clear and accurate records relevant to your practice’.
30. Evidence suggests staff did not record drinks offered to Mr I on a fluid balance chart or in the food charts. Subsequently, we have no way of knowing if sufficient drinks were offered to Mr I or the amount of fluid he drank.
31. We have seen evidence Mr I was offered suitable foods and assistance to eat. We also saw evidence staff did not force Mr I to eat. We consider this was appropriate given Mr I’s advanced dementia and in line with nutrition in dementia guidance.
32. We have seen no evidence the Trust weighed Mr I or referred him to a dietician on admission to inform an appropriate care plan in accordance with nutrition guidance.
33. We have identified failings in record keeping as staff did not record what drinks were offered to Mr I. Due to this, we do not know if Mr I was offered sufficient, appropriate drinks and how much he drank. We go on to consider the impact of these failings later in our report.
Physiotherapy
34. Mrs I says staff did not ensure Mr I participated in physiotherapy, advising her he was too tired. She says as a result his mobility deteriorated. Mrs I says at the care home, Mr I was able to walk around unaided and interact with residents. He required assistance with activities of daily life such as eating, washing and toileting, but there were no major issues with his mobility. In the hospital Mr I lost his ability to eat, drink, use the toilet and walk, and he was rarely conscious whenever Mrs I visited him in hospital.
35. Mrs I told us Mr I did not require any physiotherapy whilst in the care home. He also did not require any walking aids. On the Friday before being admitted to hospital, Mrs I took him out for a coffee and a brief walk where he had no mobility issues.
36. In its final response the Trust said the physiotherapy team attempted to mobilise Mr I on 26 August 2022 and again on 31 August 2022. It said on 31 August 2022 Mr I managed to transfer into a chair using a rotunda but due to his reduced cognition it was difficult for him to follow commands.
37. On 22 August 2022 it is documented Trust staff had a conversation with the care home who confirmed Mr I was previously independently mobile and did not use mobility aids but had fallen on two occasions that year. The Trust planned to review Mr I’s rehabilitation for mobility when he was able. There are no further notes from the physiotherapy team until 25 August 2021.
38. Between 22 August 2021 and 24 August 2021 Mr I was in bed being repositioned by nursing staff.
39. On 25 August 2022 the physiotherapy team attempted to assess Mr I’s mobility. It was noted his drowsiness was preventing his ability to mobilise.
40. On Friday 26 August 2022 the physiotherapy team assessed Mr I with nursing staff who agreed he was too confused to mobilise. It was noted he was usually independently mobile in the care home. The plan was to try and mobilise him at the weekend. There is no evidence in the records to suggest the physiotherapy team mobilised Mr I over the weekend.
41. On Wednesday 31 August 2022 the physiotherapy team assessed Mr I again. It was noted he needed assistance from two members of staff to sit on the edge of the bed. He made a safe transfer to a chair and sat out of bed for four hours. Mr I was completely off his baseline of being independently mobile. The plan was to increase his mobility ‘as able’.
42. On 1 September 2022 the physiotherapy team saw Mr I and noted he was disorientated. Mr I needed full assistance to be hoisted into a reclining chair by two staff. It was noted Mr I’s new baseline was to be lifted using the hoist. The notes state Mr I was ready for discharge to a care home from a rehabilitation perspective.
43. There is no evidence in the records to suggest the physiotherapy team assessed Mr I between 1 and 6 September 2022.
44. On 7 September 2022 at 11.15am the physiotherapy team responded to Mrs I’s concerns regarding Mr I’s declining mobility. The team informed Mrs I her husband was drowsy and non-compliant with rehabilitation. They said he was presenting with poor standing balance and was not safe to mobilise other than hoisting out of bed.
45. On 7 September 2022 at 11.30am the physiotherapy team assessed Mr I. They noted Mr I was not safe to mobilise due to drowsiness and inability to follow instructions. Mr I was non-compliant with instructions and needed the help of two staff members to maintain a sitting balance on the end of the bed. Mr I managed a hoist transfer well with assistance from two staff members.
46. There is no documented evidence in the records to suggest the physiotherapy team assessed Mr I between 8 and 13 September 2022.
47. The ‘decline in mobility’ section of the nursing care plan is blank.
48. On 13 September 2022 the physiotherapy team noted Mr I was too drowsy to sit on the edge of the bed and remained for hoist transfer. There is no documented evidence in the records to suggest the physiotherapy team assessed Mr I after 13 September 2022 prior to his discharge on 15 September 2022.
49. Mr I presented to the hospital with acute COVID-19 and reduced oral intake. According to physiotherapy guidance (quality standard one), ‘people who are hospitalised with COVID-19 should have their rehabilitation needs assessed and a personalised rehabilitation plan with outcome measures developed with the multi-disciplinary team (MDT) as soon as clinically appropriate’.
50. Our physiotherapy adviser told us whilst a person is in a hypoactive or drowsy state, alongside acute confusion, it would be difficult to engage a person in active physiotherapy, it would be an expectation that a rehabilitation or management plan to help optimise mobility would be identified at a clinically appropriate time in accordance with physiotherapy guidance quality standard one.
51. Mr I was seen by members of the rehab team on at least six occasions, but the majority of these he was deemed either too confused or too drowsy to mobilise. There is no rehabilitation plan documented until 7 September 2022 where members of the MDT concluded Mr I needed maximum help of two to maintain sitting balance on the edge of the bed, was not safe to transfer to a chair using a rotunda, and a hoist was to be used.
52. This plan is in line with point 1.6 of the physiotherapy guidance which says, ‘needs assessments, care planning and reviews are timely, take into account the person’s response to rehabilitation, their personalised outcome measures and their changing needs’.
53. There is evidence a history was obtained from family and Mr I was described as being mobile unaided prior to hospital admission and usually interacted well. The physiotherapy guidance states, ‘rehabilitation and/or symptom management is holistic based on the personalised needs assessment, outcome measurement and rehabilitation plan’. Our physiotherapy adviser told us the expectation would be symptom management for Mr I’s change in alertness, in line with this guidance.
54. We would expect the MDT to consider this change in alertness alongside a deterioration in mobility could be a symptom of Mr I’s COVID-19, or as a feature of delirium. Delirium guidance sections 1.1 and 1.3 recommends a ‘think delirium’ approach stating, ‘be aware people in hospital or long-term care may be at risk of delirium’.
55. We asked our physiotherapy adviser what actions the Trust should have taken to ensure Mr I could participate in physiotherapy. Our physiotherapy adviser told us, from the patient records, it is noted Mr I was not sufficiently alert to take part in physiotherapy, however there isn’t a clear consideration of why he was drowsy for long periods of time.
56. Assessing for, and managing delirium is described in the delirium guidance. A 4AT score of four is suggestive of delirium. Section 1.6.4 states, ‘Ensure the diagnosis of delirium is documented both in the person's record or notes, and in their primary care health record’.
57. A 4AT score of four was documented on 23 August 2022 during the ward round, there is no clear consideration of whether Mr I’s level of alertness was due to delirium.
58. Section 1.3.1 states, ‘at presentation, assess people at risk for recent changes or fluctuations that may indicate delirium. These may be reported by the person at risk, or a carer or relative. These changes may affect:
• cognitive function • perception • physical function • social behaviour
If any of these changes are present, the person should have an assessment’.
59. The above section of delirium guidance would likely have benefitted any MDT decision making, as if a delirium had been diagnosed (or not), this may have informed Mr I’s rehabilitation plan.
60. Our physiotherapist adviser told us, although no clear guidelines exist, accepted best practice and current campaigns such as #endPJparalysis advises patients are encouraged to sit out of bed and move. The available evidence shows Mr I only sat out of bed in a chair on three days during his admission, 31 August, 1 September and 7 September 2022.
61. Our physiotherapist adviser told us maintaining mobility involves an MDT approach, which includes all staff involved with patient care. It can be seen the ‘decline in mobility care plan’ has not been completed, which indicates a team approach was somewhat lacking.
62. We asked our adviser if Mr I met the criteria for discharge in terms of rehabilitation. Our adviser said the history given by Mr I’s relatives, and the care home, would indicate Mr I was a long way from his mobility baseline. He may have reached a point of optimisation for leaving hospital, but there is no evidence of a personalised rehabilitation plan in terms of his ongoing rehabilitative care management.
63. Rehabilitation guidelines describes how ‘regular needs assessment helps ensure signs of deterioration and/or worsening disability are recognised and appropriate care and/or rehabilitation is in place. Regular review by the MDT should identify any individual needs for equipment including oxygen provision, adaptations and specialist input to help maximise independence and maintain it for as long as possible’.
64. We have seen evidence the Trust formulated a care plan on 7 September 2024 when it was clinically appropriate and in accordance with physiotherapy guidance.
65. We did not see evidence the Trust considered Mr I’s change in alertness alongside his deterioration in mobility to inform a rehabilitation plan in accordance with physiotherapy and rehabilitation guidance.
66. There is little evidence the Trust encouraged Mr I to get out of bed, this happened on only three occasions during his admission. This is not in line with advice from #endpjparalysis campaign (NHS England)
67. The failings we identified in this part of Mrs I’s complaint are lack of consideration of Mr I’s alertness and failure to get Mr I out of bed on more than three occasions throughout his admission. We go on to consider the impact of these failings later in our report.
Discharge
68. Mrs I complains her husband was not fit to be discharged as he was rarely conscious, and staff had struggled to get him to eat or drink. She told us on 15 September 2022, a nurse was very concerned about discharging Mr I in the condition he was in. Mrs I said she felt distressed and helpless. She says the poor care Mr I received in the hospital led to Mr I’s sudden decline and untimely death.
69. In its final response the Trust said Mr I could sometimes be drowsy on the ward, however, would normally wake up to be fed. The nurse on the discharge unit did not know this about Mr I and would probably explain why she was concerned. The Trust says a junior doctor went to see Mr I in the discharge lounge, possibly after Mrs I had left. The nurse in the discharge lounge documented Mr I picked up after Mrs I arrived and ate his dinner. The nurse also confirmed Mr I was felt ready for discharge as his infection was treated and his blood tests were all improved.
70. We reviewed Mr I’s medical records during his admission to the hospital with the help of a physician adviser.
71. On 21 August 2022 Mr I was admitted to hospital with shortness of breath and cough with sputum. He had tested positive for Covid-19 the day before admission. It was noted his oral intake had been poor.
72. Mr I was treated for Covid-19 with intravenous antibiotics, steroids, nebulisers and intravenous fluids. The admission plan was to discharge Mr I to his care home when he was eating and drinking.
73. During a ward round on 25 August 2022, a doctor noted Mr I was eating and drinking well with no concern from the nurses. He was sleeping but arousable and had no pain. He had a high temperature on admission but there had been no spike in temperature since then. A doctor noted Mr I was medically fit for discharge but not fit for discharge in terms of mobility or rehabilitation.
74. During Mr I’s inpatient stay there are frequent record he was recurrently confused, sometimes aggressive and sometimes drowsy, though tending to wake up to eat meals.
75. As Mr I was off his baseline mobility he was kept in to attempt to mobilise him and to ensure he was eating and drinking sufficiently. Attempts at mobilising him were unsuccessful such that on 1 September the physiotherapist documented a new baseline mobility of being hoist transferred.
76. On 14 September Mr I had a NEWS of 0. The National Early Warning Score (NEWS) is a predictor of patient deterioration and includes seven measurements - temperature, blood pressure, respiratory rate, oxygen saturation, oxygen supply, heart rate, and level of consciousness. The score range is from 0 to 20 with 0 being very good with low risk of deterioration.
77. On 15 September 2022 at 5pm, a nurse on the discharge unit was concerned Mr I was very drowsy and had low intake of food at lunchtime. She called for a doctor to review Mr I.
78. At 5.30pm Mrs I came to see Mr I. Mr I woke up and Mrs I helped to feed him.
79. At 6.40pm a doctor reviewed Mr I. The nurse explained she had requested a review as Mr I was drowsy and had not eaten but had woken up and eaten when Mrs I arrived at 5.30pm. The doctor said if there were any problems he would come back to cannulate Mr I for intravenous fluids if he was not right. The doctor advised the nurse to call him again if there were any further problems.
80. There are no notes to suggest Mr I required any further help from a doctor, and he was discharged as planned.
81. We asked our physician adviser what criteria needed to be met in order for Mr I to be discharged. They told us the criteria is outlined in the Department of Health and Social Care’s hospital discharge and community support guidance, Annex D: criteria to reside – ‘maintaining good decision-making in acute settings’.
82. Every person on every general ward should be reviewed on a twice daily ward round to determine the following. If the answer to each question is ‘no’, active consideration for discharge to a less acute setting must be made:
• requiring ITU or HDU care?
• requiring oxygen therapy/NIV?
• requiring intravenous fluids?
• NEWS2 greater than 3? (clinical judgement required in persons with AF and/or chronic respiratory disease) • diminished level of consciousness where recovery realistic?
• acute functional impairment in excess of home or community care provision?
• last hours of life?
• requiring intravenous medication?
• undergone lower limb surgery within 48 hours?
• undergone thorax-abdominal/pelvic surgery with 72 hours?
• within 24 hours of an invasive procedure? (with attendant risk of acute life- threatening deterioration)
83. Our physician adviser said the list of criteria ends with the statement, ‘clinical exceptions will occur but must be warranted and justified. Recording the rationale will assist meaningful, time efficient review’, which means exceptions may be made on clinical judgement.
84. Our physician adviser told us there are two key reasons why Mr I’s discharge was appropriate. There was nothing more that could be done for Mr I in hospital. He did not require inpatient treatment. His oral intake was a little erratic, but that was not something the hospital could realistically resolve.
85. Intravenous fluids are sometimes given but offer no meaningful solution – people still need to drink themselves and intravenous fluids are sometimes counterproductive as they may stop people being thirsty which removes the incentive to drink for older confused people. The best solution is repeated encouragement by people familiar to the confused person, as is evidenced by the positive response to Mr I’s wife’s presence on 15 September.
86. Mr I had a PEACE plan (Proactive Enhanced Advance Escalation Care Plan) drawn up on 13 September. This is a document to help health care professionals deliver the best and most appropriate care to people with life limiting illnesses. The plan mentions it has been discussed with Mr I’s wife.
87. The clinical picture, supported by the PEACE plan, was Mr I was coming to the end of his life, and that there was little that could be done aside from keeping him as comfortable as possible. In such a situation, the criteria for discharge are less relevant as the expectation is the person is dying and nothing productive can be achieved by remaining in hospital.
88. Our physician adviser told us, Mr I’s discharge was appropriate, because he met the criteria for discharge, and he was a justified exception to the clinical criteria for discharge due to having a PEACE plan.
89. We do not see failings in the Trust’s decision to discharge Mr I on 15 September 2022. We do not make this decision without recognition of the distressing circumstances at the time and the impact on Mrs I and her family.
Impact
90. We next considered the impact of the failings we have identified. Mrs I told us she believes failings in care led to Mr I’s death. She told us this experience has led to feelings of sadness, frustration, anger and a complete lack of faith in the health service.
91. We saw the Trust did not weigh Mr I or refer him to a dietician on admission. We asked a physician adviser for help in understanding the impact these failings may have had on Mr I.
92. It is difficult to link the failure in not weighing Mr I or referring him to a dietician to his prolonged survival, because of his advanced dementia. This meant he was at significant risk of deterioration and death irrespective of referral to a dietician.
93. Our physician adviser referred to a clinical review article which states, ‘loss of appetite and difficulties with eating and maintaining weight are almost universal and expected complications of progressive dementia, even when appropriately textured foods and oral supplements are offered’.
94. Taking account of our advice, we are unable to link the failure to weigh, or refer Mr I to a dietician to his death. We understand why Mrs I has raised these concerns, and hope our explanations are helpful.
95. We saw no evidence the Trust considered Mr I’s change in alertness alongside his deterioration in mobility to inform a rehabilitation plan in accordance with physiotherapy and rehabilitation guidance. We also saw evidence the Trust encouraged Mr I to get out of bed on only three occasions during his admission. This is not in line with advice from #endpjparalysis campaign (NHS England)
96. Our physician adviser told us physiotherapy is challenging in a person who is confused or has dementia, and this is more so with more severe confusion. Mr I’s dementia was advanced, and this led to him being poorly cooperative with physiotherapy. There is no evidence a lack of physiotherapy leads to death, and we are therefore unable to link the failings we saw in relation to physiotherapy to Mr I’s sad death. Whilst we cannot link the failings to a clinical impact on Mr I, we can see how it will be upsetting for Mrs I and her family to know these aspects of care were not to the expected standard. We therefore make recommendations to the Trust to address this.