NH Trust
Failed to provide appropriate care for his mobility & nutrition
14. Mrs F says due to the inadequate physiotherapy and nutritional care from NH Trust during this admission her father’s physical condition was allowed to deteriorate and he came out with reduced mobility and reduced mental capacity.
15. Our physiotherapist adviser said the records indicate NH Trust provided appropriate care for Mr Z’s mobility during this period. The records show NH Trust carried out a thorough assessment of his condition prior to admitting him to hospital which provided the physiotherapy team with a good idea of his recent history.
16. The records indicate the physiotherapy team provided Mr Z with 31 therapy sessions during this admission, with additional therapy sessions provided by NH Trust’s occupational therapy team. Our physiotherapist adviser said the therapy sessions consisted of mobility practice, exercises and activities as well as therapy with dogs. The records indicate Mr Z was independently mobile prior to his admission and he needed physiotherapy support to maintain his mobility whilst he remained in the care of NH Trust. The records indicate Mr Z was able to mobilise independently when discharged.
17. The NICE guidance for acute medical care says for people admitted to hospital with a medical emergency, clinicians should provide access to physiotherapy and occupational therapy 7 days a week.
18. The GMC guidance says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
• promptly provide or arrange suitable advice, investigations or treatment where necessary.’
19. We carefully considered Mrs F’s complaint and the information she provided. We found NH Trust provided an appropriate programme of rehabilitation using a variety of methods to maintain Mr Z’s mobility. We found no evidence the physiotherapy care provided by NH Trust during this admission was detrimental to his condition.
20. The NICE nutrition guidance states:
‘All hospital inpatients on admission should be screened for malnutrition and the risk of malnutrition.
Nutrition support should be considered in people who are malnourished, as defined by any of the following: a body mass index (BMI) of less than 18.5 kg/m2, unintentional weight loss greater than 10% within the last 3–6 months, a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.
Nutrition support should be considered in people at risk of malnutrition, defined as those who have: eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer
Healthcare professionals should consider using oral, enteral or parenteral nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition, as defined above.’
21. Our dietitian adviser said there is no evidence in the records to indicate failings in how NH Trust managed and supported Mr Z’s nutrition. NH Trust assessed Mr Z using the Malnutrition Universal Screening Tool (MUST) following his admission on 24 February 2022, and at regular intervals throughout his admission, to establish and then monitor his risk of malnutrition.
22. The initial assessment recorded that Mr Z was at low risk of malnutrition (MUST score of 0) and required general ward-based support and encouragement with his nutrition. Our dietitian adviser said the records support this view and there is no evidence to indicate he required any additional, more intensive support with his nutrition during the first few weeks of his admission.
23. Mr Z’s weight on admission was 67kg and the records indicate it did fluctuate slightly over the following weeks. The records show his weight dropped to 65.9kg in mid-April (MUST score of 1 was recorded at this time) and the nursing team made a verbal referral to the dietitian for a review of his nutritional needs.
24. Our dietitian adviser said such a reduction in weight would not usually pose a significant risk and a referral to the dietitian would not usually be indicated with this score. However NH Trust referred him to enable the dietitian to assess his needs and make recommendations to support his nutrition.
25. The dietitian assessed Mr Z on 22 April 2022 and recommended additional nutritional supplements (Ensure Compact drinks) to help support his nutrition. Following this and throughout the remainder of his admission, Mr Z’s weight increased and his weight when discharged on 18 May 2022 is recorded as 68kg.
26. We carefully considered Mrs F’s complaint and the information she provided. We found NH Trust provided appropriate support to assist Mr Z with his nutrition and no evidence the nutrition care provided by NH Trust during this admission was inadequate or detrimental to his condition.
27. We found NH Trust took the appropriate steps in line with the NICE nutrition guidance to assess Mr Z’s risk of malnutrition and the support he required, monitor his nutritional intake and weight and provide support when he needed it. We found NH Trust referred him to its dietitian proactively to give him the best opportunity to prevent a deterioration in his condition from reduced nutrition.
28. The records include fully completed daily food charts which indicate Mr Z received appropriate support and nutrition during this period. There are isolated instances where he did not finish all of the meals provided to him and on some occasions he refused his meals. We acknowledge that such instances cannot always be prevented even with the most appropriate measures being put in place. However we found the support and additional supplements provided by NH Trust were successful in maintaining Mr Z’s nutrition during this admission.
Failed to ensure his medication review was completed in reasonable timeframe
29. Mrs F says the review should have taken 28 days but NH Trust kept her father in hospital much longer. The records indicate Mr Z was diagnosed with dementia in June 2020. At the time of his admission on 24 February 2022 his dementia had become advanced and he had started to demonstrate aggressive behaviour. The records also indicate he had been losing weight and wandering from his home. Due to the progression of his symptoms Mr Z was admitted to hospital for review and detained under the MHA. Mr Z remained in hospital until he was discharged to a care home on 18 May 2022.
30. The NHSE guidance says patients should be discharged to a less restrictive setting as soon as their purpose of admission is met and they no longer require care and treatment that can only be provided in hospital. Our psychiatrist adviser said the 28 day period referred to by Mrs F is the maximum duration a patient can be detained under Section 2 of the MHA. 28 days is not the maximum duration for a review and such reviews can often take longer depending on the individual circumstances of the patient and the results of the initial medication trials and treatment. In line with the NHSE guidance patients should only be discharged once it is safe to do so.
31. Our psychiatrist adviser said the aim of a review is to attempt to find a resolution of the symptoms that led to the need for the review. In Mr Z’s case NH Trust needed to mitigate the risk of his aggression and wandering, identify a suitable discharge environment and put in place appropriate treatment and support before he could be discharged. The records indicate during the course of his admission NH Trust monitored Mr Z’s behaviour and reviewed his care plan, behaviour management plan and his medications.
32. Our psychiatrist adviser said the records support the view the review took as long as it did because of the complexity of Mr Z’s needs and not due to any failings on the part of NH Trust. Our psychiatrist adviser said if NH Trust had not taken sufficient time to adequately review Mr Z’s needs at this time it would have led to a worsening of his symptoms and increased the risk he posed to himself and others.
33. We carefully considered Mrs F’s complaint and the supporting information she has provided. We acknowledge how distressing this time was for her and her family. We found no evidence to indicate NH Trust should have completed the review and discharged her father within 28 days of his admission on 24 February 2022.
34. The NHSE guidance says the length of hospital stay in older adult acute inpatient mental health services was around 80 days in 2021 and 2022. It seems Mr Z’s needs were very complex and NH Trust had to address several factors before it was safe to discharge him. We found no evidence NH Trust failed to ensure the review was completed in reasonable timeframe.
Failed to provide her father with appropriate antipsychotic medication
35. Mrs F says NH Trust tried too may medications and attempted them for too long before moving on to alternatives. She says her father was first given risperidone and then quetiapine, which she says are antipsychotic medications and inappropriate for a patient who has dementia. Mrs F also says NH Trust provided her father with a lot of ‘pro re nata’ medication (PRN, medication which is provided as and when needed). She says this caused her father to be overly medicated and very drowsy and caused his condition to decline.
36. Antipsychotic medication may be prescribed for people with dementia who develop changes such as aggression and psychosis which put them, or those around them, at risk of harm. Antipsychotic medication can help to reduce the frequency or intensity of these changes. However, they also have risks and can cause possible side effects, which the doctor must consider when deciding whether to prescribe them. The NICE dementia guidance says:
‘Only offer antipsychotics for people living with dementia who are either at risk of harming themselves or others or experiencing agitation, hallucinations or delusions that are causing them severe distress.
Follow the 2012 Medicines and Healthcare products Regulatory Agency (MHRA) advice for health and social care professionals on prescribing antipsychotics to people living with dementia.
Be aware that for people with dementia with Lewy bodies or Parkinson's disease dementia, antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions. Be aware that interventions may need to be modified for people living with dementia.
Before starting antipsychotics, discuss the benefits and harms with the person and their family members or carers (as appropriate).
When using antipsychotics: • use the lowest effective dose and use them for the shortest possible time • reassess the person at least every 6 weeks, to check whether they still need medication.
Stop treatment with antipsychotics: • if the person is not getting a clear ongoing benefit from taking them and • after discussion with the person taking them and their family members or carers (as appropriate).’
37. The MHRA guidance says:
‘Advice for healthcare and social-care professionals:
For prescribers considering using antipsychotics in patients without a current prescription:
• carefully consider, after a thorough clinical examination including an assessment for possible psychotic features (such as delusions and hallucinations) whether a prescription for an antipsychotic drug is appropriate.’
38. The records indicate Mr Z presented with high risk to himself from self-neglect, wandering, poor compliance with his medications, potential retaliation to his aggression towards others, as well as posing a high risk to others due to his aggressive behaviour. Our psychiatrist adviser said in light of these risks it was appropriate and in keeping with the NICE dementia guidance and MHRA guidance for NH Trust to commence Mr Z on a trial of antipsychotic medication.
39. The records indicate the trial was to see whether short term antipsychotic medication helped bring Mr Z’s symptoms of aggressive behaviour under control. NH Trust initially trialled the antipsychotic medication risperidone. The records indicate risperidone provided a poor therapeutic response, did not reduce Mr Z’s symptoms of aggression and may have contributed to his symptoms of stiffness. For this reason NH Trust stopped the medication on 10 March 2022 in line with the NICE dementia guidance and changed to the antipsychotic medication quetiapine.
40. To manage his symptoms NH Trust gradually increased Mr Z’s dose of quetiapine from 25 mg on 14 March 2022 to 50mg on 28 March 2022 and then 100mg on 11 April 2022. The records indicate the trial of quetiapine, and the increasing dose required to manage his symptoms, had the adverse side effect of causing Mr Z to become drowsy. The records also indicate Mr Z suffered two falls during the trial with quetiapine. For this reason, in line with the NICE dementia guidance, NH Trust stopped quetiapine and instead trialled trazodone, a medication to treat depression and anxiety, for the remainder of his admission.
41. Our psychiatrist adviser said this was a trial of medication in a controlled environment to see which was effective and which wasn’t. The records indicate when Mr Z showed adverse effects from one medication, as he did first with risperidone and then quetiapine, the medication was stopped and an alternative treatment trialled until the required results were achieved. Our physician adviser said such reviews can take time before a suitable result is achieved and the records indicate the trail was conducted in line with the NICE dementia guidance and moved on at the correct times.
42. Our psychiatrist adviser said there are always risks associated with such treatments, which can sometimes include but are not limited to falls, unexpected changes in behaviour and drowsiness. However the trial of medication was the correct approach to take and was the purpose of the admission. The risks would have been greater if the review was not carried out and if his symptoms gone untreated. Our psychiatrist adviser said Mr Z’s symptoms would have worsened and posed a greater risk to himself and others possibly leading to increasing morbidity and reduced life span.
43. The records indicate NH Trust monitored Mr Z’s symptoms of aggression and provided PRN lorazepam when his aggression was heightened. The NICE lorazepam guidance says:
‘Lorazepam (off-label indication) should only be used for the treatment of challenging behaviour associated with delirium on the advice of a specialist.
Start at the lowest possible dose (0.5–1 mg) orally and titrate in increments if necessary, after an interval of 2 hours until there is a clinical response.
The maximum dose in 24 hours should not exceed 2 mg.
The most frequently reported adverse effects include: • Daytime drowsiness • Dizziness • Muscle weakness • Ataxia (loss of coordination)
Review the person regularly and discontinue lorazepam as soon as possible.’
44. In its complaint response to Mrs F NH Trust said:
‘Please see below a list of when your father was given PRN medication and the reason it was given as record in his records.
• 7 April 2022 – 1mg Lorazepam given at 21.05 following the incident with a co patient • 9 April 2022 – 1mg Lorazepam administered as he appeared upset, on edge and was pacing around • 10 April 2022 – 1mg Lorazepam administered as he attempted to hit a male co-patient, staff intervened, your father was swearing, angry and upset • 12 April 2022 – 1mg Lorazepam administered due to agitation • 13 April 2022 - 1mg Lorazepam administered as he attempted to punch the domestic unprovoked, staff intervened to prevent harm • 15 April 2022 - 1mg Lorazepam administered due to agitation • 17 April 2022 - 1mg Lorazepam administered as he was resistive attempting to punch and kick staff
Since 17 April 2022 no further PRN medication has been given.’
45. Our psychiatrist adviser said the information available to us supports the view NH Trust prescribed PRN lorazepam in line with NICE lorazepam guidance. The records indicate NH Trust monitored Mr Z after the PRN medication was given for any adverse effects.
46. Our psychiatrist adviser said there is no evidence in the records to indicate Mr Z’s episodes of drowsiness were due to inappropriate provision of medication from NH Trust. Our psychiatrist adviser said in addition to any effects of the medication provided by NH Trust it is important to understand the progression of Mr Z’s dementia would also contribute to any episodes of drowsiness.
47. We carefully considered Mrs F’s complaint and the supporting information she has provided. We acknowledge how distressing this time was for her and her family. We found no evidence NH Trust failed to provide her father with appropriate antipsychotic medication. We found the medications attempted by NH Trust were appropriate for the trial and initiated, provided and changed in line with the NICE dementia guidance, the MHRA guidance and the NICE lorazepam guidance. We found no evidence to indicate the medication provided during this admission was detrimental to Mr Z’s condition.
Failed in its duty of care to safeguard her father
48. Mrs F says NH Trust failed to safeguard her father. She says he was injured by another patient following an altercation on 7 April 2022, suffering a broken nose. In its complaint response to Mrs F NH Trust said:
‘On 7 April 2022 in the evening your father approached another patient and punched him in the face. Unfortunately, this patient retaliated and punched your father which resulted in a nosebleed, a superficial cut to the side of his nose, a bruise over the nasal septum and his nose appeared fractured.
An ice pack was placed over his nose, ward staff contacted the duty doctor who attended the ward to review and examine your father, he was given paracetamol for pain. The duty doctor documented that bleeding had stopped soon after the incident, there was no loss of consciousness, no vomiting and all physical observations were completed and within normal range. The duty doctor did also document a possible nasal fracture; however, the management plan was conservative management and he expected spontaneous healing.’
49. The DOH safeguarding guidance says:
‘Safeguarding adults is about the safety and well being of all patients but providing additional measures for those least able to protect themselves from harm or abuse. Many patients are able to safeguard their own interests and protect themselves from neglect, harm or abuse. However, some adults are in vulnerable situations and are less able to protect themselves or make decisions about their safety.’
The safeguarding principles include:
‘Prevention
Prevention of harm or abuse is a primary goal. Prevention involves helping the person to reduce the risks of harm and abuse that are unacceptable to them.
Proportionality and least intrusive response appropriate to teg risk presented
Responses must be the least restrictive of the person’s rights and take account of the person’s age, culture, wishes, lifestyle and beliefs. Proportionality also relates to managing concerns in the most effective and efficient way.’
50. The purpose of the admission was to attempt to mitigate the risk posed by Mr Z’s symptoms of dementia including his aggressive behaviour. To do this NH Trust trialled several medications and closely monitored Mr Z to see the impact the medication had on his symptoms. The records indicate at points during this admission NH Trust also put in place 1-1 and 2-1 supervision to reduce the risk posed by his behavioural and psychological symptoms and his potential to act unpredictably and aggressively towards others.
51. However the records indicate the increased intervention during the times NH Trust was providing 1-1 and 2-1 supervision would often provoke an aggressive reaction from Mr Z increasing the risk of injury to himself, other patients and NH Trust staff. Our psychiatrist adviser said it was therefore a fine balancing act for NH Trust to provide appropriate supervision whilst not exacerbating Mr Z’s symptoms.
52. The records indicate NH Trust had placed Mr Z on standard observation at the time of this incident and he was no longer under 1-1 supervision. Our psychiatrist adviser said had he still been under 1-1 supervision at this time it is possible the incident could have been prevented. However given Mr Z’s previous aggression towards MH Trust staff in his personal space during 1-1 supervision it is also possible continuing it for longer could have worsened his feelings of anxiety and aggression creating an environment where his aggressive behaviour occurred more frequently.
53. The records indicate this was an isolated incident and there are no other reports of Mr Z suffering harm or injury as a result of his behaviour or the behaviour of other patients. Our physician adviser said the risk of such incidents cannot be completely eliminated even with the appropriate measures such as observation and medication being put in place. The aim is to reduce the risk as much as possible.
54. We carefully considered Mrs F’s complaint and the supporting information she has provided. We acknowledge how distressing this incident was for Mr Z and how upsetting it was for Mrs F and her family to learn about it. We also considered the advice from our psychiatrist adviser, the DOH safeguarding guidance and the information in the records.
55. We found no evidence NH Trust failed in its duty to safeguard Mr Z as a result of this incident or that the incident happened due to failings on the part of NH Trust. We found no evidence there were any further measures NH Trust could have put in place to predict or prevent the incident on 7 April 2022.
56. During our discussions Mrs F also said NH Trust restricted her from accompanying her father on walks during visits. The records indicate NH Trust took this decision as a measure to reduce the risk of injury to Mr Z or others. Our psychiatrist adviser said as Mr Z was suffering from advanced dementia and impaired mobility, in addition to the risk of aggressive behaviour or suffering a fall, it was an appropriate decision for NH Trust to restrict family taking him out for walks to ensure his safety and the safety of others.
57. We acknowledge how upsetting this decision would have been for Mrs F. We found no evidence to indicate this decision was inappropriate or not in keeping with the DOH safeguarding guidance.
NGH Trust
Left her father in A&E for 3 days before moving him to a ward
58. Mrs F says NGH Trust kept her father in A&E for too long and he should have either been discharged back to the care home or placed on a ward much sooner. She says NGH Trust told her it couldn’t discharge him as the care home wouldn’t take him back and they didn’t want to admit him to hospital as he was not medically unwell. Mrs F says it was only after the family intervened that her father was moved from A&E onto a ward.
59. The records indicate Mr Z arrived in A&E at NGH Trust at 5.22pm on 4 July 2022 due to concerns raised by the care home about his symptoms of delirium and unpredictable behaviour. Mr Z was moved to a room in the Emergency Department Clinical Observation Area (EDCOA) at 6.55pm for blood tests to look for potential causes of his delirium. As NGH Trust has said in its complaint response to Mrs F, the EDCOA functions in the same way as a ward and patients have individual rooms with beds.
60. After reviewing the results of his blood and urine tests NGH Trust decided Mr Z was not medically unwell and did not require a hospital admission for treatment of a medical condition. The records indicate as his admission was due to his symptoms of delirium and unpredictable behaviour, and as no physical problems were identified, he was assessed by NGH Trust’s acute mental health team. The acute mental health team discussed the possibility of Mr Z being admitted back to NH Trust at 11.50pm.
61. The records indicate NH Trust asked NGH Trust to perform further tests to rule out infection. The tests were carried out and came back on 5 July 2022 showing no signs of infection. NGH Trust referred Mr Z to NH Trust on the same day. The records indicate on 6 July 2022, after reviewing the referral NH Trust decided not to transfer Mr Z back into its care at this time as he was not displaying aggressive behaviour and did not require a mental health assessment.
62. The records indicate his previous care home declined to accept Mr Z back as it felt it could not manage his behavioural issues. As it was now clear that Mr Z’s discharge was going to be complex and require social care input to identify a suitable dementia nursing home, NGH Trust transferred him to a medical ward at 11.41pm on 6 July 2022.
63. The discharge guidance says the NHS and local authorities have a duty to co-operate and provide the patient with a placement that meets their needs. It says the discharge process should support safe and timely discharge to the right place and with the right treatment, care and support for individuals. As his previous care home felt it could not provide the care he needed, NGH Trust acted in line with the discharge guidance in placing Mr Z in the EDCOA and then on a medical ward rather than discharging him from A&E.
64. The records indicate Mr Z was kept in A&E for I hour and 33 minutes before NGH Trust moved him to the EDCOA. He then spent 2 days and 6 hours in the EDCOA undergoing tests and whilst NGH Trust explored the possibility of a transfer to NH Trust before moving him to a medical ward on the 6 July 2022.
65. Our A&E adviser said as the EDCOA is a similar environment to a medical ward there is no evidence in the records to indicate Mr Z would have received a different standard of care had he been moved sooner. There is no evidence to indicate his stay on the EDCOA was detrimental to his condition and it was an appropriate environment to provide his care given the possibilities being explored by NGH Trust at this time. Once it was established that transfer to NH Trust or discharge back to his previous care home was not possible it was appropriate to admit him to a ward until suitable discharge arrangements could be made.
66. We carefully considered Mrs F’s complaint and the supporting information she has provided. We acknowledge how distressing this incident was for her and her family. We also considered the advice from our A&E adviser, the discharge guidance and the information in the records.
67. We found no evidence to indicate it was inappropriate for NGH Trust to care for Mr Z in the EDCOA whilst carrying out tests and exploring the options for possible transfer and discharge. We found no evidence the time he spent in the EDCOA was inappropriate or detrimental to his condition.
Failed to provide appropriate nutrition and help and support with eating and drinking
68. Mrs F says her father needed assistance with his meals but NGH Trust didn’t provide it and as a result he didn’t eat enough food. She says he lost 10kg in weight in 3 weeks as a result of the poor nutritional care from NGH Trust and this had an impact on his physical condition.
69. Our dietitian adviser said the evidence in the records indicates failings in how NGH Trust managed and supported Mr Z’s nutrition. In its response to Mrs F’s complaint NGH Trust has acknowledged it miscalculated the initial MUST score and it says this is why it missed the opportunity to refer Mr Z to the dietitian and provide the nutritional care he needed.
70. Our dietitian adviser said even in light of the failing with the MUST, there is other evidence in the records to indicate NGH Trust failed to consider Mr Z’s nutrition and other signs that should have been identified and acted upon. The records of the daily food charts are poor quality and are not fully completed. Some days the food charts note that Mr Z did not eat his meals and some days have no entries at all.
71. The records provide no evidence to indicate Mr Z’s poor oral intake was considered or acted upon by NGH Trust. There is no record of NGH Trust acknowledging the difficulties he had with eating and drinking at mealtimes and no records of any efforts being taken to support him. Our dietitian adviser said the records provide no evidence to indicate NGH Trust considered Mr Z’s nutritional needs and the support he required at any point.
72. The records indicate NGH Trust did not weigh Mr Z during the first few weeks and instead estimated his weight. When it did weigh him on 24 July 2022 his weight was 54.3kg which is a significant change from his previous weight. The records indicate he was in a frail condition during this admission and NGT Trust recorded his BMI at 18.5 which would support the view he was at increased risk of malnutrition.
73. Our dietitian adviser said there were clear signs his weight was heading in a downward trajectory during this admission. There are also clear signs he was not eating sufficient food to maintain his nutrition. However there is no evidence NGH Trust considered whether Mr Z needed to be assessed by the dietitian at any point and no measures were put in place to provide support with his nutrition.
74. We carefully considered Mrs F’s complaint and the information she has provided. We found NGH Trust did not act in line with the NICE nutrition guidance and provide appropriate support to assist Mr Z with his nutrition. We think this is a failing.
75. We acknowledge NGH Trust accepts it miscalculated the MUST when Mr Z was admitted and this led to the initial failure to refer him to the dietitian. However it seems NGH Trust missed further opportunities to provide nutritional care and support which may have been beneficial to him.
76. The records indicate he was at risk of malnutrition, had lost a significant amount of weight and was not eating sufficiently. We think NGH Trust should have acted on the signs that Mr Z was having difficulty with his nutrition and referred him to the dietitian. Nutritional support had proved successful previously and we think an adequate dietitian review would have led to nutritional support measures being recommended which is likely to have provided Mr Z with some degree of comfort and improved his nutritional intake.
Failed to maintain her father’s mobility
77. Mrs F says NGH Trust kept her father in bed throughout his admission which was mentally distressing for him and led him to become frailer. She says as a result of his increased frailty her father suffered three falls shortly after he was discharged from hospital.
78. The NICE guidance for acute medical care says for people admitted to hospital with a medical emergency, clinicians should provide access to physiotherapy and occupational therapy 7 days a week. However the records indicate that when he was admitted to the medical ward Mr Z was medically optimised for discharge. The records also make it clear that this was a social admission, meaning he needed to remain in hospital until his social circumstances could be resolved, rather than because of a medical problem.
79. Our physiotherapy adviser said the records provided to us by NGH Trust do not include any notes to demonstrate physiotherapy was provided to Mr Z during this admission. The records provided by the Trust do not include any specific physiotherapy records and the records from the ward rounds do not make any reference to physiotherapy in Mr Z’s care plans. Our physiotherapy adviser said this would indicate NGH Trust decided physiotherapy was not considered necessary for Mr Z during this admission.
80. The records indicate Mr Z was moving around his bed space and mobilising independently on the ward following his admission to the medical ward. Our physiotherapy adviser said reports of Mr Z being independently mobile would support the view that physiotherapy was not required at this time.
81. However the records indicate NGH Trust restricted Mr Z to his bed and his chair during this admission due the lack of staff available to provide 1-1 supervision. It is widely acknowledged that prolonged immobility can have a negative impact on a patient and contribute to reduction in muscle mass, bone density and impairment in other body systems within the first week of bed rest.
82. Our physiotherapist adviser said under these circumstances it would have been appropriate for NGH Trust to provide Mr Z with some degree of physiotherapy while being restricted to his bed to maintain his mobility and general function. There is no evidence in the records to indicate NGH Trust provided or considered this.
83. The records indicate Mr Z was able to mobilise independently following his admission to the ward on 6 July 2022 and the handling assessment of 8 July 2022 indicates he had no mobility problems at that time. The record of the subsequent handling assessment of 16 July 2022 indicates Mr Z required a degree of support with his mobility. Following this the records indicate Mr Z was still able to mobilise up until 23 July 2022. However the discharge summary states that by the time he was discharged on 26 July 2022 he was ‘confined to bed or chair.’
84. Our physiotherapy adviser said the information in the records indicates the lack of physiotherapy from NGH Trust during this admission, after it had decided to restrict Mr Z to his bed and chair had a negative impact on his mobility. The records indicate there was a marked deterioration in his mobility at the point he was discharged compared to when he was admitted.
85. We carefully considered Mrs F’s complaint and the supporting information she has provided. We also considered the advice from our physiotherapist adviser, the NICE guidance for acute medical care, the GMC guidance and the information in the records.
86. We think after it decided to restrict Mr Z to his bed and chair, NGH Trust should have provided him with physiotherapy to maintain his mobility and general function. We think the lack of physiotherapy from NGH Trust during this admission is a failing.
87. We cannot say that this failing resulted in the falls Mr Z suffered after he was discharged as Mr Z was always at risk of suffering a fall and there is no recorded evidence of the circumstances of the falls. However we think this failing had a negative impact on his mobility and general wellbeing whilst on the ward.
Failed to provide appropriate anti-psychotic medication & Inappropriately treated him with risperidone and lorazepam medication
88. We have decided to address these two points together as they are very closely linked.
Mrs F says NGH Trust over medicated her father with antipsychotic medication to sedate him, make him easier to manage and prevent him from wandering. She says when the family visited him they could see he was barely conscious as a result of the antipsychotic medication NGH Trust used.
89. Mrs F says her father could not tolerate risperidone due to the side effects and he was also sensitive to lorazepam. She says NGH Trust should have known this and not used these medications.
90. The records indicate following his admission NGH Trust provided Mr Z with trazodone as this was the medication he was being treated whilst in the care home prior to his admission. Our psychiatrist adviser said there is no evidence in the records to indicate the treatment with trazodone, or the doses provided by NHS Trust, were inappropriate. The records indicate NGH Trust continued the trazodone treatment put in place during the previous medication review from NH Trust to ensure Mr Z received the treatment to help manage his behavioural and psychological symptoms of dementia. The records indicate NGH Trust provided Mr Z with low doses of trazodone consistent with his previous treatment.
91. The records indicate in its attempts to manage Mr Z’s behaviour NGH Trust also provided him with one dose of risperidone on 5 July and a second dose on 6 July 2022. This was despite the medication review during his previous hospital admission trialling risperidone and discontinuing it due to the poor impact it had on his symptoms and the unwanted side effects it caused. In its response to Mrs F’s complaint NGH Trust said it provided risperidone as it was indicated in his GP records, which it seems were not updated with the medications from his previous discharge from hospital of 18 May 2022.
92. The NICE dementia guidance says:
‘Before starting antipsychotics, discuss the benefits and harms with the person and their family members or carers (as appropriate). Consider using a decision aid to support this discussion. NICE has produced a patient decision aid on antipsychotic medicines for treating agitation, aggression and distress in people living with dementia.’
93. Our psychiatrist adviser said there is no evidence to indicate the two doses of risperidone had a negative impact on Mr Z or caused his condition to deteriorate. The records indicate NGH Trust provided Mr Z with low doses on each occasion. However it seems NGH Trust should not have prescribed or administered risperidone during this admission due to the results of the previous trial. We found NGH Trust did not act in line with the NICE dementia guidance before providing Mr Z with two doses of risperidone. We think this is a failing.
94. The records indicate the Trust gave Mr Z two doses of lorazepam on the 7 and 8 July 2022 after he became aggressive. Our psychiatrist adviser said the information available to us so far supports the view NGH Trust prescribed PRN lorazepam in line with NICE lorazepam guidance and provided Mr Z with low doses on both occasions. Our psychiatrist adviser said there is no evidence in the records to indicate Mr Z’s episodes of drowsiness were due to inappropriate provision of medication from NGH Trust. In addition to any effects of the medication provided by NH Trust it is important to understand the progression of Mr Z’s dementia would also contribute to any episodes of drowsiness.
95. We carefully considered Mrs F’s complaint and the supporting information she has provided. We acknowledge how distressing this time was for her and her family. We acknowledge NGH Trust provided risperidone on 5 and 6 July 2022 in an attempt to control her father’s aggressive behaviour. This was not in keeping with the NICE dementia guidance given his previous reaction and the decision not to continue treatment with risperidone during the previous medication review. We partly uphold this point of complaint.
96. We found, other than the 2 doses of risperidone, the antipsychotic medications provided by NGH Trust were appropriate for Mr Z’s condition and symptoms during this admission and provided in line with the NICE dementia guidance, the MHRA guidance and the NICE lorazepam guidance. We found no evidence to indicate the medication provided during this admission was detrimental to Mr Z’s condition or that his periods of drowsiness were due to inappropriate provision of antipsychotic medication from NGH Trust.