Admission to Rydal Ward at MC Trust from 9 to 15 December 2020
12. Mrs S says MC Trust failed to provide her mother with the treatment she needed to prevent her physical condition from worsening during her admission to Rydal Ward between 9 and 15 December 2020. Mrs S says her mother’s physical condition deteriorated so much she had to be taken to A&E and admitted to hospital for medical treatment.
13. The CQC standards point to the key idea that the standard of health care in a specialist mental health setting should be as good as any other setting. It says:
‘A good service will ensure that people with mental health problems receive the same standard of physical healthcare as any other member of society. They may deliver this through their own appropriately qualified and experienced staff or in partnership with other providers. There are two main tasks for practitioners in mental health services:
• Medical assessment to ensure physical illness is not causing the psychiatric presentation
• Monitoring for adverse physical effects of antipsychotic treatment or other causes of poor physical health.’
14. The RCPS guidance says:
‘Physical healthcare
Patients have follow-up investigations and treatment when concerns about their physical health are identified during their admission. This is undertaken promptly and a named individual is responsible for follow-up. Advice may be sought from primary or secondary physical healthcare services.
The team including bank and agency staff are able to identify and manage an acute physical health emergency.’
15. The records indicate Mrs A had a history of Alzheimer’s disease and related dementia. She was admitted on 9 December 2020 under section 2 of the mental health act (MHA) due to an increase in her symptoms of psychosis. The records indicate she had started to display confused behaviour, reduced awareness and had experienced hallucinations. Our psychiatrist adviser said such features of psychosis are possible complications of Alzheimer’s disease but may also be caused by a physical health problem such as an infection. For this reason it was appropriate to admit her to a specialist mental health unit so she could be assessed and a plan of treatment put in place in a safe and appropriate environment.
16. The records indicate following her admission to Rydal Ward, MC Trust carried out extensive investigations which included biochemistry tests (blood tests used to evaluate the functional ability of several critical organs and systems of the body) which did not identify anything abnormal. The records show MC Trust performed haematology tests (blood tests which look for a variety of blood conditions) which did not identify anything abnormal. The records of these tests show Mrs A’s white blood cells were not raised indicating there was no immediate signs of infection.
17. MC Trust performed an electrocardiogram (ECG, a test that records the electrical activity of the heart, including the rate and rhythm) which the records show did not identify anything abnormal. The records also show Mrs A’s food intake and fluid balance (the regulation of water and electrolytes in the body which is measured by monitoring the amount of fluid entering and leaving the body to determine whether there is a deficit or excess) were normal and regular observations were carried out by MC Trust’s clinical and nursing team.
18. Our psychiatrist adviser said Mrs A’s condition on admission suggested she was experiencing hallucinations, paranoia and disorientation. The records indicate the investigations carried out by MC Trust to try to identify the reason for the deterioration in her mental state, and the observations put in place to monitor her condition for any further deterioration, were appropriate and consistent with the CQC standards.
19. The records indicate Mrs A’s physical condition remained stable until 9.38am on 15 December 2020. At this time Mrs A was reviewed by MC Trust’s medical emergency team due to concerns raised during the morning observation rounds about a noticeable increase in her confusion. The MC Trust medical emergency team assessed Mrs A and identified she was suffering tachycardia (a heart rate over 100 beats per minute) and her heart rate was recorded at 114 beats per minute at this time. Tests also found her oxygen saturation level had dropped to 91% (a sign that her oxygenated blood supply had reduced).
20. It seems at this point Mrs A’s medical needs became the priority. Our psychiatrist adviser said the change in her symptoms indicated a possible infection or other specific medical problem which would require transfer to an acute hospital (a hospital equipped to provide immediate care for severe medical conditions). The records indicate the staff on Rydal Ward recognised this and transferred her to A&E at Whiston Hospital, an acute hospital at MWL Trust for investigation of her symptoms and treatment in line with the RCPS guidance.
21. To support her view that the care her mother received on Rydal Ward caused her condition to deteriorate Mrs S points to the fact her mother had to use a wheelchair and a catheter despite previously being independently mobile and continent. She says this demonstrates how her condition deteriorated very quickly after her admission due to the poor care provided by MC Trust.
22. We acknowledge Mrs A became unwell during this admission requiring transfer to an acute hospital. We also acknowledge that she required support with her mobility and had a catheter fitted during this admission. Our psychiatrist adviser said there is no evidence in the records which would indicate the physical deterioration Mrs A suffered was due to inadequate or improper care from MC Trust. Our psychiatrist adviser said on the balance of probabilities, it is likely the deterioration in her physical condition was due to a combination of the worsening of her Alzheimer’s related dementia and an as then unidentified infection.
23. We carefully considered Mrs S’ complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate MC Trust failed to provide Mrs A with appropriate care and treatment or that her condition deteriorated due to lack of care and treatment during this admission.
24. We found when Mrs A’s physical condition deteriorated MC Trust acted appropriately to involve its medical emergency team and transferred her to an acute hospital in line with the RCPS guidance.
Care provided by MWL Trust from 15 to 20 December 2020
25. Mrs S says MWL Trust failed to provide her mother with the treatment she needed to prevent her condition from worsening following her transfer on 15 December 2020 until she became involved in her mother’s care on 20 December 2020.
26. The GMC guidance states doctors must provide a good standard of care and when assessing patients must:
• adequately assess the patient’s conditions, taking account of their history and where necessary, examine the patient
• promptly provide or arrange suitable advice, investigations or treatment where necessary
27. Mrs A was transferred to A&E on 15 December 2020 and admitted to hospital. The records of her admission state she was experiencing weakness, reduction in her usual level of mobility, increased confusion, tachycardia and reduced oxygen levels. Our physician adviser said the main clinical finding in the records at this time is Mrs A’s tachycardia. MWL Trust performed blood tests which identified elevated levels of C reactive protein (CRP, a protein made in the liver that increases when there is inflammation in the body) consistent with infection. MWL Trust diagnosed infection of unknown source and started treatment with antibiotics.
28. MWL Trust performed a physical examination of Mrs A’s chest and abdomen and a chest X-ray which found no signs of abnormalities. The records indicate MWL Trust concluded her infection was most likely to be a urinary tract infection (UTI) and changed her medication to a more appropriate antibiotic (trimethoprim). The records show by 17 December 2020 Mrs A was experiencing urinary retention and MWL Trust reinserted her urinary catheter which enabled a large volume of urine to be passed.
29. Our physician adviser said MWL Trust’s medical assessments of Mrs A from 15 to 20 December 2020 showed evidence of an infection which was causing delirium, and the most likely source of the infection was from her urinary tract. The records indicate MWL Trust recognised the evidence of infection and prescribed appropriate antibiotics to treat it. The records indicate MWL Trust actively assessed Mrs A’s clinical state during the first five days of her admission and made daily entries in her clinical notes to track the progress of her physical condition. The records also indicate MWL Trust performed blood tests during this period to track the progression of the infection.
30. Our physician adviser said there is no evidence in the records to indicate MWL Trust failed to provide Mrs A with the medical care and treatment she needed to prevent her physical condition from worsening. The records indicate NWL Trust investigated the cause of her condition and provided treatment in line with the GMC guidance.
31. To support her view that the care her mother received between 15 and 20 December 2020 was inadequate, Mrs S says MWL Trust failed to assist her mother with her nutrition and fluid intake, maintain her hygiene and ensure she took her medication. She says it is only when she became involved in her mother’s care on 20 December 2020 that these aspects of her care improved. In its response to Mrs S’ complaint MWL Trust has acknowledged it fell short in some of these aspects of care and has apologised.
32. The NICE nutrition guidance states:
• Screening for malnutrition should be carried out by healthcare professionals with appropriate skills and training • All hospital in-patients should be screened on admission and screening should be repeated weekly or when there is cause for clinical concern (for example; unintentional weight loss fragile skin and poor wound healing) • Nutrition support should be considered for people who have eaten little or nothing for more than 5 days and /or are likely to eat little or nothing for the next five days or longer.
33. The NMC guidance recommends nurses:
• Use evidence-based, best practice approaches for meeting needs for care and support with nutrition and hydration, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions • Observe, assess and optimise nutrition and hydration status and determine the need for intervention and support • Use contemporary nutritional assessment tools • Assist with feeding and drinking and use appropriate feeding and drinking aids • Record fluid intake and output and identify, respond to and manage dehydration or fluid retention.
34. The records indicate MWL Trust assessed Mrs A’s risk of malnutrition during this period and noted she was a medium risk and required assistance with her nutrition. The records indicate MWL Trust provided intravenous fluids (specially formulated liquids that are injected into a vein to prevent or treat dehydration) after she was admitted to the ward and put in place a plan of 1:1 nursing care to assist with her nutrition, hygiene and medication. Unfortunately the records indicate Mrs A was frequently resistant to care and support as a result of the deterioration in her Alzheimer’s disease.
35. Our nurse adviser said Mrs A’s food charts from 17 to 20 December 2020 show she had a very poor food intake during this time. The records also indicate MWL Trust did not record her weight during this period. Despite her poor food intake and medium risk of malnutrition, there is no evidence in the records to indicate NWL Trust considered referring her to the dietitian. The records indicate Mrs A was taking on oral fluids during this time and it would have been in line with the NICE nutrition guidance to refer her to the dietitian to consider whether optimising her nutrition with supplements may have been appropriate given her poor food intake.
36. We cannot see from the information in the records that this led to a deterioration in Mrs A’s condition at this time. However we acknowledge Mrs A’s nutrition improved with the support provided by Mrs S from 20 December 2020. We think the lack of a referral to the dietitian is a failing and a missed opportunity to provide specialist support which may have been beneficial in improving Mrs A’s nutrition during the initial days of her admission.
37. The NMC guidance says nurses should:
• demonstrate the knowledge, skills and ability to act as a role model for others in providing evidence-based, person-centred nursing care to meet people’s needs related to mobility, hygiene, oral care, wound care and skin integrity
• observe, assess and optimise skin and hygiene status and determine the need for support and intervention.
38. The NMC code says nurses should:
• make sure you deliver the fundamentals of care effectively • avoid making assumptions and recognise diversity and individual choice • make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay.
39. The records indicate MWL Trust assessed Mrs A and concluded she required ‘full assistance’ with her hygiene needs. The nursing notes in the records make frequent reference to the support the nursing team provided to assist with her hygiene. However the records also indicate Mrs A was often resistant to attempts from the nursing team to provide personal care.
40. In its response to Mrs S’ complaint MWL Trust has acknowledged it had difficulty providing personal care to Mrs A on some occasions and this led to incidents where adequate hygiene care had not been provided when Mrs S attended to visit her mother. MWL Trust has apologised for the occasions where the care fell below the required standard and we think this is appropriate to address this failing.
41. We acknowledge that maintaining hygiene where a patient is experiencing significant mental health and behavioural difficulties such as those Mrs A was experiencing is often a challenging aspect of care. We found no evidence to indicate the incidents where MWL Trust were unable to provide Mrs A with appropriate personal care led to an unremedied injustice or caused her condition to deteriorate during the first five days of this admission.
42. With regards to medication administration the RPS guidance recommends:
• Records are kept of all medications administered or withheld, as well as those declined • Such records are completed at the time of the administration/refusal or as soon as possible thereafter and are clear, legible and auditable • When a medication is not administered or refused, details of the reason why (if known) are included in the record and, where appropriate, the prescriber multidisciplinary team is notified in accordance with the organisational policies and procedures. Appropriate action is taken as necessary.
43. The medication administration charts in the records show MWL Trust provided and recorded Mrs A’s medications in line with the RPS guidance during the period 15 to 20 December 2020. There is only one documented occasion when MWL Trust did not provide her medication and this relates to one 10mg dose of aripiprazole which was prescribed to be given orally at night but was not administered on 17 December 2020. The reason is documented on the medication administration chart as ‘drug not available’.
44. The records indicate Mrs A needed assistance with her medication from the nursing team and on some occasions her medication was provided to her with yoghurt or water to make it easier to take. The records do not provide evidence of any significant concerns around Mrs A accepting medication during the first five days of her admission. However in its response to Mrs S’ complaint MWL Trust acknowledges that on occasion she would refuse to take her medication. MWL Trust has apologised for this and for the instances where Mrs S attended to visit her mother and saw medication left on her table. We think this is appropriate to address this concern.
45. We acknowledge encouraging compliance with medication where a patient is experiencing significant mental health and behavioural difficulties can be challenging for both the patient and the care provider. The wishes of the patient and the distress they are experiencing have to be considered. We have seen no evidence so far to indicate the incidents where Mrs A refused her medication and the incidents where Mrs S found it had been left on her table led to an unremedied injustice or caused her condition to deteriorate during the first 5 days of this admission.
46. We carefully considered Mrs S’ complaint and the supporting information she has provided. We acknowledge how distressing this period in hospital was for her and her mother. We also considered the information in the records, guidance and the advice we have received.
47. We have found failings in the nutritional care provided by MWL Trust during this period, in particular there was a failure to refer her to the dietitian in order to optimise her nutritional intake when it became clear her food intake was poor. We partly uphold this point of complaint as we have not found any evidence of failings in any other aspects of the care and treatment provided by MWL Trust during this period that have led to an unremedied injustice.
Admission to Rydal Ward at MC Trust from 1 to 17 January 2021
48. Mrs S says MC Trust failed to provide her mother with the treatment she needed to prevent her physical condition from worsening following her transfer back to Rydal Ward on 1 January 2021. Mrs S says her mother’s physical condition deteriorated so much she had to be taken to hospital for medical treatment again on 16 January 2021.
49. The records indicate Mrs A was transferred back to Rydal Ward on 1 January 2021. Although her medical condition had not fully resolved by this time the records indicate MWL Trust felt it had become stable enough for her to continue her mental health investigations on Rydal Ward. Our psychiatrist adviser said it was appropriate to transfer Mrs A back at this time as she still required observation under Section 2 of the MHA to investigate why she had developed symptoms of psychosis and whether she needed further treatment for them.
50. Our psychiatrist adviser said the records state Mrs A was still experiencing hallucinations, paranoia and confusion when she returned to Rydal Ward. By this time she also required support with her mobility, continence care and monitoring of her fluid levels for indications of a repeat of her urine retention. The records indicate MC Trust continued to review Mrs A’s medication in line with the CQC standards and continued to provide the antibiotic medication for her infection. Our psychiatrist adviser said there is no evidence in the records to indicate that any aspect of her care was neglected.
51. The records indicate Mrs A’s physical condition deteriorated again on 16 January 2021. The daily observations state the nursing team felt she had not been her usual self during the previous two days and had become more confused and lethargic, increasingly sleepy and less mobile around the ward. She was reviewed by the on-call doctor who felt her deterioration was likely due to her infection. The records indicate Mrs A also vomited following administration of her medication that evening. Due to the concerns MC Trust had about her physical condition the nursing team called an ambulance to transfer Mrs A back to Whiston Hospital for medical treatment.
52. Our psychiatrist adviser said there is no evidence to indicate her deterioration was due to poor or inadequate care. Our psychiatrist adviser said there is no evidence in the records to indicate the Mrs A’s deterioration can be linked to any action or inaction from MC Trust during her admission to Rydal ward.
53. To support her view that the care her mother received on Rydal Ward caused her condition to deteriorate Mrs S points to the fact her mother had to use a wheelchair and a catheter again very soon after she went back.
54. The admission summary in the records when she was transferred back to Rydal Ward on 1 January 2021 states Mrs A’s mobility had deteriorated since her previous admission and she was considered a high risk of suffering a fall. The records indicate the catheter was put in place on 7 January 2021 due to Mrs A experiencing urinary retention.
55. Our psychiatrist adviser said the provision of a wheelchair is appropriate for a patient who is considered at high risk of suffering a fall. Mrs A’s reduced mobility was recorded on the day of transfer and cannot be attributed to any aspect of care provided to her on Rydal Ward during this admission. The records indicate Mrs A had suffered urinary retention previously which had been successfully treated with the provision of a urinary catheter. There is no evidence in the records to indicate her urinary retention and the need for a catheter was a due to failings in the care provided to her on Rydal Ward during this admission.
56. We acknowledge Mrs A became unwell during this admission. Our psychiatrist adviser said there is no evidence in the records which would indicate the physical deterioration Mrs A suffered was due to inadequate or improper care on the part of MC Trust. Our psychiatrist adviser said on balance of probabilities, based on the evidence in the records, it is likely the deterioration in her physical condition was due to a combination of a worsening of her Alzheimer’s disease and her ongoing infection.
57. We carefully considered Mrs S’ complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate MC Trust failed to provide Mrs A with appropriate care and treatment or that her condition deteriorated due to lack of care and treatment during this admission.
Admission to MWL Trust from 17 January to 21 February 2021
58. Mrs S says MWL Trust failed to provide her mother with the treatment she needed to prevent her condition from worsening following her transfer from MC Trust on 17 January 2021 until she was discharged home on 21 February 2021.
59. During her admission on 17 January 2021 MWL Trust noted Mrs A had rapidly deteriorated over the previous two days, was approaching the end of life but did ‘not appear to be dying’ at that time. MWL Trust admitted her to a ward for antibiotic treatment and the records indicate it felt this was the ceiling of care (the highest level of intervention deemed appropriate by a medical team for a patient) it could provide to Mrs A due to the deterioration in her condition.
60. MWL Trust performed blood tests which identified an elevated CRP level of 113, diagnosed UTI and started treatment with oral amoxicillin antibiotic medication and intravenous fluids. On 25 January 2021 the records indicate MWL Trust escalated Mrs A’s antibiotic medication to intravenous tazocin as her CRP had not reduced as much as it had hoped. The records indicate on completion of the seven-day course of intravenous tazocin antibiotic medication Mrs Feeny’s CRP had reduced significantly to 55.
61. The records indicate MWL Trust identified the cause of Mrs A’s deterioration and provided the appropriate antibiotic medication to treat it. Our physician adviser said the records indicate MWL Trust also investigated whether there were any other additional causes for the deterioration in her condition. MWL Trust performed a CT scan of Mrs A’s abdomen to look for any indications of hidden sources of infection such as an abscess. The CT scan report was completed on 28 January 2021 and identified no new significant findings.
62. On 5 February 2021 MWL Trust provided a second course of intravenous tazocin antibiotic medication. The doctors also provided steroid treatment from 12 February 2021 to attempt to improve Mrs A’s overall clinical state. The records indicate despite the antibiotic medication and steroid treatment, Mrs A’s condition continued to deteriorate. By 21 February 2021 the records indicate she had become more withdrawn, less communicative and her oral food intake had decreased.
63. Our physician adviser said the evidence supports the view Mrs A’s deterioration occurred despite appropriate efforts being taken by MWL Trust to manage her condition. The records indicate MWL Trust took multiple steps to try and optimise and improve Mrs A’s condition, however the interventions were unsuccessful. Our physician adviser said there is no evidence in the records to indicate there were any additional steps MWL Trust could have taken to improve Mrs A’s condition or change her outcome.
64. To support her view that the care provided by MWL Trust was inadequate Mrs S says it failed to provide appropriate nutrition and fluids and maintain her mother’s hygiene which caused her condition to deteriorate.
65. During her admission on 17 January 2021 MWL Trust noted Mrs A was not eating and drinking sufficiently prior to her admission. Our nurse adviser said despite this initial view of her poor nutrition and fluid intake the daily food and fluid charts in the records are poor quality and not fully completed. In its response to Mrs S’ complaint MWL Trust has acknowledged it failed to keep adequate food and fluid charts and apologised. As a result of Mrs S’ complaint MWL has taken steps to improve its recording and maintaining of food and fluid charts, which we think is appropriate to address the failings in record keeping.
66. The entries that are recorded in Mrs A’s food and fluid charts often contradict the records in the daily notes about the food and fluid she had taken. For this reason we are unable to say with any clarity whether Mrs A took on appropriate food and fluid during this admission. The records indicate MWL Trust did not weigh Mrs A and therefore it is also unclear if she lost weight during this admission.
67. The records indicate MWL Trust referred Mrs A to its dietitian and speech and language therapist (SLT) and she was assessed by each specialist. The records provide some evidence that as a result of the input from the two specialists MWL Trust occasionally provided Mrs A with nutritional supplements. However the information in the records provides no evidence to indicate MWL Trust put in place a consistent plan to manage Mrs A’s nutrition and fluid in line with the NMC guidance. As Mrs A had obvious needs in this regard we think this is a failing.
68. Mrs A was very unwell and her condition was rapidly deteriorating due to her advanced dementia and infection when she was admitted to MWL Trust on 17 January 2021. The records indicate her desire for food and fluids was diminishing at this time, most likely due to her advanced Alzheimer’s disease. We think, although it is unlikely to have had an impact on her outcome, a consistent plan to manage Mrs A’s nutritional care would likely have provided her with some degree of comfort and support during this difficult time.
69. The records indicate Mrs A required assistance with all of her hygiene needs. The nursing notes in the records indicate assistance was given as required but Mrs A would sometimes need encouragement with her personal care. In its response to Mrs S’ complaint MWL Trust has acknowledged it had difficulty providing personal care to Mrs A on some occasions and apologised for the occasions where the care fell below the required standard. We think this is appropriate to address this concern.
70. We acknowledge maintaining hygiene where a patient is very unwell and approaching the end of their life can be challenging for both the patient and the care provider. We found no evidence to indicate the incidents where MWL Trust were unable to provide Mrs A with appropriate personal care led to an unremedied injustice or contributed to the deterioration in her condition.
71. Mrs S says MWL Trust decided to switch her mother’s care to palliative care (care aimed at improving the quality of life of patients who are facing problems associated with life-limiting illness) and discharge her home. She says she agrees with the decision to discharge her mother home. However she says her mother did not receive the care she needed during the period she remained in hospital after this decision was made.
72. Our physician adviser said there is a persistent concern expressed in the records by MWL Trust from the very beginning of this admission that Mrs A may be approaching end of life. The NICE end of life guidance says it is good practice to identify if patients are likely to be approaching the end of life. Our physician adviser said there is no specific test to establish this but the NICE end of life guidance says risk factors could include those with advanced progressive conditions (such as Alzheimer’s disease) and general frailty.
73. The records do not formally describe a switch by MWL Trust from active care and treatment to palliative care. On Friday 12 February 2021 there is clear evidence in the records of active treatment from MWL Trust aimed at improving Mrs A’s condition, including the use of steroid treatment. On Monday 15 February 2021 the records state there had been no improvement in Mrs A’s condition and indicate a likely need to move to end of life care.
74. Further entries in the records on 15 and 16 February 2021 indicate the medical and allied health professionals (SLT and dietician) had moved the focus of their care interventions to end of life care. The records indicate advanced care planning and fast track discharge planning is considered at this point to enable Mrs A to spend the time she had remaining with family at home.
75. Our physician adviser said at the point MWL Trust appears to have made the decision to move to palliative care (Monday 15 February 2021), there is no evidence to indicate it was inappropriate given the lack of improvement achieved through the investigations and active treatment. 76. We carefully considered Mrs S’ complaint and the supporting information she has provided. We acknowledge how distressing this period of treatment and the loss of her mother has been for her. We also considered the information in the records, guidance and the advice we have received.
77. We have found failings in the nutritional care provided by MWL Trust during this admission, in particular there was a failure to put in place a consistent plan to manage Mrs A’s nutrition and fluid. We partly uphold this point of complaint as we found no evidence of failings in any other aspects of the care and treatment provided by MWL Trust during this admission that have led to an unremedied injustice.