The Trust
Care after discharge
18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
19. The Trust have said the short term support service (STSS) appropriately discharged Mr A back into the care of the Practice and his nursing home. It says neither the nursing home or the Practice asked its service to assess Mr A again and therefore they assumed all care was in hand.
20. As part of our work, we have reviewed Mr A’s physiotherapy records. They show the STSS first assessed him at the nursing home on 20 November 2020. The STSS then reviewed Mr A on 15 December 2020, 18 December 2020, and 5 January 2021. The Trust discharged Mr A from the STSS on 11 January 2021.
21. The STSS noted during this period Mr A: • may benefit from muscle relaxation treatment, which the STSS handed over to the Practice and followed up on during subsequent reviews • could complete his exercises independently when prompted verbally • responded better to active movement and the nursing home staff needed to encourage him to straighten his legs during personal care and encourage the exercises • would not be able to regain any mobility, and the exercises were intended to prevent further contractures.
22. Section 8 of the Quality Assurance Standards for Physiotherapy outlines that physiotherapists should gather and analyse the best available information to formulate a treatment plan, identify appropriate treatment options, and arrange a discharge or transfer of care on completion of the treatment plan.
23. Our physiotherapy adviser has said the records show the STSS appropriately assessed Mr A’s condition and created a treatment plan which included exercises and a recommendation for Botox injections which could only be actioned by the Practice. We have seen evidence in the records the STSS reviewed Mr A three times to check the exercises were effective in preventing further stiffness.
24. From the records, nursing home staff were using a full body hoist to help move Mr A prior to the physiotherapy input. Our physiotherapy adviser explained any exercises would not be able to reverse Mr A’s contractures. Mr A did not have any rehabilitation goals which would have required the physiotherapy team to continue their involvement. They explained transfer of care to the Practice and a recommendation for Botox injections was an appropriate treatment plan.
25. Our physiotherapy adviser explained it would not be the responsibility of a community physiotherapy team to continue to monitor the condition of patients once it had discharged them. They said if Mr A’s condition worsened and he needed physiotherapy input again, then it would be the responsibility of the nursing home staff to notify the relevant health care professionals.
26. We understand Mrs E cared deeply about her father’s health and would want to know healthcare professionals were providing proper support. We understand she felt the Trust could have done more to ensure the nursing home staff were continuing the exercises. We have not seen evidence to indicate a clinical need to do this.
27. Taking into account the evidence we have seen, we have not seen indications to support the view the Trust should have followed up on Mr A’s care after he was discharged from the STSS. We have not found indications of failings in the Trust’s actions.
Physiotherapy referral to OT
28. The Trust has said the assessment did not identify Mr A required an OT referral.
29. GMC guidelines say clinicians must ‘refer a patient to another suitably qualified practitioner when this serves their needs’.
30. Our physiotherapy adviser explained it was difficult to conclude whether the STSS should have referred Mr A to OT, as Mr A eventually did need an OT assessment in 2022.
31. The STSS notes between November 2020 and January 2021 showed nursing home staff were using specialist hoisting equipment to move Mr A. With specialist equipment in place this may not have indicated to the Trust Mr A had an immediate unmet need for an OT assessment.
32. There is no record the nursing home staff raised any concerns about Mr A’s equipment to the STSS staff, or that the care home referred Mr A to OT.
33. We appreciate Mrs E felt an earlier referral may have provided equipment to prevent further deterioration in Mr A’s health. We can understand Mrs E identifying a possible missed opportunity in Mr A’s medical records will have been distressing.
34. We have not seen indications the Trust saw or were made aware of any unmet OT needs during STSS assessment period. We cannot say the Trust should have made a referral to OT. We have not found indications of failings in the Trust’s actions.
Lack of communication from physiotherapy team
35. The Trust said the referral for physiotherapy input said Mr A had a recent diagnosis of dementia. It said this did not indicate he was unable to understand the information or follow instructions. It explained nursing home staff were present at all consultations, and they are generally assumed to be the point of contact for patient’s relatives and representatives.
36. OPG guidance “How to be a health and welfare attorney” states an attorney with health and welfare LPA can make decisions if the donor (person who would normally make the decision for themselves) loses their mental capacity (ability to make own decisions).
37. OPG guidance on Mental Capacity Act code of practice also states some people with conditions like dementia have fluctuating capacity, and a person must be assumed to have capacity unless it is established, they lack capacity for the decision.
38. We looked at the records for the four in-person STSS assessments between November 2020 and January 2021. We cannot see any clear declaration in the record saying Mr A did not have the capacity to understand their input during assessment, or showing nursing home staff raised any concerns to the STSS about Mr A’s capacity.
39. There is also no record of Mr A or the nursing home staff asking the STSS to contact Mrs E to update her or notifying them of the LPA. There was therefore no indication to the Trust during this period Mr A required an attorney to step in to make medical decisions on his behalf.
40. We can also see the physiotherapist shared all information and treatment plans with the nursing home staff. There was no indication to the Trust at the time the nursing home staff would not pass along this information to Mr A’s family if needed.
41. We have not found indications of failings in the Trust’s actions.
42. We understand Mrs E feels let down by the Trust not informing her of Mr A’s contractures. We note in the response to Mrs E’s complaint the Trust have said it planned to raise awareness about capacity and contacting relatives within the team. It outlined a plan to liaise with staff in the care settings to establish if there are relatives who need to be informed about care. This will hopefully assure Mrs E the Trust has taken the opportunity to learn from her experience.
The Practice
Health Monitoring
43. The Practice said it did not have a responsibility to actively monitor Mr A’s health whilst he was in the care of a nursing home. It explained it discussed Mr A at multi-disciplinary team (MDT) meetings when requested. It also explained the nursing home staff did not ask the Practice to review Mr A before he went into hospital. It explained there is a frailty team who go into care homes and can monitor health more regularly, and the nursing home did not request this support for Mr A.
44. Our GP adviser said they were not aware of any enhanced responsibility the Practice would have had over Mr A’s care. Patients in nursing homes require care from professional staff who should be monitoring their health and wellbeing. Normal practice would be for the nursing home staff to contact the Practice if they felt like anyone needed a medical review.
45. Our GP adviser explained some Practices do offer enhanced care (e.g. regular ward rounds within the nursing home). This would be a locally determined policy as there is no national requirement for the Practice to do this. Even if this enhanced care was in place, the Practice would likely see people at the request of the nursing home staff.
46. GMC Good Medical Practice guidelines state any investigations of treatment clinicians provide must be based on the assessment they and the patient make of their needs and priorities. This means clinicians cannot investigate or begin treatment of a condition if they do not have the evidence basis of the patient’s needs, or if these needs have not been shared with them.
47. We looked at the GP records to assess whether the Practice responded appropriately to the information shared with it about Mr A’s health. We are looking at the period of care which led up to and followed Mr A’s hospital admission. We will focus on the Practice response to Mr A’s contractures at a later point in this statement as it comes under a separate complaint component.
48. Records show the Practice discussed Mr A at an MDT meeting on 25 March 2022 as he had tested positive for COVID- 19, meaning there was a clinical need to review his health.
49. The practice nurse noted a foot wound on 7 April during a home visit to check on Mr A’s health after COVID- 19. From this date until 21 June district nursing staff (not employed by the Practice), the nursing home staff and a podiatrist (not employed by the Practice) provided wound care. This information is present on the GP records but would not have been seen or reviewed by a GP without a request for review.
50. The Practice rang Mr A and a carer from the nursing home on 23 May 2022 for a telephone consultation about his chest and recent COVID-19 infection. The record does not show the carer brought up any concerns about Mr A’s wound during this call or asked the Practice to review Mr A in person.
51. Following Mr A’s discharge from hospital, the hospital discharge letter dated 10 July asked the Practice to arrange an appointment with Mr A, this is the first time the Practice were asked to review Mr A’s wound and health.
52. A GP saw Mr A on 11 July and examined and swabbed his wound. On 12 July there is a note stating social workers are involved in Mr A’s care and he needed an MDT review.
53. The Practice reviewed Mr A at an MDT meeting on 19 July. In between 25 March and 19 July there is no evidence showing the nursing home staff or other healthcare professionals asked the Practice to discuss Mr A’s health and care.
54. A nurse from the Practice frailty team saw Mr A on 19 July who then updated Mr A’s emergency healthcare plan (EHCP) with his new medical needs. This is a document designed to make communication about a patient’s status and needs clear in the event of a healthcare emergency.
55. On 2 August the Practice discussed Mr A at another MDT meeting. The actions from this were for the frailty nurse to review Mr A again which was completed the same day. The notes are limited for the meeting but suggest the Practice reduced Mr A’s risk level, meaning he returned to the “care home list” needing less frequent MDT reviews.
56. The Practice next saw Mr A in person on 13 August. There is no record of a request for an appointment or review before this date. On 26 August a GP spoke to a nurse who updated them Mr A seemed to be deteriorating. On 30 August nursing home staff called the Practice to report further deterioration.
57. On 31 August a GP saw Mr A in the care home and planned to review again in a week. On 8 September the Practice saw Mr A and again planned for a home visit review in two weeks, based on his current health.
58. We appreciate Mrs E was learning a lot of distressing information about Mr A’s health during this period and felt more could have been done by the Practice to prevent Mr A from ending up in hospital with sepsis.
59. The evidence we have viewed indicates the Practice could not have known about the seriousness and deterioration of Mr A’s wound between 7 April and 21 June because it was not asked to review Mr A during this time. We do not see any indications of failings in its actions.
60. Following Mr A’s discharge from hospital, we have seen indications the Practice were regularly involved in Mr A’s health and treatment and responded to all requests for review and referrals from Mrs E, the nursing home staff, other health professionals, and social workers. We do not see any indications of failings in their actions following Mr A’s discharge from hospital.
Palliative status
61. Mrs E provided us with an email response from the vascular surgeon who discharged Mr A. The email response says “the decision was that he was not a candidate for surgery and therefore should not be readmitted under the vascular surgical team. We said if the wounds became infected they could try antibiotics in the community but otherwise he should be for palliative care”.
62. The Practice said it agreed the hospital had decided Mr A was to receive palliative care on discharge from hospital, and it put appropriate planning in place because of this in his EHCP. The Practice also noted the discharge letter stated Mr A was not for re-admission to hospital for the wound. It does not say he is “palliative” or “terminal”.
63. The World Health Organisation defines palliative care as an approach to improve the quality of life of patients (adults and children) and their families who are facing problems associated with life-limiting illness, usually progressive. Palliative care can be provided at any stage of a patient’s illness.
64. The GMC defines approaching end of life as when a patient is likely to die within the next 12 months. The NHS defines end of life care as support for people who are in the last days or months of their life.
65. The Practice said when the GP discussed with Mrs E about Mr A, they agreed further hospital admissions for the wound deterioration would not be appropriate. This means he would not receive active treatment for the wound, but he was not at the end of his life.
66. The Practice explained it assessed Mr A on 8 September 2022 (the day before Mr A died) and planned to review him in two weeks’ time. It did not expect Mr A to die as quickly as he did.
67. We can see from the medical records the Practice discussed the palliative care approach with Mrs E on 13 July 2022, and updated Mr A’s EHCP on 22 July 2022. The records say they agreed a palliative approach.
68. We can also see Mrs E shared her concerns about Mr A’s health and deterioration with the Practice on 26 August 2022. The contemporaneous record of this conversation in the GP record is consistent with the account given by the Practice in their response. The Practice agreed Mr A was palliative, not yet end of life.
69. We recognise this conversation must have been incredibly difficult for Mrs A, and it is possible that the difference in medical terminology for palliative and end of life was not made clear.
70. The GP records from this conversation also show a plan to move Mr A to end of life care if he stops being able to take in any medication, fluid, and food.
71. The GMC Good Medical Practice guidelines say a clinician should refer a patient to another practitioner when this serves the patient’s needs.
72. In the context of palliative care, our GP adviser said the Practice should refer if the patient had a palliative care need it felt the patient needed specialist help with. Not every patient near the end of life needs to be under a specialist palliative care service.
73. The Practice referred Mr A to the specialist palliative care team on 31 August after nursing home staff informed them on 30 August Mr A had deteriorated slowly over the weekend, in addition to a request from a social worker involved in Mr A’s care.
74. After the Practice made a referral on 31 August, the palliative care team’s plan was to discharge Mr A as he did not have any complex symptoms which required their expert help. The palliative care team decided it would discharge Mr A from its service, and planned to do this when it could hand over care to the Practice frailty nurse who was away.
75. On 1 September the palliative care team records state Mr A had now been put on end of life care and the Practice had issued prescriptions to manage his pain and comfort. On 6 September the palliative care team planned to stop reviewing Mr A and to keep his case open until care could be fully handed over to the Practice frailty nurse. Mr A died on 9 September before the Practice could take over Mr A’s care.
76. We have seen indications the Practice considered Mr A to only receive palliative care from 13 July 2022, updated his EHCP, and referred him for specialist palliative support when Mr A’s social worker requested it.
77. We have seen indications the Practice appropriately recognised Mr A was for palliative care and made appropriate plans to support him during this time. We do not find any indications of failings in the Practice’s actions.
Communication
78. The Practice has told us it does inform people with Power of Attorney about patient’s conditions, but only if the patient or the attorney requests this.
79. There is no specific guidance about communication with an attorney with Lasting Power of Attorney. Guidance from the OPG Guardian for Medical disclosure information to attorney’s and deputies outlines that attorneys should be able to access medical records to help them make informed decisions about care. There is no reference to when or how an organisation should share information when the attorney has not requested it.
80. As explained before, attorneys with health and welfare Legal Power of Attorney can make decisions on behalf of another person when they lose their capacity. We have also established that capacity is fluctuating and professionals must not assume lack of capacity.
81. Our nurse adviser explained a GP is not solely responsible for assessing capacity, anyone who is trained to assessed capacity can do so. As Mr A’s primary caregiver, the nursing home would likely be the most appropriate service to have assessed Mr A’s capacity and shared this with the Practice or requested an assessment from a GP. We cannot see evidence of either happening in the records available.
82. Mr A was diagnosed with dementia and Alzheimer’s disease on 16 October 2020. The only indication about capacity we can see in the record is from 22 July 2022 when the frailty nurse updated the EHCP which states Mr A lacks capacity. It is not clear is staff assessed Mr A’s capacity or if this was information Mrs E shared with the Practice.
83. The EHCP also states staff should contact Mrs E to discuss if a hospital admission would be in Mr A’s best interests. This shows when the Practice was aware of questions around Mr A’s capacity, it planned to include Mrs E in important healthcare decisions.
84. Our nurse adviser explained it is normal practice for nursing home staff to provide the bulk of the family/power of attorney liaison rather than the Practice. We have established the Practice were not informed about the deterioration of Mr A’s wound condition after 7 April 2022 until 22 June 2022 and therefore could not have shared information earlier.
85. After Mr A’s discharge on 8 July 2022, the Practice had contact with Mrs E on 13 July, 19 July, 22 July and 26 August. There is no evidence to suggest it did not share information when requested or did not include Mrs E in decisions and conversations about Mr A’s care.
86. Mrs E has not provided us with any specific dates where she requested information and did not receive this, so we cannot conclude there is any indication the Practice did not follow the information sharing guidelines. We appreciate she may have expected the Practice to contact and inform her about Mr A’s health without having to ask, however there is not any guidance to support this as normal information sharing practice. We will not be taking further action here.
Physiotherapy goals and contractures
87. The GMC good medical practice guidelines state that to provide clinical care, clinicians must refer a patient to another suitably qualified practitioner when this serves their needs.
88. We have seen in the medical records that Mr A’s contracture care was handed over to the Practice on 11 January 2022. We can see the GP made a referral to a joint musculoskeletal and pain service (JMAPS). JMPAS rejected the referral explaining that it would only consider Botox injections if the knee contractures were affecting a patient’s personal hygiene. The service also advised the referral should go to a specialist Botox clinic. The Practice shared this with the nursing home and advised them to contact the Practice if Mr A’s contractures or pain became worse.
89. The Practice then sent a referral to the specialist Botox clinic. It reviewed Mr A on 22 April 2021. The consultant at the Botox clinic advised Mr A had arthritis in his knees and right ankle, and there was no evidence of muscle spasticity. It concluded there was no indication that Mr A required spasticity medication like a Botox injection. They noted that if Mr A’s pain becomes difficult to manage that they should consider steroid injections and a review from an orthopaedic team. It then discharged Mr A back to the Practice.
90. The specialist Botox clinic had not asked the Practice to carry out any additional actions, therefore the response was not shared with the nursing home. Our GP adviser explained this was appropriate as there was no new information to share. The Practice has told us there is no further mention of Mr A’s contractures in his medical records from 22 April 2022. This would suggest nursing home staff did not ask the Practice to review Mr A’s contractures again.
91. Our adviser explained the nursing home staff caring for Mr A would have the ultimate responsibility to monitor and request reviews of Mr A’s health.
92. The Practice responded appropriately to the physiotherapy request for a referral and appropriately asked the nursing home to inform them if his condition worsened. We cannot see indications of failings in the Practice’s actions. We will not be taking further action here.
Medication and supplements
93. The Practice explained in its response it did provide appropriate medication and provided supplements when Mrs E and the nursing home staff had told them Mr A was struggling with his food and drink intake.
94. The GMC guidance for good medical practice in proposing, prescribing, providing and managing medicines and devices states clinicians should only prescribe medicines if they have adequate knowledge of the patient’s health needs. It goes on to say clinicians must make suitable arrangements to monitor and review a patient after prescribing medications.
95. The Practice would therefore be unable to prescribe anything without information gained from the nursing staff who were primarily responsible for monitoring Mr A’s health.
96. We can see in the records Mr A was unable to swallow his medication in tablet form and the nursing home staff requested liquid tablets on 24 August. The Practice pharmacist was on leave at this time, a GP spoke to nursing home staff and made the changes to medication on the 26 August 2022.
97. The Practice prescription records show the Practice prescribed supplements the same day they were requested on 26 August 2022. As explained previously, the Practice did not have an enhanced requirement to proactively anticipate Mr A’s health needs and responded appropriately and timely to requests.
98. The medical records show the Practice reviewed Mr A’s pain relief and management on several occasions following his discharge from hospital.
99. On 11 July the Practice adjusted an Oramorph (liquid morphine) prescription in response to staff reporting Mr A was drowsy. On 26 August the Practice re-prescribed Oramorph with instructions to use it during dressing changes in response to Mrs E raising concerns nursing staff were not providing pain relief properly. On 5 September the Practice prescribed Zomorph (morphine in capsules) in response to nursing staff requesting more pain relief.
100. There is evidence the Practice regularly reviewed Mr A’s pain medication and adjusted it based on his needs. Our GP adviser explained the Practice responded appropriately to requests for review and again reiterated the role of the Practice is to respond and review rather than to proactively provide treatment. This is in line with GMC guidance.
101. The Practice prescribed antibiotics on 11 July, 23 August, 31 August, 1 September, 2 September and 5 September. The Practice prescribed these after a GP or the frailty nurse reviewed Mr A in response to concerns the wound was infected.
102. Following Mr A’s discharge from hospital, the Practice prescribed Doxycycline, Erythromycin ethyl succinate and Clarithromycin which are types of antibiotics on 11 July, 23 August, 31 August, 1 September, 2 September and 5 September.
103. Our adviser explained these are commonly used antibiotics and the Practice appropriately prescribed these to combat the infection in Mr A’s wound. The Practice prescribed these after reviewing Mr A themselves in response to concerns shared by Mrs E and the nursing home staff.
104. As outline above, the GMC guidance states clinicians should only prescribe medication if they have adequate knowledge of the patient’s health needs. The evidence shows the Practice responded to all requests and reviewed Mr A before prescribing antibiotics.
105. Mrs E has not provided us with evidence of times where the Practice did not respond to requests for antibiotics. We appreciate Mrs E may have felt frustrated repeatedly requesting medication. We have established the reactive role of the GP throughout this statement and therefore do not consider they should have prescribed antibiotics without the information about infection.
106. We therefore consider there were no instances where the Practice did not act on information shared about Mr A’s health and need for medication. We appreciate Mrs E may have felt frustrated repeatedly requesting medication. We have not seen indications the Practice failed to respond to requests for medication or supplements and will not be taking further action here.
Referral to OT
107. GMC good medical practice guidelines state professionals should make a referral if a need is identified. If a need is not identified, we cannot expect the Practice to have made a referral.
108. Our GP adviser explained the hospital discharge summary to the Practice did not make any recommendation for the Practice to refer Mr A to OT, only Speech and Language Therapy (SLT) which was actioned.
109. We have not seen indication the hospital or nursing home approached the Practice to refer Mr A to OT, or that the Practice was aware he had needs which required OT support. We therefore will not take further action here.
Conclusion
110. We have not seen indications of failings in the Trust’s or the Practice’s actions and will not be taking further action. We understand how concerned Mrs E is about the care her father received. We hope that our explanation helps to reassure her that her father received appropriate care.
111. We do not underestimate how distressing it must have been for Mrs E to see Mr A deteriorate so quickly, and we are truly sorry that he died nine weeks after his discharge from hospital. We would like to take this opportunity to extend our sincere condolences to her and her family.