Waiting time to use the toilet 17. Mrs H says Miss E was ‘pinned by the bed desperate for a commode with no staff available, she waited 3 hours until staff were brought from theatre, following 2 enemas’. Mrs H told us the Trust had also given Miss E oral laxatives. We understand how upsetting this experience was for both Miss E and Mrs H.
18. Mrs H told us the incident she complains about took place on 18 or 19 November. The clinical records are very sparse and there are no medication charts prior to 21 November. This poor record keeping means we are not able to see when the Trust gave Miss E an enema around these dates, or what action it took.
19. We accept the incident occurred as Mrs H described. We have no reason to doubt her account. We can see the Trust complaint response accepted it did not have any records of what happened, and that it has properly apologised for the incident and accepted the delay was unacceptable.
20. The Trust did not act in line with The Royal Marsden Manual of Clinical Nursing Procedures, which says that after administering an enema staff should:
‘Ensure that the patient has access to the nurse call system; is near to a bedpan, commode or toilet; and has adequate toilet paper.
Record in the appropriate documents that the enema has been given, the effect on the patient and the result (colour, consistency, content and amount of faeces produced), using the Bristol Stool Chart.’
21. We are pleased the Trust acknowledged the failings and apologised. The Trust wrote to this office at the start of this investigation to explain the changes it has made in staffing and hospital environment. This information was not available at the time the Trust responded to Mrs H’s complaints.
22. The Trust’s complaint response to Mrs H did not recognise what led to the failings in administering the enema, or that not keeping records of what happened led to a failure to properly meet Miss E’s needs. We have made recommendations from paragraph 55 to address this.
Impact 23. Mrs H was concerned the delay in helping Miss E to the toilet may have led to the compartment syndrome, as Miss E was pressing her leg on the bed side whilst waiting. She told us she believes this caused the bruising to Miss E’s hip.
24. We considered whether the incident led to compartment syndrome, and whether it played a part in Miss E’s sad death. From the chronology of how the condition developed we did not think we could reach that conclusion.
25. The records for 15 November showed Miss E had left hip pain. The Trust examined her and found a haematoma. A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within soft tissue and may display as a purple coloured bruise. Sometimes, haematomas may not show up as a bruise and can be more deeply located.
26. The Trust continued to monitor the haematoma over the next few days and noted on 16 November that it planned to undertake further assessment by carrying out imaging.
27. The Trust carried out a CT scan on 17 November. This confirmed the presence of generalised swelling and a large haematoma in the left thigh. The Trust noted this, and that it intended seeking a surgical opinion the next day.
28. The team treating Miss E discussed the haematoma with the orthopaedic specialist the next day, 18 November, and drew up a plan to monitor the situation, as no intervention was needed. The plan outlined that the specialist team should be contacted if Miss E’s skin began to breakdown.
29. On 19 November the family mentioned Miss E’s leg swelling was worse, and harder than before. The Trust examined the leg and arranged another consultation with the orthopaedic specialist. The orthopaedic specialist arrived to review Miss E at midnight on 20 November and the Trust commenced the care and treatment for compartment syndrome at this point.
30. Our physician adviser explained that spontaneous muscle haematoma is recognised as a complication of cirrhosis (a condition where the liver is severely damaged), which Miss E had. They explained this does not always cause problems, but in this case it also caused generalised swelling, evident on 17 November. When this swelling did not resolve itself as had been hoped, it went on to directly cause the compartment syndrome.
31. Our physician adviser said the train of events was from a blood clotting abnormality to haematoma, to generalised swelling, to this worsening. We find this clinical situation was likely caused by liver disease which led to the spontaneous muscle haematoma, the onset of which was days before the incident complained about.
32. We cannot find a link to Miss E putting pressure on her leg when waiting to use the toilet. We can not say it was caused or exacerbated by any pressure Miss E may have placed on her leg. Our physician adviser had not heard of any cases where compartment syndrome had been caused or worsened by such a situation.
33. We know the incident impacted on Mrs H and caused her uncertainty and worry about what happened and whether this was linked. As outlined in paragraph 22 we have made recommendations at the end of this report to remedy this.
Care and risk assessments and one-to-one care 34. Mrs H told us that when Miss E was discharged from the ICU the family were concerned because they did not think she was well enough. She said they only agreed because the Trust said Miss E would be given one-to-one care. Mrs H told us Miss E was very vulnerable and she did not think the Trust had carried out the assessments it should have, to keep her safe.
35. Our nursing adviser told us all risk assessments and care plans should be reviewed when a patient transfers from ICU. This is because they will have received one-to-one care on the ICU and this is the only place where this is standard. Individualised nursing care (including the level of supervision) can then be planned following assessment. The NMC standards say:
‘demonstrate the ability to accurately process all information gathered during the assessment process to identify needs for individualised nursing care and develop person-centred evidence-based plans for nursing interventions with agreed goals.’
36. We have not seen evidence that this happened as it should.
37. Miss E was discharged from the ICU to the ward on 26 November. The records show that she required enhanced care. Enhanced care refers to the use of additional staff to enhance patient safety. This can be through one-to-one nursing, enhanced observations, close observation or supervision.
38. The records show that on admission to the ward, Miss E had ongoing delirium and noted that as she was sleeping she would need assessing during the day of 27 November. Despite this, there are no nursing assessments or care plans within the records following discharge from ICU. This is a failing.
39. The records do not show evidence Miss E was cared for in line with enhanced care requirements, or that any care plans or assessments were carried out, as required by the guidance in paragraph 35.
40. Mrs H told us about two incidents she thinks are related to the failure to provide enhanced care and carry out assessments. These were an incident where another patient pulled out a wound drain on 27 November, and an unwitnessed fall on 7 December.
41. We think the likelihood of another patient pulling Miss E’s drain out would have been reduced if there had been an accurate assessment of need. This is because the assessment would inform the level of supervision and observation needed by Miss E. The records show the Trust agreed to one-to-one supervision after the drain was pulled out.
42. In relation to the fall, the records show one-to-one supervision had been stepped down. We understand why Mrs H is concerned this could happen, as the Trust did not share this information with the family. The records show Miss E fell out of bed while looking for her slippers in the early hours of the morning. Our nursing adviser told us such falls are difficult to prevent. Patients must be able to make their own decisions, such as whether to call for help using the nurse call system.
43. Miss E was improving by this time and was able to make her own decisions. For this reason we find the fall may have still happened even if the Trust had carried out an accurate assessment of need.
Impact 44. We carefully considered whether we could say the impact was as Mrs H worried, that Miss E’s chances of survival and recovery were compromised. We could not reach this conclusion.
45. We concluded we could not say Miss E had a poorer outcome as a result of the issues identified, even taking into account the cumulative effect of everything that happened.
46. The Trust put the drain in Miss E’s thigh on 24 November, following the compartment syndrome surgery. A surgical drain is a tube used to remove fluid from a wound that could otherwise lead to infection and pain. It was this drain that was pulled out.
47. Our physician adviser told us the records from 26 November show the drain output had stopped draining fluid and blood from the wound site. This suggests it was approaching the time when it would no longer be needed. The records show the removal was due on 27 November.
48. When the incident happened the ward staff reacted immediately to put pressure on the wound to stop the bleeding. The Trust arranged for Miss E to be reviewed by the orthopaedic specialist and the team managed the wound from this point with dressings. Our physician adviser said there were no adverse long term physical or clinical impacts evident.
49. We could not say this had a wider impact on Miss E’s physical condition, or that it led to or added to any deterioration. There is no evidence of this in the medical notes or the discharge summary.
50. In relation to the fall on 7 December, there is no evidence this led to any long term impact. The records show Miss E had a shallow cut on her head and she continued with her physical recovery. If this had caused long term issues and clinically or physically weakened her we would have expected to see evidence of this, and there was none.
51. Miss E sadly died on 10 February 2023. There is no evidence to show the causes of death were in any way caused or worsened due to any failings on the part of the Trust.
52. The Trust complaint response recognised it needed to make improvements and gave a detailed account of this in the complaint response:
‘The Safer Nursing Care Tool assessments have been completed accurately for all wards in January 2023. This data is now being collated. Meetings have been arranged in March 2023 with each Business Unit and the Deputy Chief Nurse, Chief Matron, Service Line Manager, financial colleagues and the People Data and Information Lead will review staffing ratios for each ward focusing on the acuity and dependency of patients within each ward, ensuring flexibility is built in for wards who are caring for patients with complex needs. A report will then be written and presented to the Trust Board for approval as it is anticipated based on provisional data thus far that some wards will require a staffing uplift.
As an outcome of the investigation it has been determined that there are further areas for improvement which the Trust needs to address which have an impact on nurse staffing and thus patient care, these are: • A specific risk assessment needs to be developed to determine the safety of ward areas for patients who have complex needs and are being transferred from the Critical Care Department to a ward environment • The health roster system needs to be updated to include an auto-roster function and ensure further education is given to nursing staff to utilise the system more effectively • Nursing staff require more focused education on using red flags on the Safe Care system and the Trust needs to be able to run a report detailing the red flags • Some of the Trust’s policies will need to be reviewed which include the Nursing and Midwifery Safer Staffing Policy for In-patient wards and departments and the Enhanced Care and Supportive Engagement Policy based on the points above • The Trust needs to review the Full Escalation and Capacity Protocol and determine when it is enacted • Review the provisions for relatives/carers who stay with patients within the hospital notably fold away beds • Review the opportunity of having kinship roles within the Trust’
53. We consider these to be positive improvements and changes. We have made recommendations for the Trust to provide an update to Mrs H.
54. There is no evidence the Trust has recognised the lack of care plans or assessments and the role this may have played. We have made recommendations in relation to this.