11. 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.
Mobilising 12. Miss P has concerns about the Trust’s treatment of her mother whilst she was on ICU. She is concerned it did not mobilise her mother enough, or appropriately. She says this contributed to her deterioration which she feels was linked to her death.
13. We sought clinical advice from a physiotherapist to help us understand how the Trust managed this. The NICE hip fracture guidelines set out:‘1.7 Mobilisation strategies:1.7.1 - Offer people a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery. 1.7.2 - Offer people mobilisation at least once a day and ensure regular physiotherapy review’.
14. The NICE quality statement also explains:‘Early restoration of mobility after hip fracture surgery can be beneficial for the person because it can reduce the length of hospital stay and avoid the complications of prolonged bed confinement. Rehabilitation at least once a day has potential benefits of improved mobility, increased independence, and reduced need for institutional care. A physiotherapist assessment is needed before the rehabilitation starts. People should be offered support with rehabilitation every day while in hospital, which can be given by members of the multidisciplinary team when the physiotherapist is not present. This support should continue after discharge from hospital’.
15. Ms Y was admitted to ICU at the Trust on 31 August 2022 following hip surgery due to a hip fracture, for rehabilitation and discharge planning.
16. From 1 to 7 September, the physiotherapy team attempted to physically assess Ms Y several times but failed to do so. This was because Ms Y became distressed or upset and refused. There is documented evidence to show nursing staff used a stand aid or hoist to support Ms Y to sit out in a chair during this period.
17. From 8 to 15 September, the records suggest Ms Y was much more settled and happier on ICU. The evidence supports at this point she was mobilised daily with the assistance of two people and a rollator frame and sat out in a chair. This was carried out by the physiotherapist or nursing team.
18. Following this, from 16 September until Ms Y was discharged on 21 October, the records show Ms Y was mobilised regularly with the assistance of one person and a rollator frame and sat out in the chair.
19. The above evidence shows Ms Y was mobilised appropriately in line with the guidance during her admission. A record from a multidisciplinary meeting on 20 September further suggests ‘Ms Y’s mobility has improved during her stay on ICU’. It also explains a diagnosis of dementia and hospital admissions can impact a patient’s functional ability and can result in creased frailty and decreased mobility.
20. This supports that Ms Y was adequately mobilised, as she improved from being dependent on a stand aid to be transferred from the bed to chair on admission, and on discharge she was able to mobilise with the assistance of one person and a rollator frame. We hope this provides Miss P with reassurance the Trust was taking steps to mobilise her mother in line with guidance.
Nutrition and visiting 21. Miss P says her mother was not coping well in hospital and had not been eating because of her dementia. She asked the Trust if she was able to visit to encourage her eating and drinking, and to support her. The Trust said it was policy she was not allowed. Miss P feels this contributed to her mother’s deterioration and death.
22. We contacted the Trust to ask it for a copy of this policy and it responded to say it does not have a Trust wide visitation policy. During the Covid-19 outbreak it says it followed guidance from the government, and it has qualified staff which are capable of feeding patients.
23. We sought clinical advice to help us carefully consider how the Trust managed Ms Y’s nutrition and request to visit to provide support.
24. The patient experience guideline says: ‘1.2.7 Ensure patient’s nutrition and hydration are adequate at all times, if the patient is unable to manage this themselves by: • providing regular food and fluid of adequate quantity and quality in an environment conducive to eating • placing food and drink where the patient can reach them easily • encouraging and helping the patient to eat and drink if needed • providing appropriate support, such as modified eating and/or drinking aids.’
25. Our nursing adviser explains the evidence supports the Trust were managing Ms Y’s nutrition in line with this guidance. This can be difficult in patients with dementia as they can often have a fluctuating appetite, as set out in the managing dementia in nutrition guidebook. The records show the nursing team were aware Ms Y needed assistance and encouragement with feeding, and it is documented this was done. Her weight did not drop further supporting this feeding was in place.
26. Regarding Miss P’s request to visit to aid with feeding, we recognise the Trust has made reference to adhering to covid guidelines. The date of events in question was September 2022. The covid restrictions the Trust have referred to changed from March 2022 onwards. The updated guidance allowed for patients with a cognitive impairment, such as dementia, to have somebody with them to ensure their mental and physical wellbeing.
27. The visiting briefing sets out patients could be accompanied by two visitors where appropriate and necessary to assist their communication and to meet their health, care emotional, religious or spiritual care needs.
28. The patient experience NICE guideline also sets out the below: ‘1.2 Essential requirements of carePatients have needs other than the treatment of their specific health conditions. There should be recognition of the potential need for psychological and emotional support, as well as of the importance of meeting fundamental needs such as nutrition and pain management. Attention to these fundamental needs applies particularly to inpatient settings, but they should also be addressed in other settings where healthcare is provided’.
29. The clinical records say it was against Trust policy for Miss P to visit at the time, although we recognise from the Trust’s correspondence with us, it says it does not have a visitation policy.
30. In line with the above guidance, the Trust should have given consideration to allow Miss P to visit at mealtimes. There is an indication the Trust got something wrong here, as national guidance at the time suggests patients with dementia may be accompanied where necessary to support their mental and physical needs.
31. As a result, our nursing adviser has gone on to carefully consider the impact of this, specifically if the outcome could have been avoided. As set out above, our nursing adviser explains there is evidence to show the Trust was managing Ms Y’s nutrition appropriately. The medical records support Ms Y’s weight did not drop. From this we can be reassured. The clinical evidence does not support this led to Ms Y’s death or deterioration.
32. We still recognise Ms Y’s oral intake could have improved with Miss P there and the Trust should have considered her request to visit. On balance, it is a possibility Ms Y may have eaten and drank more with support from Miss P.
33. Although we have not seen a link to the outcome, we acknowledge there is still an indication a mistake was made in not considering Miss P’s request. It is understandable this caused Miss P distress when she wanted to support her mother whilst she was unwell.
34. Based on this, we have discussed this with the Trust to see if it would be prepared to apologise for this. The Trust has agreed to apologise for the distress caused to Miss P. We are satisfied the Trust is taking these steps to resolve the complaint, and do not need to take further action at this time.
35. We would like to take this opportunity to thank Miss P for taking the time to share her complaint with us and reiterate how sorry we were to learn about her mother’s deterioration.