The Trust did not provide appropriate dietary and nutritional care and support through the community service.
12. 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.
13. Ms T told us she feels the Trust did not provide her with appropriate care. She told us the Trust did not check her weight often enough, did not provide her with appropriate information on how to increase her calorie intake on a liquid diet, did not provide a comprehensive care or meal plan, and did not provide appropriate supplements for nutritional support.
14. Ms T told us this lack of care meant she lost weight during this time, and she experienced a deterioration in her mental wellbeing.
15. The Trust has said it provided appropriate care to Ms T.
16. Below we will break down this complaint component into sub-sections.
Weight assessment
17. There is no specific timeline advised in the frameworks for how often community dietitians should weight patients. Our adviser explained specific weight timeframes would not be applicable in every case. The NICE Nutritional Support of Adults (CG32) guidance states patients having oral nutrition support should be monitored every three to six months, or more frequently if there is any change in their clinical condition.
18. Ms T’s clinical records show staff checked her weight on a two monthly basis, on15 February, 25 April, 20 June, and 20 August. Ms T reported she weighed 44kg in July 2023 prior to the Trust’s period of care. Between 15 February and 20 June, the dietitians weighed Ms T and noted her weight increased from 41.9kg to 44kg.
19. Our adviser explained Ms T’s weight was increasing, meaning there was no clinical concern to suggest the Trust needed to increase its management. Our adviser explained gradual weight gain is more sustainable over rapid weight gain, there was no clinical concerns from the objective weight data. There was no clinical need for dieticians to weigh Ms T any more frequently.
20. A record from 25 April states Ms T was unhappy with the amount of weight she gained and wanted to gain more. It is likely that the family’s expectations of weight gain were above what would be recommended or achieved by dietician support. It is unclear how much staff tried to manage this expectation. Our adviser suggested written communication and confirmation of what to expect may have been helpful at the start of support, but this would not have any clinical impact on Ms T’s weight gain.
21. We have not seen failings in the Trust’s actions as they followed the appropriate clinical guidelines and there was no indication of a clinical need to monitor Ms T’s weight more. The Trust could have provided written communication of what to expect from care to help manage expectations, which may have helped manage Ms T’s expectations.
Information about increasing calories, nutritional management and supplements
22. Our adviser explained the role of a dietitian is to work alongside recommendations from Speech and Language Therapy (SLT). Prior to January 2024, SLT advised Ms T should be on a texture modified diet (foods and liquids specifically prepared to make them easier to swallow) and advised a level 4 puree diet due to choking risk.
23. A dietician re-referred Ms T to SLT on 18 January after an initial video consultation on 17 January 2024, as Ms T had reported concern SLT did not assess her properly during COVID. There is nothing in the record showing SLT changed their recommendations following an appointment in April 2024. Our adviser explained SLT would be responsible for any assessments or changes to this dietary recommendation, and it would be outside of the remit of a dietician to change this or recommend anything different without input from SLT.
24. Our adviser explained dietitians need to consider patient preference when creating any care plans, and that patients are at the centre of their care. Treatment plans should be co-produced as much as possible.
25. There is evidence Ms T made multiple comments to dietitians stating she did not want to be on Ensure (an oral nutritional supplement (ONS)) for much longer and it was affecting her bowel movements. The dieticians responded to complaints about the Ensure product and considered other ONS options including reviewing Ms T’s flavour preferences to avoid taste fatigue.
26. The North Central London prescribing guidance: Prescribing of oral nutritional supplements (ONS) in primary care (Adults) says staff should set and document realistic and measurable goals, offer food first advice, prescribe ONS if required, and review this regularly.
27. The records show the Trust were regularly reviewing the prescribed ONS and provided information about fortifying her food with olive oil. The community dieticians reviewed Ms T’s ONS tolerance and nutritional needs on 15 February, 27 February, 29 February, 7 March, 28 March, 25 April and 9 May.
28. On 20 June community dieticians planned to review Ms T. The records show they ended the assessment early due to feeling unsafe. Ms T’s care was handed over to another dietician who reviewed Ms T on 20 August.
29. Ms T used a variety of supplements to support her nutrition, some NHS advised, and others bought from Spain. The records show Ms T had been taking ONS for several years, and the family made repeated complaints about the types of supplements Ms T was on.
30. The records show, Ms T was not completely reliant on supplements to meet her nutritional needs, and these were in line with the guidelines and what the NHS would normally recommend.
31. There are multiple recorded instances of Ms T and her daughter requesting a thorough meal plan as part of the community dietician support. During an assessment on 26 April 2024, Ms T requested a diet plan with calories written down for all meals. There is no evidence staff actioned this specific request.
32. Our adviser explained dieticians can provide meal planning for patients, such as those with significant eating disorders. They said it would not be ideal to provide very specific meal plans for patients, as the strict regime can contribute to taste fatigue and a lack of variety within meal plans can result in challenges meeting nutritional requirements over time. These kinds of plans are not very flexible, for example in case the patient becomes reliant on specific meals that suddenly become unavailable (e.g. with a pharmacy supply issue).
33. Notes from previous assessments with the dietician service from 2020 and 2022 show staff explained specific meal planning was not part of their service, and they could provide advice on how to increase calories instead. We can see that the dietician service last provided a type of meal plan for Ms T in 2022.
34. The dietician notes show the dieticians provided loose meal planning advice (e.g. soups twice a day, fortifying the soups) based on what Ms T had reported she could tolerate.
35. On 24 April the community dieticians recorded Ms T was not always able to make the soups and disliked soups made by her carers at the time. Ms T’s preferences also changed throughout the period of care, so staff may have considered a looser meal plan better able to meet her needs.
36. It is likely that the Ms T’s expectations of the service were above what staff could provide. We can see clear evidence between 2020 and 2024 the Trust informed Ms T and her family the Trust did not usually offer this kind of service.
37. We have seen nothing to indicate the Trust did wrong in the advice and information it provided to Ms T. We have seen no indications the Trust neglected Ms T’s nutritional needs.
The Trust removed Ms T’s Ensure prescription without consent or communication.
38. We have assessed this complaint by comparing what should have happened with what did happen. We have seen no indications something has gone wrong.
39. Ms T has told us the Trust removed her Ensure prescription without communication or consent. Ms T told us that this caused distress and made her lose access to vital nutrients for weeks until they restored the prescription.
40. The Trust said it responded appropriately to the information Ms T provided about her lowered tolerance for Ensure milkshakes. It says the prescription was appropriately reduced, not removed.
41. On 17 January, the referral to the dietician service states Ms T was taking Ensure three to four times a day. During the dietary assessment, the dietician recorded Ms T was managing two Ensures a day and was reducing this to one as she was worried about taking too many supplements.
42. The notes from the community dieticians on 15 February state Ms T was getting tired of having Ensure all the time and would like to try other options. The plan from this assessment was to continue Ensure twice a day.
43. On 7 March the community dietician rang Ms T to check on her supplement tolerance. The notes say Ms T was still taking two Ensures a day, and that the community dietician advised her to continue with this. On 28 March the community dietician rang Ms T for another review, which notes to continue with two to three Ensure milkshakes a day.
44. On 25 April the community dieticians reviewed Ms T in person where she complained and questioned why they changed her Ensure prescription from three times a day to twice a day. The notes say this was previously agreed in their appointments as both Ms T and her daughter confirmed the third Ensure was only taken sometimes. The plan for this appointment says to continue Ensure twice a day.
45. On 9 May the community dietician rang Ms T who said she preferred Ensure to the Altraplen Compact Daily supplement. Based on Ms T’s reported intake of two Ensure milkshakes and two Acta Solve Savoury soups a day and no regular homemade soups, the dietician decided to increase the Ensure prescription to three a day.
46. The North Central London prescribing guidance: Prescribing of oral nutritional supplements (ONS) in primary care (Adults) outlines the need to set goals and assess the continued need for ONS. Therefore, it would be appropriate to reduce ONS and explore other options if the patient is reporting it is no longer working for them or meeting their needs.
47. Our adviser explained Ensure is technically a medication, and that medication is not prescribed above what is needed. This prevents stockpiling which could result in out-of-date supplements or providing an opportunity for patients to take more than is clinically necessary. Therefore, the Trust should only prescribe what the patient is reporting to tolerate.
48. When Ms T raised a concern about the reduced prescription, the dietitian re-assessed and restored the prescription to three times a day.
49. Ms T’s daughter has said in one of her complaints to the Trust Ms T was unable to eat solids and relied entirely on Ensures for nutrition. We have not seen evidence she was only reliant on this one supplement. From the records available, Ensure was prescribed to be a top up to meet her nutritional needs.
50. We appreciate that Ms T disputes the conversations about the amount of Ensure milkshakes she was drinking occurred. Given the multiple references to this in records from three staff members, we conclude on the balance of probabilities this was discussed.
51. Even if Ms T was not fully aware of the change from three times a day to twice a day it had no clinical impact. It is clear in the documentation that this reduction did not leave Ms T completely without Ensure and other supplements, and that her weight was gradually increasing.
52. We have not found indications of failings in the Trust’s actions.
The Trust inappropriately gave Ms T a behaviour warning letter without prior warning or attempt to address the issues with her.
53. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Ms T has claimed.
54. Ms T told us she received a behaviour warning letter out of the blue on 20 June. She told us this letter was thrown at her and the allegations within the letter were false. She told us this caused significant distress to her, and the stress of this had a significant effect on her mental health and weight.
55. The Trust apologised that Ms T was upset by the letter. It explained the letter was handed to Ms T on 20 June following reported inappropriate behaviour during a visit on 24 April. The Trust said it appreciated Ms T’s medical needs can affect her mood and mental health and explained there is a need to formally recognise unreasonable behaviour.
56. There are two Incident Reports on Datix from dieticians visiting Ms T’s home, about her behaviour, one dated 24 April 2024 and one 20 June 2024. There is a ‘yellow card’ warning letter, also dated 20 June 2024, addressed to Ms T, from the Service Manager of the Nutrition and Dietetics Service at the Trust.
57. The incident record from 24 April states Ms T was very frustrated and upset and staff described her behaviour as unreasonable and rude. Staff gave a verbal warning about her behaviour before being able to continue the appointment. The staff member involved filed an incident report on 10 May.
58. The Whittington Health NHS Management of violence and aggression at work policy, lists examples of behaviour which will not be accepted during home visits, including harassment, continuously difficult and challenging behaviour which creates an atmosphere that inhibits optimal care, threatening or abusive language, and racial or other discriminatory remarks. The policy also states the Trust has a zero-tolerance policy for aggressive and violent behaviour.
59. We appreciate Miss T disputes she displayed this behaviour. The evidence from the Trust shows staff felt intimidated or at risk of harm during the alleged incidents, even if Ms T and the Trust disagree on what exactly happened. Therefore, it was appropriate for staff to follow this policy when they felt Ms T displayed any of the above behaviours on 24 April and 20 June.
60. The policy outlines the process to follow when staff feel they have experienced aggressive or violent behaviour, which includes an initial verbal warning, followed by a written behaviour agreement, a formal warning letter, and removal from the service if the behaviour continues.
61. Staff reported giving a verbal warning to Ms T about her behaviour and de-escalated the situation to continue providing support.
62. Staff wrote up the incident report on 10 May, 12 working days after the incident. A manager note from 15 May states they spoke to the staff member involved to ask if they wanted to write to Ms T about her behaviour. The staff member said this may not be helpful. The notes state staff should not attend alone after this incident and the Trust would consider next steps if the behaviour was repeated.
63. This shows staff had given Ms T a verbal warning and put a plan in place to consider next steps if Ms T repeated the alleged behaviour. This is in line with the Trust’s behaviour management policy.
64. The record from 20 June states Ms T and her daughter were verbally aggressive and prevented staff from addressing medical issues. The record states staff gave Ms T a written warning letter following on from the verbal warning at the previous appointment because the behaviour continued. The staff member involved filed an incident report on 21 June. The Trust informed the Clinical Lead and Service Manager about the incident.
65. The first line of the letter states it is a behaviour agreement letter, which is the second step in the behaviour management policy. The Trust wrote the letter in response to the alleged unacceptable behaviour on 24 April.
66. We have concluded that even with the delay, the Trust had already made Ms T aware it considered the behaviours unreasonable via the verbal warning at the time of the incident in April. We appreciate Ms T’ surprise at receiving the letter on 20 June and can see why it was unexpected. We do not consider it was out of the blue as the Trust had taken the first step of providing a verbal warning, in line with its behaviour policy, at the time of the incident in April.
67. Staff seem to have given the letter to Ms T when she allegedly began displaying similar aggressive behaviours. It is clear from the notes this letter escalated the situation and the staff felt they had to leave the house for their safety. We again appreciate Ms T disputes these behaviours. We recognise the behaviour policy suggests a warning letter should be given in a calm time and with hindsight it may have been helpful for staff to have issued the letter following the first incident or at a calmer time.
68. The Trust could have provided this letter at another time as suggested in the policy. If the letter was a response to the seriousness of the original incident, staff could have presented this to Ms T earlier following the first incident in April. If the letter was intended as a response to Ms T continuing to show the same alleged abusive behaviours staff experienced on 24 April, then the staff ideally should have left the home and presented a letter following this outlining the unacceptable behaviour on both occasions.
69. Either way, based on the zero-tolerance policy for these alleged behaviours, it was appropriate for the Trust to provide Ms T with this letter even if the timing was not in line with best practice.
70. We can appreciate the situation was tense. We can also appreciate the distress caused to Ms T by the timing of this letter. The Trust has explained the necessity of the letter and apologised for the distress Ms T may have felt in receiving it.
71. The Trust’s actions have not led to an injustice, as it was appropriate for the Trust provide Ms T with this letter based on how staff felt following the incidents. There could have been better timing. It is unlikely better timing would have resulted in a different behaviour management outcome.
The Trust did not provide translators during appointments
72. Ms T has told us she speak Spanish and requires a translator to help her understand. Ms T has told us the Trust did not provide or offer any translators for the appointments, and the Trust misrepresented her ability to speak and understand English in the complaint responses. Ms T said this made her feel distressed as she was more vulnerable during these appointments.
73. The Trust said there are documented interactions with Ms T via face to face, email and telephone which indicate she can speak and understand English well enough to be seen alone. It also said it had offered Ms T an interpreter at times in the past and declined.
74. We have reviewed Ms T’s medical records and the Trust’s policies for their interpreting service.
75. The Trust’s policy for the provision of the Interpreting Services from the period of treatment states the Trust is committed to ensuring everyone whose first language is not English receives the support they need to communicate with healthcare staff and to access health services. The guidance states if a referral to a service does not identify a language support need, the clinical team delivering care are responsible for identifying the need.
76. The Patient Guide for the Whittington Health NHS Trust Interpreting Service states the patient should inform the health professional they need an interpreter. We cannot see record of Ms T requesting interpreting services. This patient guide is available on the Trust’s website in Spanish.
77. Notes from multiple appointments in 2020 with another Trust dietitian state the clinical assessments were carried out in Spanish (as the dietitian spoke Spanish) as Ms T had poor English. In October 2024 Ms T attended with a personal assistant who spoke Spanish and interpreted. We can see no other reference to Ms T requesting a translator.
78. The records between January 2024 and June 2024 make note of Ms T’s daughter’s presence in the meetings. The notes indicate Ms T’s daughter was acting in a supporting role rather than a direct translator. We acknowledge Ms T’s daughter told the Trust Ms T does not speak fluent English and relies on her and interpreters for communication in medical appointment. The Trust acknowledged in its complaint response Ms T’s daughter was occasionally interpreting some information for Ms T.
79. In one of Ms T’s responses to the Trust (written by Ms T’s daughter) she explained they declined an interpreter because Ms T’s daughter is trained to interpret. The policy states if the patient insists on using a family member to translate then this should be respected if the situation is appropriate for the family member to translate, and this should be documented in the patient’s notes.
80. We cannot see documentation of Ms T’s request for her daughter to translate for her or for them declining a translator. It is also not clear from the notes when a translator was offered and declined. We believe the Trust could have done more to ensure Ms T had access to an impartial translator if needed, and documented decisions more to confirm whether Ms T required a translator aside from her daughter.
81. On 25 April, the community dietitians attended when Ms T was alone in the house. The record includes a detailed explanation of Ms T’s ongoing issues with supplements, flavour preferences, and the first complaint about the Ensure prescription reduction. There is a record of Ms T being unhappy with the amount of weight she had gained and her expectations of the service.
82. The documentation of what Ms T said is consistent with later complaints made to the Trust and to us. It is unlikely on the balance of probabilities the Trust could capture this level of detail consistent with later reports if the information did not come directly from Ms T during this appointment. This would indicate a lack of translator did not restrict Ms T’s ability to access a service or communicate her needs.
83. Following this appointment there was one phone call review on 9 May where it suggests the dietitians spoke to Ms T directly without her daughter present to support her. The detail from these records support the view Ms T was able to communicate her needs and preferences effectively as there is record of her preference for Ensure and the prescription returning to three times a day in response to Ms T’s reported needs. Again, this would indicate a lack of translator did not inhibit Ms T from accessing care and expressing her needs.
84. We appreciate Ms T is not fluent in English, and accessing a professional translator during these two appointments would likely have given her the best level of understanding and opportunity to communicate. Based on the evidence seen we do not consider the lack of translator directly led to Ms T being unable to understand and communicate her needs enough to access healthcare support or led to staff not recording or meeting her needs.
85. We have not found evidence of an unremedied injustice in the actions of the Trust, as we cannot see evidence Ms T was adversely affected. Ms T was still able to access healthcare and communicate her needs, and did not lose out on care as a result of the indicated failings in translation.
86. We thank Ms T for bringing her concerns to us, and we hope our statement reassures her the care she received was in line with the professional guidance.