Walsall Healthcare NHS Foundation Trust (WHC)
Fracture and discharge
35. Mrs Y complains staff at WHC failed to diagnose her mother, Mrs I, with a fracture of her femur (upper leg bone) and incorrectly discharged her home.
36. WHC said in cases of suspected neck of femur fractures following falls, where an X-ray has not identified a fracture, it is usual practice to undertake a mobility assessment to determine the patient’s ability to weight bear. It said the assessment is a means of safety netting, as in these instances, underlying fractures are not always visible on plain film X-rays and so the assessment can be an indicator for further investigation. WHC acknowledged there was no documented evidence a mobility assessment was completed.
37. We have seen the records from WHC state Mrs I had an X-ray of her pelvis/hip to rule out a neck of femur fracture (a broken hip). This was reviewed by the emergency doctor, and the radiographer on duty advised there was no acute bony injury seen. Following a discussion with the trauma and orthopaedic registrar, the decision to discharge Mrs I was made.
38. The records document Mrs I and her grandson, who was with her at the time, were advised she should take analgesia (painkillers) for pain, use a walking frame for assistance with mobility and see her GP, or return to the department if she had any further concerns.
39. BOAST, The Care of the Older or Frail Orthopaedic Trauma Patient, standard three, states, ‘When indicated, cross-sectional imaging should be obtained at initial presentation in the emergency department’.
40. NICE guideline CG124, states doctors should ‘Offer MRI if hip fracture is suspected despite negative Xrays of the hip of an adequate standard. If MRI is not available within 24 hours or is contraindicated, consider CT’
41. It is noted Mrs I reported a significant level of pain, requiring morphine, was reported as not being able to weight bear, and had a shortened and rotated (twisted) leg. WHC records do not indicate further X-rays or scans were considered.
42. Our consultant adviser informs us, the description of Mrs I’s leg and her level of pain was consistent with a displaced femur or hip fracture. Records indicate Mrs I did not receive a complete examination and consideration of a femur fracture, when the X-ray of the hip and pelvis did not show a fracture. There is also no documented examination of Mrs I’s range of movement.
43. GMC Good medical practice, section 7, states ‘In providing clinical care you must: • adequately assess a patient’s condition(s), taking account of their history, including • symptoms • relevant psychological, spiritual, social, economic, and cultural factors • the patient’s views, needs, and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary’
44. We understand how important it is to be fully assessed when visiting hospital. It is our view the assessment provided to Mrs I did not meet BOAST and NICE guideline CG124 referred to above. This is because a complete assessment was not carried out given her presentation and pain levels in line with GMC’s Good medical practice. We consider this was a failing. Therefore, the decision to discharge at that time without the full assessment of symptoms was also a failing. We consider the impact of these failings later in our report.
Operation delays and communication
45. Mrs Y says WHC unnecessarily delayed her mother’s operation on several occasions and she was caused unnecessary worry and fear by receiving a call from the consultant whilst her mother was being operated on.
46. WHC records document Mrs I’s operation was cancelled three times. Initially this was because her haemoglobin (HB) count was low. Our orthopaedic adviser informs us it is acceptable to reschedule an operation in such circumstances. This is because a low HB level could indicate anaemia. As blood loss is common during surgery, surgeons and anaesthetists aim to minimise blood lost to help give patients the best chance for recovery. This is also in line with NICE CG124, section 1.2.2 which states surgeons should ‘Identify and treat correctable comorbidities immediately’.
47. The second occasion was because it unfortunately was found after Mrs I had already been given the anaesthetic, the Laminar flow system was not working correctly. This is a system of fans for ventilation which help prevent contamination in the operating environment.
48. Our orthopaedic adviser informs us as Mrs I had multiple joint replacements near the fracture site which would be exposed during surgery, it would be reasonable to do the operation in a laminar flow theatre to minimise risk of infection. It is noted Mrs Y informed staff her mother had both knee and hip replaced.
49. With this in mind it is our view it was reasonable for WHC to cancel the operation if the laminar flow was not available because of the possibility of an increased risk of infection. The records show a discussion with colleagues was held regarding this, which is in line GMC Good medical practice.
50. The third occasion was because an operation on a person ahead of Mrs I took longer than expected. This meant the time available for the other patients on the list, including Mrs I, was reduced, and her operation could not go ahead.
51. We understand how upsetting cancelled operations can be for both patients and families and do not underestimate the effect felt by Mrs Y and her mother. There is no indication the cancellation of any of the operations was unreasonable.
52. Our orthopaedic adviser informs us it would generally be appropriate to communicate with close family members regarding surgical decisions, delays, and sometimes after completion of surgery especially for patients lacking capacity for consent.
53. This is in line with the GMC, Seven principles of Decision Making and Consent, which states, ‘The choice of treatment or care for patients who lack capacity must be of overall benefit to them, and decisions should be made in consultation with those who are close to them or advocating for them.’
54. It is not possible to tell from the records when during the operation the call was made. Our orthopaedic adviser tells us it is acceptable and standard practice with some surgeons to inform family members after successful completion of surgery to reassure the family.
55. We appreciate it can be frightening waiting for news on a loved one, who is having an operation. The decision to update Mrs Y was in line with GMC guidance, as referenced above.
Assistance and physiotherapy in hospital
56. Mrs Y says WHC staff did not offer her mother any assistance to stand following her operation whilst in hospital. She also says her mother was not provided with any physiotherapy before she was discharged home and received inadequate physiotherapy once she was discharged. This element of the complaint is not addressed in the response from WHC dated 31 May 2023.
57. WHC nursing records indicate Mrs I was intermittently confused following her successful operation, on 27 April 2023. It was noted the occupational therapist was unable to complete an initial assessment on 28 April 2023, due to this and the drowsiness she displayed.
58. Records indicate a physiotherapist first attended Mrs I on 30 April 2024. They assessed her as safe for hoisting form bed to chair. The ward round on 2 May 2023 indicates the plan was for Mrs I to start to bend her leg.
59. The physiotherapist is documented as seeing Mrs I twice on 4 May 2023 and being advised by the consultant she could flex her knee easily in the knee brace and could weight bear ‘as tolerated’. The physiotherapist noted Mrs I’s weight bearing status was not documented but had been verbally advised to the consultant at the ward round on 2 May 2023.
60. They also state Mrs I was able to flex her leg to 60 degrees when sitting and 40 degrees when lying down but did struggle to flex to enough for the sara stedy in place, and needed assistance to move her bottom forward. Sara stedy is a frame used by physiotherapists to assist patients with mobility when sitting and standing
61. Records document Mrs I was assisted to sit and then stand three times with two people, but she was unable to fully stand, and once sat again needed the hoist to move position or to get into bed. We note it is also documented Mrs I was okay to go back to the care home, and the physiotherapist recommended the use of a riser-recliner chair. The physiotherapist also stated therapy could try and progress Mrs I’s mobility once she was discharged.
62. There is documentation of a conversation between the physiotherapist and Mrs I’s daughter and granddaughter. Mrs Y is noted as saying her mother was able to mobilise short distances with a walker before her admission, and had limited mobility on her right leg, due to a previous injury.
63. On 11 May 2023 the physiotherapist worked with Mrs I again and documented her continued difficulty with sitting/standing and using the sara stedy although the maximum assistance from physiotherapy offered (three people). It was noted Mrs I was sliding forward when in the chair and was not considered safe to sit out. Nursing staff were advised to continue to use the hoist.
64. On the physiotherapist visit on 15 May 2023 it is documented Mrs I had a lot of difficulty moving across the bed, continued to be unsafe to sit in a chair, and had a lot of difficulty with sitting and standing. The documented plan was for Mrs I to be discharged back to the care home, and the hoist to continue to be used when transferring to or from bed.
65. WHC records indicate during her inpatient stay in the acute hospital Mrs I received six physiotherapy interventions between 27 April and 23 May 2023. Initially she was seen regularly, then from 16 May she was not seen again till discharge to the Intermediate Care Team (ICT). This means she had no physiotherapy intervention for eight days prior to discharge on 23 May 2023.
66. Our physiotherapy adviser informs us there is limited guidance that would apply to Mrs I while in hospital and after discharge, that would describe the exact amount or type of physiotherapy she should have received or standing and walking provision.
67. During the eight days, as a hoist was being used to transfer her, nursing and care staff would have been unable to provide opportunity for standing, or transfers. All standing and transfer practice would have had to be exclusively provided by physiotherapy service.
68. The documentation shows no exercises, or any practice of transfer, standing or activity for these eight days, and no reason is shown for this.
69. Our physiotherapy adviser informs us deconditioning of limbs can occur in frail and elderly patients, such as Mrs I, quickly. Deconditioning is a process following a period of inactivity, bedrest or sedentary lifestyle, which can cause:
• increased risk of reduced bone mass and muscle strength • reduced mobility • increased dependence, confusion • It can result in falls, constipation, incontinence, depression, swallowing problems and pneumonia and can leads to demotivation, and general decline in health and the ability to accomplish daily living activities.
70. Although there is no guidance on this, there is a large body of research evidence of deconditioning effect by the British Geriatrics Society.
71. It is our view the evidence indicates no failings on behalf of nursing staff regarding assisting Mrs I with standing. The evidence indicates the nursing staff followed the physiotherapist’s instructions and used the hoist to move Mrs I.
72. It is our view the there was a failing in the provision of physiotherapy provided by physiotherapy staff. This is because in the final eight days of her admission she did not continue to receive physiotherapy care when it was required. As a hoist was being used by nursing staff to transfer her, any exercises would have had to be done by physiotherapy staff. There is no evidence that exercises, or any practice of transfer, standing or activity was done with Mrs I for these eight days.
73. NICE guideline NG211, states personalised exercises should be provided as soon as possible after a traumatic injury to maintain and improve muscle function, strength and range of movement.
74. Exercises which should be considered include general aerobic, core strengthening, resistance and task specific (such as standing and walking) balance training. The guidance also advises the frequency and dose of these exercises should be determined on an individual basis, using clinical judgment and expertise.
75. We recognise how important exercise and movement is for someone in hospital especially after surgery. There are no reasons documented why physiotherapy and exercises were not in place for the full admission. Overall, the physiotherapy provided to Mrs I whilst she was an inpatient did not meet NICE guideline NG211. This is a failing. We consider the impact of this failing later in our report.
Physiotherapy following discharge
76. Mrs Y says her mother the Trust did not provide personalised physiotherapy for Mrs I after her discharge. She only received basic physiotherapy once a week from the home’s regular physiotherapist.
77. This element of the complaint has not been addressed by WHC.
78. NICE guideline NG211 sets out, ‘Rehabilitation programmes of therapies and treatments should: • form part of the person's rehabilitation plan, and be tailored to their individual needs • include (as appropriate) physical, cognitive and psychological therapies and treatments such as physiotherapy, exercise, occupational therapy, psychology and orthotics, as well as injury-specific therapies and treatments’
79. Our physiotherapy adviser informs us the normal practice is the responsibility for evaluating the need for physiotherapy after discharge lies with the hospital physiotherapists. These teams would generally coordinate with community physiotherapy teams, after performing an assessment before discharge. After this it would be the responsibility of the clinician who is determining there is a need for further physiotherapy.
80. WHC’s summary of therapies document, dated 16 May 2023 indicates Mrs I started physiotherapy on 15 May 2023. A summary of Mrs I’s current abilities is included.
81. The community therapy plan, completed at WHC on 23 May 2023 indicates the plan was to progress Mrs I to using a rolled wheeler with exercises, and to refer her to the Reablement Officer (RO) for this. The physiotherapy notes on 24 May 2023 states a full assessment was needed of Mrs I’s needs and indicates she should continue with therapy as able, and this was reiterated at the multi-disciplinary (MDT) meeting on 31 May 2023.
82. The notes on 9 June 2023 states Mrs I was being discharged back to her original care home, and state that the home ‘have physio and so patient could receive ongoing therapy from there’. The records indicate Mrs I received physiotherapy on eight occasions between her discharge on 24 May 2023 and 19 June 2023, whilst in the interim care home. The records indicate these sessions were in line with of NICE guidance NG211.
83. We have seen the physiotherapist at the interim care home contacted the Home and asked for Mrs I to be referred to a physiotherapist once they were back in its care.
84. Mrs I attended the trauma and orthopaedics clinic at WHC a number of times following her discharge. Each clinic letter comments on her progress and the physiotherapy she was receiving at that time.
85. The clinic letters of 10 July 2023 and 1 August 2023 set out she is having physiotherapy.
86. The clinic letter dated 12 October 2023 includes a request to her GP to arrange physiotherapy. A copy of the letter was sent to the GP.
87. The clinic letter of 20 October 2023 states Mrs I and her daughter complained she was not getting much input from the physiotherapist. It confirms an electronic form has been sent to the physiotherapist.
88. We have seen Mrs I was seen regularly in clinic following her surgery and physiotherapy was discussed and further referrals made. This is what we would expect.
89. We understand how important physiotherapy is following surgery to build up movement of a limb. We have seen that WHC acted in line with NICE guideline NG211. It considered physiotherapy on discharge and clinic appointments discussed physiotherapy and action was taken when required to follow up on further physiotherapy. Once discharged from inpatient care the provision of therapy was provided by primary care.
Impact
90. Mrs Y says her mother’s physical health was severely reduced by the actions of WHC, leading to the loss of her independence, inability to use the adaptations her family provided to her home, and a reduction in her mental health. She also believes the actions of WHC contributed directly to her mother’s death.
91. She says herself and her family have suffered emotional distress watching the care her received, seeing her suffer unnecessary pain, have her health and independence damaged, and deal with the death of her mother.
92. We have seen there was a missed opportunity to fully assess Mrs I on 13 April 2023. This led to a missed diagnosis of fracture and discharge that day. She was readmitted to the Trust and diagnosed with a fracture on 19 April 2023. This means there was a six day delay in the diagnosis of her broken leg.
93. Our orthopaedic adviser informs us the type of injury suffered by Mrs I is very severe and complex and, in many cases, patients are unable to return to their previous level of function even with the best care. They also said unfortunately, following such injuries in elderly or frail patients there is a relatively high rate of mortality.
94. In the circumstances it is likely Mrs I’s reduced mobility had an adverse impact on her wellbeing. Reduced mobility would be expected due to the complex nature of the injury and the subsequent surgery, as well as her age and already somewhat limited mobility. We cannot say with any certainty the six day delay in diagnosis and missed opportunity to provide physiotherapy in the last eight days of her hospital admission was the sole reason for her reduced mobility as this could have been the case even if there were no delays.
95. We recognise Mrs I may have struggled to regain her preinjury status as she was quite elderly and frail and had limited walking ability (mobilising with frame) before the fall. We are unable to link the deterioration of her health, and subsequent death to the failings identified.
96. We acknowledge the distress experienced by Mrs Y in seeing her mother in pain for several days before diagnosis. We can link this impact to the failing found.
97. We recognise how upsetting and frustrating it will have been for Mrs Y to see her mother unable to recover to the way she was before the injury. We understand the death of her mother has added grief to an already emotional situation. We cannot link her experience of bereavement to the failings found.
98. We hope our detailed explanation of how we have reached our decision reassures her that Mrs I’s death cannot be attributed to any failings by the WHC.
99. We have considered the actions taken by WHC to put right any failings.
100. WHC said as a result of their review of the complaint and the care provided to Mrs I the following actions were agreed:
• The complaint will be anonymised and shared with the wider ED team for key points for learning.
• Both the attending ED Clinician and Nurses have been asked to undertake reflective practice to prevent this incident reoccurring in the future.
• There will be wider awareness across the department with regards to the importance of mobility assessments prior to discharge.
101. These are appropriate actions to take.
102. We do not consider the service improvements alone fully put right what went wrong and we set out recommendations below.
West Midlands Ambulance Service University NHS Foundation Trust (WMAS)
Unprofessional communication
103. Mrs Y says when WMAS staff attended her mother on 15 April 2023, they were rude and unprofessional in their communications.
104. Mrs Y states staff at Mrs I’s care home told her ambulance staff were rude to them and she did not witness or was a recipient of the claimed rudeness and unprofessionalism.
105. We understand it would be difficult to hear health staff have been rude and unprofessional. As we were not present at the time of these allegations of rudeness or unprofessionalism, and neither was Mrs Y we have no independent evidence to consider.
106. We are unable to make a decision on this element of the complaint. We recognise the tone of communication can be perceived differently by different people. We therefore cannot reach a view on the conduct of the staff.
Refusal of transport
107. Mrs Y says when WMAS staff attended her mother on 15 April 2023, they did not assess her properly and incorrectly refused to transport her mother to the hospital.
108. WMAS said although the ambulance staff felt they acted in Mrs I’s best interests, on review she should have been taken to hospital on this occasion.
109. WMAS records indicate staff performed multiple observations such as physical, heart rate and blood pressure. The physical examination indicates Mrs I had mild pain and mild swelling to the front of her upper left leg, between her groin and knee. The records state pain was worse on movement and was affecting her usual mobility, and Mrs I was ‘assisted to stand into bed’ and given painkillers.
110. UK Ambulance Service guidance states all patients presenting with pain should have at least two pain scores taken. We can see no evidence of any documented pain scores.
111. The ambulance crew documented Mrs I was alert and fully aware with no sign of confusion.
112. There is a lack of documentation of a frailty score for Mrs I, something ambulance guidance recommends for elderly patients. Our paramedic adviser said the decision whether to admit patients to hospital is not straight forward, particularly if they are elderly, and can be affected by a variety of different issues.
113. We note the crew did document their reasoning for making the decision not to admit Mrs I to hospital. They appear to have been reassured she had been seen in a hospital two days before and a fracture had been ruled out. As Mrs I was in a care home, with staff to monitor her, the crew indicate they felt her symptoms could be managed with appropriate pain relief in the community. In line with UK ambulance service guidance they referred her to the Out of Hours GP for ‘medical and social assessment’.
114. We recognise how important it is to be appropriately assessed by an ambulance crew. It is our view that the crew did not operate fully in accordance with UK Ambulance service guidelines. This is because there is a lack of documentation of pain and frailty scores. This is a failing.
115. We acknowledge WMAS response states on review Mrs I should have been taken to hospital on this occasion, The lack of documentation of pain and frailty scores means we are unable to say whether the decision not to admit Mrs I to hospital on this occasion was appropriate or not. We have seen from the observations recorded Mrs I was stable and we recognise she had support in the care home.
116. However, without recording a full assessment of her pain and frailty there is not a full assessment to consider and we cannot reach a robust decision, this means the family are left without the answers they are seeking and this is also a failing. We consider the impact of these failings below.
Impact
117. Mrs Y says her mother’s physical health was severely reduced by the actions of WMAS, and the delay in taking her to hospital significantly affected her recovery, leading to the loss of her independence, and an inability to use the adaptations her family provided to her home. She also states the actions of the WMAS staff led to a reduction in her mother’s mental health and contributed directly to her mother’s death.
118. She also states herself and her family have suffered emotional distress watching her mother receive substandard care, suffer unnecessary pain, have her health and independence damaged, and ultimately suffer the death of her mother.
119. We have found failings in the assessment of Mrs I by WMAS. This may have resulted in a missed opportunity to transfer her to hospital and have a diagnosis of her leg fracture four days earlier than it was. The type of injury suffered by Mrs I is very severe and complex and, in many cases, patients are unable to return to their previous level of function, and there is a relatively high rate of mortality following, especially if they are elderly or frail.
120. It is not possible to link her reduced mobility, or subsequent decline and death, to the failing identified.
121. We appreciate how upsetting and frustrating it will have been for Mrs Y to see her mother in pain and be unable to assist her. We can link some distress Mrs Y experienced to the failing we identified.
122. WMAS, in its response letter of 1 June 2023 offered Mrs Y an apology and acknowledged the care provided was not up to the standard expected. This is appropriate action to take. We do not consider this fully puts right what went wrong and we make a recommendations below.