Decision to admit on 7 July 2021
16. Mrs K says it was not unusual for her brother to have episodes of low blood pressure. She says he could monitor this at home with support from his GP and Parkinson’s nurses and did not need to be in the Hospital. She says it was particularly important for be in familiar surroundings with support from his family. Instead, he was in unfamiliar surroundings and his family could not visit him.
17. The Silver Book provides guidance for clinicians to improve the experience of older patients in emergency situations and to reduce the number of emergency admissions. It encourages clinicians to send home as many people who have experienced a fall as possible. They would then attend a falls clinic. The aim of this is to reduce the number of attendances at hospital emergency departments.
18. The clinical records show Mr V attended the Hospital’s emergency department at 3.55pm on 7 July 2021. A clinician assessed him at 4.24pm. They noted his history of Parkinson’s disease and a fall a few days previously. During the fall they documented that Mr V hit his head on the toilet and had a bruise. He also had a bruise to his chest but said he had not lost consciousness. The clinician noted Mr V was alert.
19. Physiological observations showed Mr V’s heart rate was slightly raised and that his blood pressure was low. These findings led to an urgent review from a doctor at 5.16pm. The doctor spoke to Mr V’s wife who said the original fall had taken place five days before. On that occasion, Mr V had lost his balance and injured his chest. The second fall had taken place on the morning of 7 July when he had hit his head. Mr V’s wife said his Parkinson’s disease medication had recently changed, and he had been more unsteady recently.
20. The doctor examined Mr V and had no concerns apart from low blood pressure and a small laceration to the back of the head. They concluded that low blood pressure had caused the recent falls and all other tests were within normal limits. They discussed Mr V with a senior colleague and decided to admit him to the Hospital for further monitoring.
21. The Emergency Medicine Adviser told us postural hypotension (where blood pressure falls when someone stands from sitting or lying down) is not uncommon for people who have Parkinson’s disease. The records do not suggest Mr V had any problems relating to his low blood pressure. It is possible that clinicians could have discharged Mr V with a follow up assessment in the community for the next day.
22. The Emergency Medicine Adviser said when a patient has had multiple falls, with significant postural hypotension, many doctors would consider admitting a patient for further assessment with input from various specialists, including Parkinson’s specialist nurses.
23. The Medical Adviser agreed. They said it was not possible to establish the reasons why doctors admitted Mr V to the Hospital. Low blood pressure is a common long-term feature of Parkinson’s disease and may not require a hospital admission. But, if two falls in a relatively short period were unusual for Mr V this could have been a concern that led doctors to consider an admission.
24. In light of subsequent events, we can see why Mrs K has questioned whether it was necessary for her brother to be in hospital. While the Silver Book encourages clinicians not to admit all patients who have experienced a fall, it does not specify that this must happen in every case. This would be a matter of clinical opinion. We do not find that doctors fell below the required standards when they decided to admit Mr V to the Hospital.
Parkinson’s disease
25. Mrs K says staff on the ward did not do enough to meet her brother’s needs as someone who had Parkinson’s disease. She questions whether there needed to be specialist input and whether it was right for him to be on a dementia ward.
26. The Nursing Adviser told us there are no specific guidelines about providing specialist wards or specialist nurses for patients in hospitals who have Parkinson’s disease. They said, in their experience clinicians usually care for people who have the condition on general medical wards. There are national guidelines, but these apply to providing support for the longer-term and do not apply to acute admissions.
27. The NMC Code says nurses must provide the fundamentals of care. Nurses are expected to have the skills to manage patients who have complex needs, including those who have cognitive changes.
28. The clinical records show Parkinson’s specialist nurses reviewed Mr V during his admission to the ward. These reviews were mainly about medication. The Nursing Adviser explained that managing medication is the main issue when managing patients who have Parkinson’s disease. We can see that a nurse reviewed his medication the day after admission. There were also assessments of falls risks and regular blood pressure monitoring.
29. The Hospital does not have a specialist ward for people who have Parkinson’s disease. The Nursing Adviser said this is not unusual in the NHS.
30. We have seen nothing to suggest Mr V needed additional specialist care. There is no evidence the dementia ward was unsuitable for him. The Nursing Adviser said the records suggest nurses provided appropriate care for Mr V. There was also input from specialist nurses when required.
31. We find nurses followed the NMC Code when managing Mr V’s Parkinson’s disease. We recognise Mrs K believes her brother should have been in a more stimulating environment. We have seen no evidence to suggest nurses failed to meet his needs.
Hydration
32. Mrs K says it was important to monitor her brother’s water intake. This is because he needed a large amount of water for his medication to be effective. She also said there was a heatwave during this period. She says there appear to be records missing relating to fluid intake.
33. The NMC Code places a direct responsibility on nurses to ensure that people in their care have appropriate support with nutrition and hydration. This is a fundamental aspect of nursing care.
34. The NMC Standards say nurses should observe, assess and optimise nutrition and hydration status and determine the need for observation and support. It says they should record fluid intake and output and identify, respond to and manage dehydration or fluid retention.
35. The Nursing Adviser explained that Mr V had Parkinson’s disease, which can cause stiffness and slowness of movement, including slow swallowing. This meant Mr V was at risk of not taking adequate fluids. The clinical records suggest he was also agitated, which increased his risk. Nurses should have assessed his requirements for assistance with eating and drinking. If he was not receiving enough hydration they should have taken appropriate action. Men should consume two litres of fluids every day. The Nursing Adviser said if Mr V’s fluid intake was lower than this, nurses should have assessed and planned his care accordingly.
36. The clinical records show nurses assessed Mr V’s ability to eat and drink on 8 July 2021. They identified he had no concerns with eating or drinking and was able to swallow. However, they also identified he needed assistance. They indicated that staff should complete fluid balance charts. The Nursing Adviser said the initial assessment and planning was appropriate.
37. The clinical records contain fluid balance charts. But these were not completed properly. The nursing notes show there were occasions when Mr V drank fluids, but these were not recorded on the charts. There were no days during Mr V’s entire admission when the records show that he consumed more than one litre of fluid. The records suggest he was taking less than half of the fluids he needed.
38. We can see some references in the records to nurses assisting Mr V with food and drink. But these references are inconsistent.
39. Mrs K was right to complain that the monitoring of her brother’s hydration was inadequate. There is no evidence that nurses gave him the fluids he needed. We find nurses did not provide this fundamental aspect of care to Mr V. They did not follow the NMC Code or the NMC Standards.
40. We asked the Medical Adviser to explain whether there is evidence to show Mr V was clinically dehydrated. They explained how there are three main indicators of dehydration. The first of these is postural hypotension (low blood pressure when changing position), which is a complication of Parkinson’s disease in the absence of dehydration. So, in Mr V’s case this would not be a reliable indication of dehydration.
41. The second indicator is blood test results showing increases in urea or creatinine (waste product from the body that are released into the blood). The third is clinical examination findings suggesting dehydration.
42. Mr V’s blood test results show a small rise in blood urea level. But, during this time he also developed an infection which would also have caused the level to rise. There is no record of any clinical examination findings that would suggest dehydration.
43. Based on the clinical records, and the advice we have received, we cannot say Mr V was dehydrated during his admission. It seems more likely than not that he was receiving additional fluids and nurses failed to record his intake correctly. But we can see why Mrs K believes her brother was not getting enough water and that this could have had an impact on her brother’s health. This has led to distress to her that could have been avoided. We consider this is an injustice to Mrs K.
Physiotherapy and mobility
44. Mrs K says staff did not encourage her brother to walk around the ward. She says physiotherapists only seem to have been involved in her brother's care after 13 July 2021 when his discharge was being considered. She questions how he became immobile. She believes earlier therapy should have allowed her brother to leave the Hospital.
45. The NMC Standards say nurses should use evidence-based, best practice, approaches for meeting patients’ care needs. It says they should accurately assess a person's capacity for independence and self-care and start appropriate interventions. The Nursing Adviser said nurses should be aware of the principles of early mobilisation in hospital for older adults. They said there should have been a mobilisation plan for Mr V.
46. The Parkinson’s Disease Guideline says clinicians should carry out a full assessment of patients with Parkinson’s Disease after a fall. It says physiotherapy should be part of an individualised care plan that addresses the specific physical impairments and mobility issues related to Parkinson’s disease, such as rigidity, bradykinesia (slowness of movement), postural instability and reduced balance.
47. The Parkinson’s Disease Guideline says the management of Parkinson’s disease following a fall should involve a multidisciplinary team approach. Physiotherapists should work alongside other healthcare professionals such as occupational therapists, nurses, and doctors to provide comprehensive care.
48. The Falls Guideline recommends that healthcare professionals should mobilise people as soon as safely possible after a fall. It says this should happen within 48 hours to prevent complications associated with immobility, such as muscle wastage, pressure ulcers or blood clots. It says mobilisation should be individualised. It says there should be careful assessment and a staged approach for those with cognitive impairment or severe frailty. Physiotherapists should provide appropriate interventions aimed at restoring mobility.
49. Nurses assessed Mr V when he moved onto the ward on 8 July 2021. They noted he was independently mobile but at risk of falls. He needed full assistance and supervision to maintain his safety. A nurse recorded that Mr V could mobilise with assistance from two people, but this was variable. They noted he was confused and that this could increase because of his Parkinson’s disease medication. A mobility assessment the next day referred to Mr V being at high risk of falls, that his mobility was variable and that he needed supervision to maintain safety. Nurses referred Mr V for physiotherapy on 12 July.
50. The Nursing Adviser told us that, initially, nurses correctly assessed Mr V’s mobility. But there should have been a plan to ensure Mr V was able to sit out of bed as an alternative to full mobilisation. They said nurses should have taken action to reduce the risk of deconditioning. They should have made more attempts to sit Mr V out of bed as an alternative to full mobilisation. Nurses did not follow the NMC Standards.
51. The Physiotherapy Adviser said communication between clinicians from different specialisms was inconsistent. For example, on 9 July 2021 a nurse recorded a need to arrange physiotherapy and occupational therapy assessments. This was not acted on for three days. This was not in line with the Parkinson’s Disease Guideline or the Falls Guideline.
52. The clinical records show there were times when Mr V was not in bed. On the night of 7 July 2021 there is a reference to him being able to walk. On the next evening, he walked twice to the bathroom. Then on 10 July a nurse recorded he was climbing in and out of bed. From that point onwards there are no references to Mr V leaving bed without assistance. There were occasions when he sat out of bed, but for the majority of the admission he remained in bed. The Trust has already recognised this and accepted this was a failing.
53. Mr V’s first physiotherapy assessment took place on 14 July 2021. There had been an attempt at an assessment they day before, but this could not happen due to staffing problems. The physiotherapists noted Mr V occasionally struggled to follow instructions and retain information. They noted he was at risk of falls when transferring from a bed to a chair and that equipment, such a hoist, would need to be used if he could not transfer.
54. On 15 July 2021 a physiotherapist and an occupational therapist carried out a combined review of Mr V. They noted he needed help with bed transfers and repositioning. He could not stand without assistance from two people because he would start to lean backwards.
55. We can see no evidence that physiotherapists produced an individualised care plan for Mr V. The assessments that took place on 14 and 15 July 2021 did not refer to Parkinson’s disease or the symptoms associated with it. There is no evidence the physiotherapists considered the impact of Mr V’s symptoms on the assessment findings. Again, this fell below the standard set out in the Parkinson’s Disease Guideline and the Falls Guideline.
56. The Medical Adviser told us there were several different factors that led to the deterioration in Mr V’s health. He became agitated and confused shortly after admission. This was a change in behaviour which suggests he had delirium. In people who have Parkinson’s disease, delirium can be caused by acute issues such as infection, constipation, head injury, pain or simply a change in environment such as a hospital admission.
57. The Medical Adviser agreed with our other advisers that there were opportunities for early mobilisation that were missed in Mr V’s care. These should have been pursued even if delirium was present. Because there were so many factors affecting Mr V's health during his admission to the Hospital, we cannot establish how much of an impact the failings in mobility and physiotherapy had on him. We can say it is likely that these issues contributed to some extent to the deterioration in his health.
58. Clearly the issues relating to Mr V’s mobility were distressing for Mrs K and her family to become aware of. We can see how they are now left not knowing how much of an effect these issues had on Mr V. We consider this is a significant injustice to them.
Decision not to discharge
59. Mrs K says a doctor told them on 13 July 2021 that her brother was fit enough to be discharged from the Hospital. She says her brother did not want to be in the Hospital and did not need to be there either.
60. The MCA Code stresses that any act, or any decision made, for a person who lacks capacity must be made in that person’s best interests. It says doctors need to consider the clinical needs of the patient and the potential benefits and burdens on the person’s health.
61. On 8 July 2021 a nurse carried out an assessment of Mr V’s capacity to make decisions. They noted that Mr V wanted to leave the ward. They also noted he was confused and lacked capacity to make any decisions about his care and treatment.
62. The Trust arranged a best interest meeting to make decisions about Mr V’s discharge. This is a meeting when a person lacks capacity to make decisions themselves. Usually this would involve relevant healthcare professionals and the patient’s family members or carers. At this point there was no lasting power of attorney (LPA) in place. This meant Mr V had not appointed any individuals to make decisions on his behalf if he lacked capacity.
63. A doctor met with Mrs K on 13 July 2021. They noted Mrs K was keen for Mr V to go home to familiar surroundings. The doctor explained that Mr V did not need any hospital treatment. They said occupational therapy would need to be involved any decision and that they would contact the family. On 15 July staff noted Mr V was ‘medically optimised for discharge’ but was awaiting input from occupational therapy or physiotherapy.
64. There is evidence that clinicians at the Hospital contacted Mr V’s family to discuss his wish to return home. The family also said they wanted doctors to discharge him from the Hospital. On 15 July 2021 records show an occupational therapist discussed Mr V’s care with his sister. They explained how he would need rehabilitation because his health had worsened since being admitted. They did not consider it would be safe for him to return home because he needed specialist equipment to transfer from a bed. Mr V’s family clearly did not agree with this view.
65. On 16 July 2021 a doctor completed another capacity assessment for Mr V. They again established he did not have capacity to make decisions about his care. He was unable to engage in a discussion about discharge or rehabilitation. Sadly, Mr V then became acutely unwell on 19 July, and it was not possible to consider these plans further.
66. The Medical Adviser told us that as long as Mr V lacked capacity for decision making, clinicians were justified in preventing his discharge solely at his request. There is evidence in the clinical records that the Hospital’s discharge facilitator attempted to contact Mr V’s next of kin to establish his social care needs. The records show that by 13 July 2021 Mr V was medically fit for discharge. But clinicians kept him in the Hospital because of the risks associated with his mobility.
67. We find clinicians followed the MCA Code. They decided to keep Mr V in hospital in his best interests. We understand why Mrs K is concerned about this decision, given the subsequent course of events. It was not possible for clinicians to anticipate that Mr V would develop sepsis and then experience a cardiac arrest. We cannot say what happened fell below the relevant standards.
Response to sepsis
68. Mrs K questions whether clinicians identified the deterioration in her brother’s health quickly enough and whether they gave him the treatment he needed.
69. The Sepsis Guideline is aimed at healthcare professionals working in the UK. It explains the symptoms that should lead clinicians to ask if someone might have sepsis. It also explains how sepsis should be treated. Clinicians should start looking for the source of the infection and take appropriate blood samples. It recommends starting an appropriate antibiotic and giving intravenous fluids within one hour of identifying that a patient could have sepsis.
70. Nurses should consider the NEWS Guideline. The NEWS aims to improve the detection of and response to clinical deterioration in patients with acute illness. It is based on a simple scoring system where scores are allocated to specific physiological measurements (breathing rate, levels of oxygen in the blood, blood pressure, pulse, consciousness and temperature). The NEWS tells clinicians how they should respond when the total score is between specific values.
71. The clinical records show nurses regularly recorded Mr V’s NEWS during his admission. On arrival his NEWS was zero, which meant he was at low risk of developing an acute illness and did not need increased monitoring. There were occasions when nurses could not calculate Mr V’s NEWS because he was uncooperative. However, nurses recorded his NEWS at least once every day and his scores were zero or one until the night of 19 July 2021. Up to that point there was no reason to escalate his care.
72. The clinical records do not suggest there was any evidence that Mr V had signs of sepsis before the night of 19 July 2021. Nurses followed the NEWS Guideline in this respect.
73. At 10.40pm on 19 July 2021 Mr V’s NEWS was four. He had a fast pulse and lower than normal blood pressure. A NEWS of four would not prompt nurses to treat him any differently than previously. But nurses increased his observations to hourly and gave him paracetamol.
74. At 11.22pm Mr V’s NEWS was nine. This represents a high clinical risk. Nurses alerted the medical team, and a doctor attended followed by a critical care outreach nurse. They took blood samples and arranged for intravenous fluids to start. They noted Mr V had already started intravenous antibiotics earlier in the day and that this should continue. Nurses confirmed they had started a sepsis pathway. These actions were taken around one hour from the time when sepsis was first suspected.
75. Nurses rechecked Mr V’s observations at 1am and noted his NEWS was then eleven. A doctor attended a few minutes later and reviewed Mr V. Doctors also requested blood samples. These did not identify the cause of the infection. By 5.20am Mr V’s NEWS had reduced to seven.
76. A doctor called Mr V’s wife at 9am and explained how it was not possible to send him home. The doctor confirmed Mr V had sepsis, and he needed to continue with intravenous fluids and antibiotics. By the following afternoon the intravenous fluids had led to an improvement and Mr V’s NEWS was then six.
77. We find nurses escalated Mr V’s care appropriately based on his NEWS. They followed the NEWS Guideline. We can also see that clinicians followed the Sepsis Guideline. They arranged to get a blood sample and provided fluids and an appropriate antibiotic.
78. We recognise Mrs K feels clinicians at the Hospital could have acted quicker. This is not what we have seen. We hope she is reassured we have seen no evidence of any failings in this respect.
Communication
79. Mrs K says clinicians at the Hospital did not provide enough information to her family about what was happening during her brother’s admission.
80. Good Medical Practice says doctors must communicate effectively. It says they must give patients information they want or need to know. It says they must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
81. The NMC Code says nurses should ensure patients are informed about their care and that information about them is shared appropriately. It says they should share information patients, or their families, want or need to know about health, care and ongoing treatment
82. The clinical records show doctors discussed Mr V’s care with his wife or sister at least once on each of 13, 15, 20 and 21 July 2021. These conversations were largely about whether Mr V should have remained in the Hospital. Up to 15 July 2021 doctors were clear that Mr V was well enough to go home, but occupational therapy disagreed, and the therapists also spoke with the family to explain their reasons. There is also evidence that clinicians made other unsuccessful attempts to contact family members by phone.
83. On the morning of 20 July 2021, a doctor spoke to Mr V’s wife by phone. They documented that they explained how Mr V had become unwell during the night. The same doctor spoke again to Mr V’s wife later in the day. They noted she was happy with the explanation and management plan. The same doctor spoke to Mrs V again the next day.
84. The records suggest doctors communicated effectively with Mr V’s family. Doctors appear to have been responsive in giving information and support. They followed Good Medical Practice.
85. Nurses established that Mr V’s was wife was his next of kin. She was identified as an appropriate family member to contact when Mr V was confused. There is evidence that nurses contacted family members when required. For example, they discussed Mr V’s care with Mrs K on 15 July. On 21 July a nurse spoke to Mrs V about the medical plan.
86. The Nursing Adviser told us the documented discussions appeared to be appropriate, but basic. We can see that, on admission the discharge co-ordinator tried to get in touch with Mr V’s wife. But there was a lack of communication between 10 and 13 July 2021 and then again between 16 and 19 July. This was below the standard expected in the NMC Code.
87. The Trust has acknowledged there were some gaps in communication. It agreed that it should have contacted Mrs V on 12 July 2021 to explain that her husband had been sedated for a scan. It said the importance of effective communication had been fed back to the nursing team. The Trust accepted that more experienced members of staff should have had conversations with the family.
88. We find doctors communicated with Mr V’s family in line with the relevant standards. But, we find, nurses did not follow the relevant standards. We can see that during the time when nurses did not contact Mr V’s family his health was stable and that doctors ensured they were contacted when this deteriorated. But we can see how the gaps in communication led to distress for Mr V’s family that could have been avoided.
Visiting restrictions
89. Mrs K says the family was prevented from visiting because of the Trust’s COVID-19 rules. She says at the same time other trusts allowed a designated person to visit Parkinson’s patients as long as they had been vaccinated and were willing to take a lateral flow test. This should have been for 30 minutes each day.
90. The Nursing Adviser said there was no national guidance they were aware of which specified that people who had Parkinson’s disease and were in hospital should be allowed visitors for 30 minutes each day. We can see that visitor restrictions were in place at the time because of COVID-19. This was in line with the COVID-19 Visiting Guidelines which said visitors were only permitted for patients in their last days of life or in exceptional circumstances. Exceptional circumstances included access for people who needed support from a familiar carer and where it was necessary for someone’s emotional needs.
91. The clinical records show Mr V’s wife was allowed to visit him on 17 July 2021 for 30 minutes. Mrs K also explained how the family was able to keep in touch with him earlier in the admission using a tablet on the ward. The family were told they could attend on 22 July 2021. Sadly, Mr V had already died before this visit could happen.
92. People with Parkinson’s disease were not automatically entitled to visitors for 30 minutes each day. But Mr V had frequently displayed agitated behaviour as a consequence of his delirium and Parkinson’s disease. Clinicians should have interpreted this as exceptional circumstances. Had they done so, Mr V’s family might have been allowed to visit, providing they met the infection control measures that were in place. This did not happen. We find the Trust did not follow the COVID-19 Visiting Guidelines.
93. We can see how Mr V may have been calmed and comforted by his family being able to visit. It is likely this would also have reduced the family’s distress. It is likely they would have been able to spend more time with Mr V before he died. This is a significant injustice to Mr V’s family.