Complaint about placement and level of supervision on transfer to the ward
14. The NICE safe staffing guidance says organisations should ‘ensure patients receive the nursing care they need… regardless of the ward to which they are allocated’. They also say patients should be located where their clinical needs can be best met.
15. The NMC code says nursing staff caring for patients should take account of the safety of people in their care and deliver the fundamentals of care effectively. Our nurse adviser explained this means nurses should think about any risks to patients’ safety (such as in Mr U’s case, the risk of falls or non-compliance with safety measures due to confusion) and think about ways to effectively deliver care whilst managing those risks.
16. The records show Mr U’s delirium made him confused and disorientated, which put him at risk of falls. A care plan was completed on 13 December before Mr U moved to the ward. This said due to the risk of falls staff should consider enhanced observations and additional safety equipment (such as falls alarms).
17. When Mr U transferred to the ward he was placed in the least visible bay, furthest from the nurse’s station (bay C), without any enhanced supervision or additional safety equipment. This remained the case on 14 December even though staff had now documented that he needed closer supervision as he was trying to climb out of bed.
18. Late on 15 December Mr U fell from bed. The following day he was moved to a more visible bay opposite the nurse’s station (bay B). A falls alarm was now in place and staff were providing more enhanced supervision.
19. We consider Mr U should have been placed in bay B when he moved to the ward and when further risks were identified. It was not appropriate for him to be placed in bay C.
20. Our nurse adviser explained Mr U’s recent discharge from HDU, where he had been supervised closely, and his established confusion and risk of falls meant he needed to be placed in a part of the ward where staff could observe him closely and implement measures to reduce the risk of falls. Even though the records also say this, it did not happen.
21. We therefore found the Trust did not act in line with the NICE or NMC guidance here. This was a failing. We next considered the impact of this.
22. Our nurse adviser explained the fall on 15 December could have potentially been avoided if Mr U was in a more visible area with enhanced supervision. Fortunately, Mr U sustained no injuries from the fall so it appears to have had no lasting impact. However, this did contribute to Mrs L’s stress and worry during her father’s admission, leaving her with concerns her father was not safe in hospital.
23. The Trust has accepted it made a mistake here. In its response to Mrs L’s complaint it recognised an enhanced level of supervision in bay B was necessary due to the additional nursing care needed to maintain Mr U’s safety. However, the Trust has not specifically apologised for the failing and we consider there is more it should do to put things right here. We set this out in the recommendations section of our report.
Complaint about the provision of fluids against SLT’s recommendations
24. The Trust’s dysphagia policy says all relevant nursing staff must ‘comply with dysphagia recommendations provided by SLT’ and ‘clearly communicate… special fluid requirements to the nursing team, housekeeper and catering providers carrying out beverage rounds’. This ensures those responsible for providing drinks to patients are aware of any restrictions so they can avoid giving them something they cannot have.
25. More generally, the NMC code says nurses must work with colleagues to preserve the safety of those receiving care and share information to identify and reduce risks. They should also effectively deliver the fundamentals of nursing care, which includes hydration.
26. The records show when Mr U transferred to the ward the SLT recommendations were that he could have ‘3-4 teaspoons of custard, yoghurt or smooth/thick soups’. Any water needed to be thickened to the same consistency using a powder that is added to liquids.
27. Mrs L told us her sister visited their father on 14 December and saw he had jugs of unthickened water and juice, and a glass, at his bedside. A care assistant said they did not know why the drinks were there but confirmed her father had drunk some earlier.
28. We looked for other evidence of this incident and saw ward staff did not document anything in Mr U’s notes about him drinking unthickened fluids. We would have expected to see a record of this from the ward staff. However, there is a note from a HDU nurse on this date as Mrs L’s sister went there to raise concerns about her father’s care on the ward, including that he had able to drink from jugs of water and juice.
29. On the balance of the evidence, we accept Mrs L’s account that her father was allowed to drink unthickened fluids on 14 December against the SLT recommendations.
30. On 16 December, SLT made recommendations that Mr U could have level 3 thickened fluids from a spoon only. Level 3 refers to the degree of thickness, with 1 being the thinnest and 4 the thickest. The liquid and thickener powder need to be carefully measured to achieve this.
31. The next incident occurred on 20 December. The records show Mr U had a jug of water left on his bedside, he was seen drinking quickly from the jug, and it likely was not thickened to level 3. This was against the SLT recommendations.
32. When we examined the evidence it suggested support staff were not adequately aware of the SLT recommendations during this time. The care assistant observed him drinking water and did not raise concerns, and he was left with jugs of water. It appears there was a failure of nursing staff to communicate the recommendations to colleagues.
33. It is unclear whether nursing staff were adequately aware of the recommendations or how to implement them. The nursing notes do not include a care plan or other documentation setting out how nursing staff were going to meet Mr U’s fluids needs.
34. Our nurse adviser says care plans are one of the fundamentals of nursing care. They should be specific to patients’ needs and explain the type of care they need to receive. In Mr U’s case, a care plan would need to include up to date information about his swallowing difficulties, intake restrictions and SLT recommendations. We cannot see any evidence of care planning while Mr U was on the ward.
35. We found the Trust did not act in line with its dysphagia policy or the NMC code. There are failings in following recommendations, communication with colleagues, and care planning.
36. We considered the impact of the failings. Mrs L is concerned they caused her aspiration pneumonia and contributed to her father’s death.
37. We cannot see any evidence Mr U developed aspiration pneumonia or became unwell after the incident on 14 December. Whilst we hope this now reassures Mrs L, we accept at the time the failing was distressing and made her worry about her father’s safety.
38. Mr U became very unwell on 20 December and was diagnosed with aspiration pneumonia. Our physician adviser says there is clear connection between this and the fluid incident on the same date, and we are therefore confident the aspiration pneumonia was a result of the failing. The records show Mr U needed antibiotics for this and recovered over the next week.
39. Unfortunately, Mr U developed another aspiration pneumonia on 3 January. By this stage his swallow had deteriorated further. He was nil by mouth (nothing taken orally) and everything was provided by a nasogastric tube. Aspiration pneumonia can happen in people who are nil by mouth when they inhale oral secretions that they are too weak to clear.
40. Very sadly, Mr U did not recover from this and died on 10 January. We asked our physician adviser whether the failings on 20 December contributed to this.
41. There are multiple entries in the records where the medical team said Mr U may be too unwell to survive the hospital admission. Our physician adviser agrees with this conclusion, and explained the evidence from even early on in the admission suggests it was more likely than not that Mr U sadly would not survive even with optimum care. This would have been due to his frailty and the severity of his illness.
42. Our physician adviser said the failings on 20 December which resulted in aspiration pneumonia would have only had a small impact on Mr U’s chances of survival as they were already very low. Importantly, however, he went on to recover from that episode of aspiration pneumonia. He then experienced another episode of aspiration pneumonia on 3 January, which sadly resulted in his death. This was not due to any failing in his care.
43. We therefore do not find Mr U’s death was avoidable or that any failings in his care contributed to this. However, we can see the failings on 20 December added to the worry and distress Mrs L was already experiencing at this time, leaving her understandably concerned about her father’s safety in hospital. It also left her wondering whether her father’s death could have been avoided which contributed to her sleep issues and flashbacks.
44. The Trust’s complaint responses do not acknowledge or apologise for the failing on 14 December. It acknowledges the failing on 20 December, but it has not adequately apologised for this or the impact it had on Mrs L. There is more the Trust should do to put things right here. We set this out in the recommendations section of our report.
Complaint about olanzapine
45. GMC guidance says doctors must take all possible steps to alleviate pain or distress, and prescribe drugs or treatment that serves patients’ needs.
46. Mr U’s delirium meant he was confused, agitated, and would pull at things such as his NG tube or urinary catheter. To manage this, doctors on HDU prescribed olanzapine. This is a medication used to treat mental health conditions including delirium.
47. Our physician adviser tells us it was appropriate to use it in these circumstances as it reduced the risk of Mr U causing himself harm.
48. When Mr U moved to the ward the doctor there decided to wean down olanzapine over the next two weeks whilst his delirium resolved. The records show this plan was regularly reviewed, and olanzapine was weaned down with the last dose on 28 December.
49. Our physician adviser says this approach was appropriate as abruptly stopping the medication could risk his agitation becoming worse.
50. We found the Trust’s actions were in line with the GMC guidance, and we see no failing here. We know this situation was worrying for Mrs L, and we hope the explanation here reassures her that this part of her father’s care was appropriate.
Complaint there was a delay in reinserting an NG tube
51. The GMC guidance says doctors should ‘promptly arrange suitable advice, investigations or treatment where necessary’. There are no standards or guidelines that set out specific timescales for reinserting an NG tube.
52. Mr U needed an NG tube due to his unsafe swallow, however his delirium caused him to pull this out on 19 December. The clinical team met with his family on 22 December to agree a plan and decided the NG tube would be reinserted to ‘deliver nutrition over the bank holiday weekend’. Mrs L is unhappy the procedure was not done until the next morning.
53. The ward team could not complete the procedure during daytime hours. Because it had not been done, the nurse looking after Mr U asked the on-call doctor to attend but they had no capacity to do the procedure. The nurses then asked the out of hours hospital team to attend, but they said it would be safer to do the procedure during working hours. It was therefore completed the following morning, on Friday 23 December.
54. The overall plan was for the NG tube to be inserted in time for the bank holiday weekend. We can see this is what happened.
55. Our physician adviser explained reinsertion of an NG tube would ideally take place the same day the decision is made, but factors such as staff capacity or other higher priority clinical tasks could mean it is unavoidably postponed.
56. We can see staff were aware of the plan, and took steps to try and get the procedure done when it was clear capacity was an issue. However, the decision was made to not do the procedure out of hours and we consider this was a sensible approach.
57. Our physician adviser explained there is a risk of harm of doing the procedure overnight (due to the level of checks needed to make sure the NG tube is in the correct place). The risk of harm from this would outweigh the benefit of the procedure. An additional day without nutrition would have had a negligible impact on Mr U’s overall condition.
58. We understand why this was a concern for Mrs L. We agree the time taken to do it was not ideal, However, for the reasons outlined above we cannot conclude there was a failing here.