Care provided by the Foundation Trust
19. Mr B and his family say there are contradictions in the complaint response as regards the interpretation of Mr C’s imaging on 16 February 2018 when he had a CT scan. Specifically, in the first complaint response (13 April 2020), the Foundation Trust described Mr C's imaging as normal whereas the Hospital Trust described the same imaging as showing a mid-line shift requiring neurosurgical opinion. In the second complaint response (13 October 2022), Mr B and his family say the Hospital Trust retreated from this, stating the appearances were normal for the injury Mr C had sustained. Mr B says his family were told by Mr C's treating neurologist while he was a patient at the Foundation Trust that this same imaging showed a deterioration in his condition. Therefore, Mr B and his family have concerns as to how the Hospital Trust’s very significant change in opinion came about. Given this, we have asked our radiology adviser to comment.
20. Having considered the relevant records, our radiology adviser says we must first consider the findings from Mr C’s CT scans on 27 December 2017 and 2 February 2018 before addressing this issue. Mr C’s scan on 27 December 2017 showed a subdural hygroma which is a collection of fluid around his brain. His scan on 2 February 2018 showed more dense material which suggests bleeding into the collection of fluid around his brain. Our radiology adviser says this is unlikely to have happened immediately after Mr C’s previous scan. More likely, there was a build-up of bleeding and fluid in the weeks between the two scans.
21. Our radiology adviser has added that this is likely to have caused some distortion of Mr C’s brain. There is evidence of a tiny amount of mid-line shift which is the displacement of brain structures across the midline of the skull due to the compression of displacement caused by adjacent masses. Also, there is some evidence of mass effect which is when a focal lesion or contusion causes surrounding areas of brain tissue or structures to be compressed or injured due to the degree of space that leaking blood, cerebrospinal fluid, or edema (swelling) takes up within the restricted skull space.
22. Mr C’s CT scan on 16 February 2018 showed a small increase in the volume of the collection of fluid around his brain, but our radiology adviser says there is no evidence of any further bleeding. There is some evidence of fibrotic bands in Mr C’s brain indicative of expected evolution of the haematoma seen previously. There was still an amount of midline shift (a tiny bit bigger than before), but no significant change from the previous scan. There is also no evidence of herniation syndrome which occurs when something inside the skull produces pressure which moves brain tissues.
23. In the Foundation Trust complaint response dated 13 April 2020, Mr B has highlighted the responses to questions 12 and 15 which appear to be discussing the CT scans Mr C had on 27 December 2017, 2 February 2018 and 16 February 2018. The response to question 12 indicates that the increase in the size of Mr C’s haematoma was expected, so no new concerns. It also explained what the doctor meant when he told the family there was no worsening (presumably relating to the scan on 16 February 2018) compared to before, so this could have been a misunderstanding. Mr B and his family say they spoke to Mr C’s doctor as they were concerned that he was not getting any better, but they were assured that Mr C was improving.
24. Nevertheless, the response to question 15 indicates there was a worsening of Mr C’s condition as his midline shift got worse from the CT scan on 2 February to the one on 16 February 2018. As outlined above and later in this report, there may have only been a tiny amount of growth, but this supports the view that Mr C’s condition got worse.
25. In the Foundation Trust complaint response dated 13 October 2022, Mr B and his family have highlighted the responses to questions 5 and 7. Both response points indicate there was no midline shift seen on either CT scan from 2 and 16 February 2018.
26. Given this, we can understand why the family consider there are contradictions in the complaint responses from the Foundation Trust, especially about an issue like Mr C’s midline shift which is a potentially serious condition. Over two years after the original complaint response, the Foundation Trust appears to have concluded there was no evidence of midline shift on Mr C’s imaging from February 2018. As highlighted earlier in this report, this conflicts with our findings of what Mr C’s imaging from February 2018 shows.
27. We appreciate why this will be concerning to Mr B and his family in terms of how it could have affected Mr C’s treatment at the time. We have commented on this later in the report. Having considered Mr C’s CT scans and his wider clinical records, our radiology adviser says the midline shift shown on Mr C’s CT scan dated 16 February 2018 is a tiny bit bigger than on the previous scans but does not reflect evidence of any new bleeding at the time. In other words, these findings had no additional effect on what the clinical team intended to do regarding Mr C’s management at the time. The records indicate that the clinical team initially proposed to manage Mr C’s condition conservatively rather than proceeding to brain surgery.
28. In summary, the contradictions highlighted by Mr B and his family regarding the interpretation of Mr C’s imaging from 16 February 2018 are from the complaint responses. Presumably, the Foundation Trust considered Mr C’s records before drafting its complaint responses, but the overall view on certain issues appears to have changed in the intervening months between the two replies. We have not noted such contradictions when we have considered Mr C’s clinical records including the relevant CT scan and report, with support from our advisers. We have given our view on the findings of Mr C’s imaging on 16 February 2018 in this report and acknowledge that the contradictions highlighted by the family may have impacted on Mr C’s management after his CT scan on 16 February 2018. This is considered elsewhere in the report.
29. Mr B and his family say there is a false assertion by the Foundation Trust that Mr C did not suffer any neurological deterioration until he suffered a fall on 9 March 2018.
30. Having considered the relevant chronology of documentation in Mr C’s records, our neurosurgeon adviser says there is a deterioration in his neurology. This is demonstrated by a deterioration in Mr C’s mobility, but also his cognition during this period.
31. When Mr C was seen in A&E on the 6 February 2018, there is documentation stating that he has normal power in all four limbs and is unsteady when he mobilises. On the 8 February 2018, the physiotherapist has raised concerns about a decline in his function. Specifically, Mr C was no longer able to mobilise independently and was requiring the assistance of two people to mobilise and transfer. On 14 February 2018, there is further documentation indicating that he was mobilising using a Zimmer frame but also required another person to assist with this. On 15 February 2018, there is documentation from the therapists stating that Mr C was unsafe to mobilise with the Zimmer frame. We have not seen documentation which describes any weakness in his arms or legs until he is admitted on 18 February 2018, which documents a mild right-sided weakness. On 9 March 2018, there is documentation indicating that Mr C required hoist transfer.
32. We are aware that Mr C had a background of refractory depression, but this had been better controlled prior to this episode of care through effective use of antidepressant medication. In addition to Mr C’s declining mobility, our neurosurgeon adviser says there was also a documented decline in his cognition, with low mood. A psychiatrist review has documented a diagnosis of cognitive impairment and depressive disorder on 23 February 2018.
33. Therefore, since Mr C’s admission on 6 February 2018, we consider there was a documented deterioration in his neurological status, as outlined above. The impact of this was that Mr C was having increased difficulty in mobilising. His mood was also lower than usual. This must have been frustrating and worrying for Mr C, and for his family to witness.
34. Mr B and his family say the original documented instructions from the neurosurgeons refer to further advice being needed if Mr C’s condition failed to improve, but the complaint response says the plan was that re-referral was only necessary in the event of his condition deteriorating. Even on the Foundation Trust’s adopted plan, that re-referral to the neurosurgeons was only needed if there was deterioration, the Foundation Trust failed to discuss the deterioration with Mr C and offer him a re-referral to the neurosurgeons despite documenting a neurological deterioration.
35. We can see from Mr C’s records that, following an initial discussion with the neurosurgical team at 11pm on 6 February 2018, there is documentation which states that surgery should be considered if there is no improvement with dexamethasone. The documentation from the consultant ward round on the 9 February 2018 also states this - ‘if not improving on dexamethasone, rediscuss with neuro’. Our neurosurgeon adviser says this conflicts with the information provided in the Foundation Trust complaint response dated 13 April 2020 (response to question 16) which indicates that re-referral was only necessary if there was a clinical deterioration in Mr C’s condition which we consider there was from the start of his admission on 6 February 2018.
36. As before, there is documented evidence by the therapists on 8 February 2018 about a decline in Mr C’s neurological function. Given this, our neurosurgeon adviser says it would have been appropriate to speak with Mr C at this point and offer a repeat CT head scan to look for any new changes and to rediscuss with the neurosurgery team regarding Mr C’s further management. Another CT scan was not performed until 16 February 2018, and that showed an increasing size of the subdural haematoma with mass effect.
37. We have not seen evidence in the records that the CT scan performed on 16 February 2018 was discussed with the neurosurgery team. If it was, our neurosurgeon adviser says Mr C should have also been spoken to at this point about potential next steps, one of which should have been re-referral to the neurosurgeons for possible surgery. The outcome of surgery (if it had been performed) is unknown, but our neurosurgeon adviser says if there was a right-sided weakness at this point which was contributing to Mr C’s poor mobility, then it is possible surgery could have improved any weakness. Unfortunately, there is no documentation stating the power in Mr C’s limbs until he is admitted to hospital on 18 February 2018.
38. In summary, given Mr C’s documented neurological deterioration after he was admitted to hospital on 6 February 2018, we consider this should have led to a prompter CT scan than the one he had on 16 February 2018. Given the findings of this scan and Mr C’s deterioration, the clinical situation and potential next steps should have been discussed with Mr C and neurosurgery. One such next step could have been re-referral to the neurosurgeons with a view to potential surgery. There is no evidence in the records this happened.
39. On this basis therefore, we consider there are failings in Mr C’s management by the Foundation Trust from 6 to 16 February 2018. We appreciate that it will cause some concern and uncertainty for Mr B and his family to know that Mr C’s management was not ideal at this time, and this is emotionally distressing for them. We have made recommendations about this.
40. As for the impact of these failings, our neurosurgeon adviser says Mr C’s treatment was potentially delayed by a few weeks. There are limited studies which have looked at the time to surgery for patients with chronic subdural haematomas, but the academic study cited in the evidence section of this report has showed that the outcome following delayed surgery for chronic subdural haematomas is not associated with a poorer outcome. It is however, associated with a longer hospital stay. Despite this, our neurosurgeon adviser has added that any patient with chronic subdural haematoma who has a focal neurological deficit (e.g. right-sided weakness), should be offered surgery as soon as possible with the aim of improving symptoms (if contributing to focal neurology) and to prevent further neurological deterioration. We have not seen any evidence that these failings by the Foundation Trust caused Mr C’s hemiplegia which is paralysis that affects only one side of your body.
41. Although we maintain that Mr C should have been offered surgery for the reasons outlined above, we do not know if he would have agreed to what would have been a complicated and risky procedure for him. The records indicate that the Foundation Trust’s plan for Mr C from admission on 6 February 2018 was for conservative management of his conditions with rehabilitation. Nothing surgical was to be considered, at least until neurosurgery had been consulted. There is evidence in the records that Mr C had sufficient capacity to make his own decisions about treatment. He did not want surgery and wanted to go home. On 13 February 2018, there is a documented discussion between Mr C and a doctor. Mr C was ‘not keen’ on surgery and was content with conservative management of his conditions including rehabilitation. It is noted that Mr C had surgery on 15 March 2018.
42. Mr B and his family say Mr C’s fall on 9 March 2018 was attributed to a cushion being incorrectly placed behind him when he was sitting outside of his bed, and the placement of the cushion was wrongly attributed to visitors rather than ward staff.
43. The records on 9 March 2018 indicate that Mr C ‘slipped from his chair’ and he was ‘found on the floor’. Given this, neurological observations were carried out by a doctor, but no injury was identified. After this type of incident, we would expect to see completion of an incident report form as referred to in the complaint response, but our nurse adviser has been unable to locate such a form in Mr C’s records from the Foundation Trust.
44. We have considered if appropriate risks assessments were carried out for Mr C when he was in hospital prior to his fall on 9 March 2018 and shortly afterwards. Our nurse adviser says the relevant NICE guidance regarding falls in older people states:
1.1.2 Multifactorial falls risk assessment
1.1.2.1 ‘Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.’
45. Having considered Mr C’s records, our nurse adviser says there is concern documented by nursing staff on 9 March 2018 about Mr C’s ‘poor cognition and unable to hold his posture to stand and downgraded to hoist transfers’. There is further documentation by the occupational health assistant indicating that Mr C was ‘now for full hoist transfers with nursing staff.’
46. There is a mobility assessment on Mr C’s admission to hospital (6 February 2018) stating he was bedbound and no indication he could sit in a chair. A manual handling assessment on 11 March 2018 indicates Mr C was unable to sit or stand independently. A falls risk assessment on the 11 March 2018 indicates he was a falls risk. Mr B and his family dispute that he was bedbound on admission to hospital on 6 February 2018. They say he walked into A&E and at that stage he could sit out. Mr B and his family acknowledge that Mr C became bedbound but not on admission. Having considered this issue further, it is noted that our neurosurgeon adviser said that Mr C had normal power in all four limbs on admission but was unsteady when mobilising. Unfortunately, by 8 February 2018, Mr C is reported is no longer being able to mobilise independently. While there appears to be some conflicting information about Mr C’s mobility status on 6 February 2018, this makes little difference to our consideration of what happened when Mr C unfortunately fell on 9 March 2018.
47. Our nurse adviser says there are a series of assessments in the records relating to falls that indicate Mr C was a falls risk. The records are not supported with falls prevention measures. As regards the series of assessments performed from the 7 to 12 February 2018, our nurse adviser says these assessments are not consistent with Mr C’s clinical findings at the time. We have not seen a series of assessments prior to Mr C’s fall on 9 March 2018 in the records provided by the Foundation Trust.
48. In summary, our nurse adviser says the written documentation by nursing staff and the therapies team within Mr C’s records are more detailed to indicate his level of risk in comparison to the falls risk assessments, as the assessments give no indication of risk or detail falls prevention requirements.
49. The Foundation Trust said Mr C had been sat out in the bedside chair on 9 March 2018 and had visitors that day. His fall occurred after the visitors left the bay. Unfortunately, no members of staff were in in the bay as they were attending to other patients. The Foundation Trust said that as a cushion had been placed on Mr C’s chair by his visitors, this may have contributed to the incident where he slipped from the chair. The cushion was not noted after Mr C’s visitors left at which point he was unsupervised.
50. The Foundation Trust added that it is not nursing practice to place cushions behind patients sitting out, as this causes them to be seated nearer the edge of the chair. Mr C had been assessed for sitting in a chair, and the Foundation Trust considered it was safe for him to do so. Unfortunately, he was not seated correctly and with the addition of the cushion, this appears to have contributed to him slipping off the seat.
51. Our nurse adviser has considered the explanation provided by the Foundation Trust for this incident and says it presents in a way to place reason for Mr C’s fall on his visitors which is unreasonable in the circumstances. This is because Mr C had been identified as being at risk of falls and therefore it was the responsibility of nursing staff to continue to manage that risk even if visitors are present, in the knowledge that Mr C was sat out of bed.
52. Section 55 of the NMC Code states: ‘share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way, they can understand’.
53. Our nurse adviser says that even if the Foundation Trust believes that Mr C’s fall was at least in part caused by a cushion being placed on his chair by his visitors, if nurses had continued their observations of Mr C during and after his visitors had left which they should have done, they should have identified the cushion to be removed at that point. Nursing staff had a duty of care to maintain Mr C’s safety even with visitors present and share clear nursing advice with them.
54. Therefore, we consider there was a failing by the Foundation Trust contrary to the NMC guidance as nursing staff should have noted the cushion placed on Mr C’s chair and removed it after explaining the increased risk of falls to Mr C and/or his visitors. We appreciate Mr B was concerned that the actions of Mr C’s visitors were potentially being blamed for contributing to him having a fall. We hope our findings provide Mr B with some reassurance, but we also recognise that they may cause him some additional concern as nursing staff were not observing Mr C as thoroughly as they should have been. We have made some recommendations about this.
55. Mr B and his family say Mr C was inappropriately transferred to the Foundation Trust from the Hospital Trust on 27 April 2018 without any adequate assessment of whether the transfer was in his best interests, or how he would be best managed.
56. As regards Mr C’s transfer back to the Foundation Trust on 27 April 2018, our neurosurgeon adviser has commented that an MRI scan was carried out on 1 April 2018. It showed an improvement in the size of Mr C’s subdural collection. Therefore, no further neurosurgical intervention was required, so it was appropriate to transfer Mr C back to his local hospital to continue with his medical care. Our neurosurgeon adviser says this is standard practice for patients who have completed their acute care in the tertiary hospital. Overall, having considered the relevant documentation at the time, our neurosurgeon adviser says there were no concerns about Mr C’s transfer.
57. We note that Mr B and his family have a specific concern that the transfer was damaging to Mr C as the Foundation Trust unilaterally changed his care plan from that in place at the Hospital Trust, especially regarding medication changes and pressure area risk management. Therefore, we asked our nurse adviser about this.
58. Having considered Mr C’s records that we received from both Trust’s, our nurse adviser has highlighted Transfer Information Forms and Admission Handover Sheets. Unfortunately, some of this documentation is incomplete and either lacks any depth of information or is unsigned or undated.
59. Our nurse adviser has been unable to locate any transfer documents in the care bundle provided to us from 27 April 2018. We have asked both Trust’s if they have any further information regarding Mr C’s transfer on this date, but neither Trust has been able to provide any additional information. Therefore, we cannot comment on any changes in Mr C’s care plan from 27 April 2018 due to insufficient evidence in the records.
Complaint response
60. Mr B and his family say the complaint response fails to address the issue that misleading advice was provided about the risks of surgery being too high for Mr C to undergo it, and the impacts of this advice.
61. Specifically, Mr B and his family say there were two conversations between his family and medical staff on 6 and 8 February 2018 about Mr C potentially having surgery, but medical staff said either the chances of a successful outcome were limited for a patient of his age, or the procedure was too risky for Mr C.
62. We can see that the family referred to these issues and conversations in their original complaint dated 18 October 2019. The initial complaint response from the Foundation Trust dated 13 April 2020 indicates that Mr C was spoken to on 6 February 2018 after he was admitted to hospital. His likely diagnosis was explained as were treatment options, conservative management, or surgery. The risks and limitations of surgery were discussed, as was the steroid medication that Mr C would have to take if he opted for conservative management. If Mr C wanted to pursue the surgical option, he could contact the neurosurgeons at the Hospital Trust, but the Foundation Trust said he chose conservative management as his preferred next step.
63. Mr B and his family were unhappy with the response to these issues from the Foundation Trust, so he raised his concerns again on 8 October 2021. When the Foundation Trust replied on 13 October 2022, it did not specifically mention the conversations on 6 and 8 February 2018, but it provided a detailed chronology of Mr C’s care at the time. It said the surgical option was always there for Mr C, but he declined this on 6 February and again on 13 February 2018. The Foundation Trust said Mr C was spoken to again after the findings of the CT scan on 16 February 2018. He did not want to go ahead with surgery, so a conservative approach was maintained. After a fall on 10 March 2018 and subsequent investigations, it was found that Mr C had worsening ride-sided weakness, and he was transferred for surgery on 15 March 2018.
64. We note Mr B’s recollection of his family’s conversations with medical staff on 6 and 8 February 2018, but these accounts do not reflect the information documented in Mr C’s records. Having considered this information, it broadly reflects what the Foundation Trust said in its complaint response. We do not dispute the account provided by Mr B about the verbal exchanges with his family, but it is not documented at the relevant times. We were not present and therefore, we cannot fully verify what was said or how it was put to Mr C and the family. Nevertheless, we would expect medical staff to highlight the risks of such complex surgery, and there certainly would have been risks for Mr C. Overall, there is insufficient evidence for us to say that misleading advice was provided about the risks of surgery on 6 or 8 February 2018 or that the complaint response from the Foundation Trust failed to address this.
65. Mr B and his family also say the complaint response fails to address what should have been done to act on the concerns documented in Mr C’s records about his imaging on 17 February 2018.
66. We note an entry in Mr C’s records timed at 11.10am on 17 February 2018. It indicates that the depth of Mr C’s subdural (bleed) haematoma had increased. This could be interpreted as his bleed got worse as Mr B has suggested in his complaint although we consider the wording of this entry is partly ambiguous. It relates to the CT scan Mr C had on 16 February 2018. Our overall analysis of this scan is outlined earlier in this report.
67. Mr B and his family raised these concerns in their original complaint dated 18 October 2019. The Foundation Trust said in its complaint response dated 13 April 2020 that there was a slight increase in the size of the bleed area (which was expected), but no new bleeding. Therefore, the doctor told the family that the scan showed no worsening compared to before, because there was no new bleeding in Mr C’s brain. The Foundation Trust said there was no clinical deterioration in Mr C’s condition and a conservative approach was being followed to his care. However, it also said that in light of the deterioration in Mr C’s condition and further worsening of midline shift shown on the CT scan, surgical drainage would have been considered at this point if the neurosurgeons had been contacted.
68. Mr B and his family were unhappy about what the Foundation Trust had said about this matter, especially an apparent contradiction about whether Mr C’s condition had deteriorated, so he raised his outstanding concerns with the Foundation Trust on 8 October 2021.
69. When the Foundation Trust replied on 13 October 2022, it reiterated much of what it had said previously about the findings of Mr C’s CT scan on 16 February 2018, but suggested there had been confusion about which CT scan was being referred to in its previous response. This was an interval scan to check if there were changes from the previous scan. The Foundation Trust did not feel the findings from this scan warranted action at the time or consultation with the neurosurgeons.
70. The Foundation Trust said there was no clinical deterioration in Mr C’s condition at the time. It acknowledged that if the neurosurgeons had been contacted at the time, they may have offered surgery, but Mr C did not want surgery and there was no new bleed. Therefore, the Foundation Trust did not feel contact was warranted and the neurosurgeons have confirmed they have no concerns about the decision. It is noted the Foundation Trust apologised that it did not previously explain the complexities in enough detail to confirm why the scan was not deemed significant, such as to warrant further consultation or referral to the neurosurgeons.
71. As outlined earlier in our report, we disagree with the Foundation Trust’s clinical view about Mr C’s condition and whether he should have been referred to the neurosurgeons. This does not mean we consider the complaint response fails to address what should have been done to act on the concerns documented in Mr C’s records about his imaging on 17 February 2018. Although the wording of the Foundation Trust’s initial response appeared to be contradictory, it acknowledged and apologised for this. We consider the second response from the Foundation Trust appropriately clarifies its view on the course of action taken after Mr C’s CT scan on 16 February 2018 and the entry about his imaging the following day.
Care provided by the Hospital Trust
72. Mr B and his family say there are contradictions in the complaint response as regards the interpretation of Mr C’s imaging on 16 February 2018 when he had a CT scan. Specifically, in the first complaint response (13 April 2020), the Foundation Trust described Mr C's imaging as normal whereas the Hospital Trust described the same imaging as showing a mid-line shift requiring neurosurgical opinion. In the second complaint response (13 October 2022), Mr B and his family say the Hospital Trust retreated from this, stating the appearances were normal for the injury Mr C had sustained. Mr B says his family were told by Mr C's treating neurologist while he was a patient at the Foundation Trust that this same imaging showed a deterioration in his condition. Therefore, the family have concerns as to how the Hospital Trust’s very significant change in opinion came about.
73. Having considered the relevant records, our radiology adviser says we must first consider the findings from Mr C’s CT scans on 27 December 2017 and 2 February 2018 before addressing this issue. Mr C’s scan on 27 December 2017 showed a subdural hygroma which is a collection of fluid around his brain. His scan on 2 February 2018 showed more dense material which suggests bleeding into the collection of fluid around his brain. Our radiology adviser says this is unlikely to have happened immediately after Mr C’s previous scan. More likely, there was a build-up of bleeding and fluid in the weeks between the two scans.
74. Our radiology adviser has added that this is likely to have caused some distortion of Mr C’s brain. There is evidence of a tiny amount of mid-line shift which is the displacement of brain structures across the midline of the skull due to the compression of displacement caused by adjacent masses. Also, there is some evidence of mass effect which is when a focal lesion or contusion causes surrounding areas of brain tissue or structures to be compressed or injured due to the degree of space that leaking blood, cerebrospinal fluid, or edema (swelling) takes up within the restricted skull space.
75. Mr C’s CT scan on 16 February 2018 showed a small increase in the volume of the collection of fluid around his brain, but our radiology adviser says there is no evidence of any further bleeding. There is some evidence of fibrotic bands in Mr C’s brain indicative of expected evolution of the haematoma seen previously. There was still an amount of midline shift (a tiny bit bigger than before), but no significant change from the previous scan. There is also no evidence of herniation syndrome which occurs when something inside the skull produces pressure which moves brain tissues.
76. In the Foundation Trust complaint response dated 13 April 2020, Mr B and his family have highlighted the responses to questions 12 and 15 which appear to be discussing the CT scans Mr C had on 27 December 2017, 2 February 2018 and 16 February 2018. The response to question 12 indicates that the increase in the size of Mr C’s haematoma was expected, so no new concerns. It also explained what the doctor meant when he told the family there was no worsening (presumably relating to the scan on 16 February 2018) compared to before, so this could have been a misunderstanding.
77. Nevertheless, the response to question 15 indicates there was a worsening of Mr C’s condition as his midline shift got worse from the CT scan on 2 February 2018 to the one on 16 February 2018. As outlined above and later in this report, there may have only been a tiny amount of growth, but this supports the view that Mr C’s condition got worse.
78. In the Foundation Trust complaint response dated 13 October 2022, Mr B and his family have highlighted the responses to questions 5 and 7. Both response points indicate there was no midline shift seen on either CT scan from 2 or 16 February 2018.
79. Given this, we can understand why Mr B and his family consider there are contradictions in the complaint responses from the Hospital Trust, especially about an issue like Mr C’s midline shift which is a potentially serious condition. Over two years after the original complaint response, the Hospital Trust appears to have concluded there was no evidence of midline shift on Mr C’s imaging from February 2018. As highlighted earlier in this report, this conflicts with our findings of what Mr C’s imaging from February 2018 shows.
80. We appreciate why this will be concerning to Mr B and his family in terms of how it could have affected Mr C’s treatment at the time. We have commented on this elsewhere in the report. Having considered Mr C’s CT scans and his wider clinical records, our radiology adviser says the midline shift shown on Mr C’s CT scan dated 16 February 2018 is a tiny bit bigger than on the previous scans but does not reflect evidence of any new bleeding at the time. In other words, these findings had no additional effect on what the clinical team intended to do regarding Mr C’s management at the time. The records indicate that the clinical team initially proposed to manage Mr C’s condition conservatively rather than proceeding to brain surgery.
81. In summary, the contradictions highlighted by Mr B and his family regarding the interpretation of Mr C’s imaging from 16 February 2018 are from the complaint responses. We would expect the Hospital Trust to have considered Mr C’s records before contributing to the complaint responses, but the overall view on certain issues appears to have changed in the intervening months between the two replies. We have not noted such contradictions when we have considered Mr C’s clinical records including the relevant CT scan and report, with support from our advisers. We have given our view on the findings of Mr C’s imaging on 16 February 2018 elsewhere in this report and acknowledge that the contradictions highlighted by Mr B and his family may have impacted on Mr C’s management after his CT scan on 16 February 2018. This is also considered elsewhere in the report.
82. Our NHS Complaint Standards guidance states ‘staff give a clear, balanced account of what happened based on established facts. Each account compares what happened with what should have happened. It clearly references any relevant legislation, standards, policies, or guidance, based on objective criteria.’
83. Therefore, we consider there was a failing by the Hospital Trust contrary to our NHS Complaint Standards guidance regarding contradictions in the complaint responses about whether Mr C had midline shift after his imaging on 16 February 2018. While we understand why Mr B and his family are concerned about this, we note that a significant amount of time elapsed between the two complaint responses and opinions on imaging can change after further scrutiny. As our clinical view about Mr C’s imaging on 16 February 2018 is documented elsewhere in this report, we do not intend to take any further action regarding this point.
84. Mr B and his family say the Hospital Trust said Mr C was ineligible for its neurorehabilitation unit in April 2018 when he should have been eligible for this care. We have asked our neurosurgeon adviser to comment on this.
85. Unfortunately, our neurosurgeon adviser says Mr C would not be eligible for rehabilitation at the Hospital Trust if he is ‘out of area.’ Like all other neurosurgical centres in the country, these are tertiary centres which accept patients for management of their neurosurgical conditions from a wide geographical area.
86. Once the acute neurosurgical episode has been completed which it had been in Mr C’s case, patients are either discharged home or back to their local hospital if further care is required. In this case, as Mr C required further rehabilitation and was not from the Hospital Trust catchment area, he was referred to his local hospital with a possibility of going to his local rehabilitation unit. Overall, it was at the discretion of the Hospital Trust as to whether Mr C had his rehabilitation at its unit. This did not happen for the reasons explained above. We understand why Mr B and his family would have been disappointed by this decision, but the course of action taken by the Hospital Trust was appropriate in the circumstances.
87. Mr B and his family say Mr C was inappropriately transferred from the Hospital Trust to the Foundation Trust on 27 April 2018 without any adequate assessment of whether the transfer was in his best interests, or how he would be best managed.
88. As regards Mr C’s transfer on 27 April 2018, our neurosurgeon adviser has commented that an MRI scan was carried out on 1 April 2018. It showed an improvement in the size of Mr C’s subdural collection. Therefore, no further neurosurgical intervention was required, so it was appropriate to transfer Mr C back to his local hospital to continue with his medical care. Our neurosurgeon adviser says this is standard practice for patients who have completed their acute care in the tertiary hospital. Overall, having considered the relevant documentation at the time, our neurosurgeon adviser says there were no concerns about Mr C’s transfer.
89. We note that Mr B and his family have a specific concern that the transfer was damaging to Mr C as the Foundation Trust unilaterally changed his care plan from that in place at the Hospital Trust, especially regarding medication changes and pressure area risk management. Therefore, we asked our nurse adviser about this.
90. Having considered Mr C’s records that we received from both Trust’s, our nurse adviser has highlighted Transfer Information Forms and Admission Handover Sheets. Unfortunately, some of this documentation is incomplete and either lacks any depth of information or is unsigned or undated.
91. Our nurse adviser has been unable to locate any transfer documents in the care bundle provided to us from 27 April 2018. We have asked both Trust’s if they have any further information regarding Mr C’s transfer on this date, but neither Trust has been able to provide any additional information. Therefore, we cannot comment on any changes in Mr C’s care plan from 27 April 2018 due to insufficient evidence in the records.