Nursing care
12. The NMC Code says nurses must prioritise people. This means making sure the needs of people needing nursing care are recognised, assessed and responded to. Nurses must deliver the fundamentals of care effectively and make sure any assistance or care they are responsible for is delivered without undue delay. Ms G says this did not happen.
13. NICE CG138 says healthcare professionals should know patients as individuals and pay attention to their fundamental needs to meet the essential requirements of care.
14. Based on what we have seen, we agree there are things the Trust should have done differently. We identified there was documentation that was not signed or dated, some missed or undocumented skin checks, and pressure ulcer risk assessments were not carried out at regular intervals.
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so, we have found the Trust has already done enough to put right the impact of these events.
16. We raised what we had seen with the Trust. It told us it would like to issue an unreserved apology to Mrs C’s family that it let them down and that they were left with concerns about her care at such a distressing time. The Trust said it appreciates the work it is doing does not change Mrs C and her family’s poor experience, but it hopes that it will go some way to reassuring them it is committed to improving this area of its care provision.
Record keeping
17. The Trust acknowledged some documentation was not signed or dated and said this was not acceptable. It said at the time of Mrs C’s admission, it had begun migration to digital documentation which automatically notes the time, date, and user who is inputting the information in order to minimise this risk.
18. This migration has continued, with more and more Trust documents/proformas becoming digital and it is considered that this will greatly improve consistency, accuracy, and legibility of documentation. Alongside this, the Trust has reminded all nursing staff of the importance of fully completing any remaining paper documents with name, date, and time to ensure care is captured correctly. It said the digitisation project is ongoing.
19. In relation to medication, there are two days where there are either two or three daytime checks not documented for the syringe driver. The Trust said this issue was covered in the End of Life Care training provided to the ward staff as an action following the local investigation into Mrs C’s care and mentioned in the Trust’s response to the family.
Care needs
20. The Trust explained it has prompts for various areas of care are on the electronic care plans on Careflow, its clinical communication platform. The Trust is looking to introduce sub-sections separating care plan documentation regarding personal cares as part of its digital migration planning.
21. The Trust said it has provided learning events and compassionate and personal cares training to the wider nursing staff in the time since Mrs C’s admission. This covered documentation of bed changes/mouthcare/specific acts in addition to provision of care. Skin integrity is checked three times daily (if the patient cooperates) and documented separately, with an escalation process if pressure associated damage is identified during these checks.
22. The Trust said it has made changes to personal care documentation to introduce more auditable and specific documentation.
23. It noted its formal response to the complaint in September 2024 acknowledged there were some days where there is documentation of only one or two checks/attempted skin checks, which indicates that there were missed/undocumented skin checks, which is not acceptable. The Trust said this was addressed with staff in response to the complaint at the time of its initial response.
24. The Trust said when Mrs C continued to decline assessments, the risks were discussed with her and a booklet about pressure areas shared with her, after which she began to agree to all requested checks. It accepts that the Purpose-T pressure ulcer risk assessment was not re-done at consistent intervals, instead taking place on day 1, day 11, day 14, day 23, and what appears to be day 30. It said it would certainly have been preferable and better practice if these assessments were done at seven-day intervals/on a specific weekday for consistency.
25. The Trust told us with patients who regularly decline skin checks, nurses will sometimes look at high risk areas when assisting the patient to use the commode, and therefore commode uses will sometimes be documented on the turn chart in addition to turns, and will also be used as a repositioning opportunity.
26. The initial Purpose-T assessment carried out on 12 June was at the time of admission when Mrs C was in resus in the Emergency Department and was reporting a pain score of 3 out of 3. This assessment indicated that she was not moving at all, which the Trust said would be consistent with the emergency presentation.
27. A second purpose T was carried out later that evening at when she was settled on the AMU ward and her pain was more controlled and indicated that she moved occasionally with slight position changes. The Trust said this is consistent with an improvement in her condition from arrival.
28. The Trust agrees that the Purpose-T undertaken on what appears to be 25 June is the only assessment that deems Mrs C to be walking independently and moving frequently and it therefore considers this is likely an incorrect or inaccurate assessment. It told us this has been highlighted to the matron so that the individual completing that assessment can be identified and additional pressure care/assessment training can be provided to them.
29. The Trust noted pressure care documentation and skin integrity assessments and checks are due to be migrated to a digital format with the provision of ‘Narrative’ software that the Trust is due to launch in the near future. This will allow it to better monitor, audit, and document patient skin care for future patients.
30. In its complaint response, the Trust had already acknowledged Mrs C’s poor experience regarding being left in wet bedding and fed this back to the nursing team.
31. It said it has also recently implemented weekly compassionate leadership rounding. This involves the matron for each ward attending weekly to ask specific ‘yes/no’ questions of five random patients/families to explore and address the levels of compassionate and individualised care that the patient/family is experiencing.
32. The Trust has provided acknowledgement and apologies, and demonstrated service improvements. We consider this an appropriate resolution in the circumstances, in line with what our NHS Complaint Standards say about taking action to put things right.
33. Before we decide if we should conduct a detailed investigation of a complaint, we also look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong in the rest of the complaint.
Medication administration
34. Our nursing adviser said the medication charts indicate Mrs C received her medications as prescribed until they were discontinued. It appears the Trust acted in line with section 1 of the NMC Code.
35. As examples, the syringe driver was commenced appropriately as part of the end-of-life management. Intravenous fluids/medications were administered as prescribed. Intravenous antibiotics were administered as prescribed for three times a day and stopped, and Mrs C’s symptoms of nausea were managed with prescribed anti-sickness medications.
36. There is no evidence of a delay administering or missed medication based on what we have seen.
Nurse call alarm (buzzer)
37. ‘Nurse call alarm’ is listed on the Trust’s two hourly patient interaction chart. It appears the buzzer was within reach for Mrs C except when there was a lack of documentation for two hours on 14 June. This is reflected consistently in the records.
38. We have considered Ms G’s account and asked our nursing adviser about her concerns. Unfortunately, it is not possible to identify from the records if the buzzer was placed in Mrs C’s hand for example. This means it is not possible to say based on the available information if it was ignored.
Cancelled procedures
39. Critical investigations were being done so in line with ‘Good Medical Practice’, point 37, the Trust would have been expected to be considerate of the family and given them information as appropriate.
40. Our physician adviser said there appear to be legitimate reasons for the procedure to be delayed or cancelled – the gastroscopy (OGD) was cancelled due to diarrhoea on 2 July and next cancelled due to Mrs C’s oxygen requirement on 7 July.
41. In practice, someone from the healthcare team (including nursing staff) would be expected to communicate the reasons for the cancellation to the patient. If, as in this case, the patient is quite unwell then a family member would be informed too.
42. Based on the available information, we have seen no signs of a failing around this.
Nil by mouth
43. Point 65 of ‘Good Medical Practice’ described how doctors must contribute to continuity of care. This involves information sharing within and across teams.
44. There is evidence of frequent dietitian assessments and no ambiguity in the records about the fact the NG insertion was to supplement feeding because Mrs C was vomiting. Our physician adviser said there is no suggestion in the medical notes that there was confusion about if she was nil by mouth.
45. We have seen no indication anything went wrong here. There is also an entry on 14 July which is specific about Mrs C not being nil by mouth. We hope our impartial view is helpful for Ms G.
End of life care
46. Point 28 of ‘Good Medical Practice’ says ‘The exchange of information between medical professionals and patients is central to good decision making’.
47. On 5 July, it appears there was a misplaced comment by someone not involved the decision making, which was then explained and addressed. Mrs C was reassured by the ward doctor and oncology team.
48. The palliative team were involved before Mrs C needed end of life care. Our physician adviser explained that was because she needed their input for symptom control.
49. The Trust went from trying to actively treating her to stopping active treatment and starting palliative care. Potentially due to discussion with different family members, including Mrs C’s husband and granddaughter, the message may not have come across fully.
50. There is evidence of communication in the records around this on 9 July where there was discussion with Mrs C, and she asked if she was dying. A good discussion is noted on 10 July with her family. There is no evidence of a sudden change in terms of moving to palliative care. It appears towards the end of Mrs C’s life, there was more communication.
51. We appreciate that Mrs C’s family were left with concerns about the care she was receiving. We recognise this must have made an already challenging time even more difficult. As it appears the Trust acted in line with the relevant guidance, we have seen no indication anything went wrong here.
52. Overall, we have seen no reason to investigate the concerns Ms G brought to us further. We would like to thank her for bringing the complaint to us and we hope we have reassured her about the care her mother received.