Nutrition
21. Mrs L told us the Trust did not recognise that her father was struggling to eat and help him to get the nutritional support he needed. The NMC Code sets out what patients and their families can expect from those who provide nursing care. It says nurses are expected to ‘observe, assess, and optimise’ a patient’s nutritional needs and determine if they need ‘intervention and support’.
22. The Trust assessed Mr M’s risk of malnutrition on his first day in hospital. It recorded Mr M had an ‘average’ to ‘good’ appetite, a normal body mass index (BMI) and had not experienced unexpected weight loss in the months before his admission. It used a Malnutrition Universal Screening Tool (MUST) and recorded him to be at low risk of malnutrition.
23. The Trust next assessed Mr M’s risk of malnutrition on 25 February. By this time, Mr M had lost just under 4kg. His MUST score indicated he was at high risk of malnutrition. The Trust referred Mr M to the dietician the following day. We can see from our independent nursing advice that taking steps to assess Mr M’s risk of malnutrition and referring him to a dietician when the evidence indicated his risk had increased was in line with the NMC Code.
24. We can see the Trust weighed Mr M regularly during his time in hospital. We recognise his weight loss of 4kg during his first week in hospital might feel shocking to Mrs L, and it clearly caused her concern. Our nursing adviser explained it is likely Mr M’s weight on admission was higher than normal because he had excess fluid in his body. This means that the weight the Trust recorded on 19 February is likely a more accurate reflection of Mr M’s weight because by this time, he had received treatment to help his body remove the excess fluid. We understand from this advice that it is likely Mr M lost closer to 1kg between 19 February and 25 February.
25. On 26 February, the Trust completed a nutrition action plan to document what it would do to support Mr M meet his nutritional needs. The Trust planned to encourage Mr M to have high calorie meals and snacks and to supplement his diet with Fortisip (milkshake-like nutritional drinks).
26. The Trust kept charts of the food Mr M ate during his admission. Unfortunately, these are incomplete. We can see one is undated, one is blank, and some do not indicate how much of the meal Mr M ate. The records show that on several occasions, Mr M did not eat an evening meal, but the Trust did not record why this was.
27. The records show only limited evidence that the Trust followed its action plan. Mr M’s food charts show he preferred soft foods like porridge and soup, and this was noted by the dietitian on 10 March. We have seen no evidence the Trust explored why this was. We understand from our nursing adviser that the Trust should have considered the possibility that Mr M preferred soft foods because his mouth was sore, or his dentures were loose.
28. We know Mrs L was particularly concerned about how loose Mr M’s dentures were when he left hospital. She told us by this time, they were slipping out of his mouth.
29. The NMC Code says nurses should assess a person’s oral care needs and provide appropriate care. Our nursing adviser explained this means nurses should assess a person’s ability to manage their oral hygiene on admission to hospital. If support is needed, there should be evidence of an oral care plan within the records. We understand the Trust should have recorded whether Mr M’s dentures were upper, lower, or both, and what level of support he needed with them.
30. Unfortunately, there is very little evidence to show the Trust’s clinical staff were even aware Mr M wore dentures. The only record is Mr M’s property form, completed on 16 March, which showed he had dentures with him.
31. Overall, the evidence available to us shows the Trust should have done more to support Mr M’s nutritional needs. The records show he had poor food intake from his admission, but there is no evidence the Trust attempted to find out why he did not want to eat.
32. We consider the Trust did not act in line with the NMC Code because it did not ‘optimise’ Mr M’s nutritional needs or take adequate steps to determine if he needed ‘intervention and support’. Furthermore, staff did not assess Mr M’s oral care needs or support him to wear his dentures. We consider this a failing.
33. We have thought about the likely impact of the failings we have identified. We cannot say there would have been a different clinical outcome, had Mr M received the nutritional support he needed. The evidence shows Mr M was moderately frail before he came into hospital and already lived with conditions affecting his heart. The evidence also shows Mr M suffered some complications following his ERCP, and that staff had concerns about his memory and a urinary tract infection. Between Mr M’s discharge from hospital on 16 March and his sad death on 28 December, he had admissions to hospital with other conditions and illnesses, including a fall, heart failure, and pneumonia.
34. Having looked at the overall picture, we consider there were many factors that contributed to Mr M’s deterioration over the following months. We have not seen anything to indicate the lack of nutritional support caused or contributed to the decline in his health, nor that on the balance of probabilities the sad outcome for Mr M would have been different if the failing had not occurred.
35. We recognise Mrs L remains deeply concerned about the impact the lack of nutritional support had on Mr M. She shared memories with us of Mr M’s time in hospital and how distressing it was for her to see his needs not being met. On one such occasion, she said she brought Mr M his favourite cake and he was only able to lick the icing off. This may have been because Mr M did not have much appetite, but because this was not explored with him, Mrs L will never know why he did not want to eat. We think this impact to her of uncertainty and distress could have been avoided.
36. We consider the Trust has not fully recognised or acknowledged the failing and so it has not taken action to put things right. We recommend the Trust takes action to recognise this failing and prevent the same thing happening again. Our recommendations are detailed at the end of this report.
Continence
37. Mrs L complains the Trust did not support Mr M to go to the toilet and relied on incontinence pads and a catheter. The RCN guidance on catheter care sets out when healthcare professionals should consider using a catheter. It says a catheter should be used when a patient is experiencing ‘acute urinary retention’, i.e. an inability to urinate.
38. On 3 March, Mr M had a bladder scan which showed just over 400ml of urine retained in his bladder. The Trust recorded it had catheterised Mr M and, over the following days, noted the catheter was ‘draining well’. The Trust removed the catheter on 12 March.
39. We understand from our nursing adviser that it was appropriate and in line with the RCN guidance for the Trust to catheterise Mr M. This is because the evidence is clear that the Trust reached the decision to put a catheter in place to resolve his urinary retention, rather than as a convenient option. As such, we have not seen any indications of a failing in service here.
40. Mrs L was also concerned the Trust relied on incontinence pads rather than helping Mr M to the toilet. The records show the way the Trust supported Mr M to go to the toilet varied during his time in hospital. Although at times Mr M used incontinence pads, the records show he also used a bottle or a commode on some occasions. On some occasions, the records show Mr M walked to the toilet with a Zimmer frame. This evidence tells us the Trust was not reliant on incontinence pads during his admission.
41. We are satisfied the Trust provided the support Mr M needed. The evidence we have seen shows the Trust acted in line with RCN guidance when he had urinary retention and in line with the NMC Code in providing support to meet his comfort and hygiene needs. We hope we have helped to address Mrs L’s outstanding concerns for this part of her complaint.
Mobility
42. Mrs L says that the Trust did not do enough to prevent her father’s mobility declining, and that it did not refer him to a physiotherapist when it should. HCPC standards for physiotherapists set out the professional standards patients and their families can expect from those who provide physiotherapy. They say physiotherapists must always act in the best interests of patients.
43. A physiotherapist assessed Mr M’s baseline mobility, meaning what he was able to do under normal circumstances, on 20 February. They also assessed his current mobility needs and noted he was ‘off baseline’ as he needed assistance to transfer from his wheelchair, when, under normal circumstances, he could walk short distances with a stick.
44. Upon his admission, the Trust recorded Mr M’s level of frailty as ‘6’ on the Rockwood Frailty Scale, indicating he was moderately frail. This tool allows healthcare professionals to assess a person’s frailty and considers their mobility, energy levels, and their ability to manage daily activities. By assessing Mr M’s mobility baseline and frailty, we consider the Trust acted in his best interests, and as such, in line with the HCPC standards.
45. Our physiotherapist adviser explained when a person is frail, it is more difficult for them to recover from illness and physical stress. It is likely Mr M’s level of frailty, his diagnosis of biliary sepsis, and recent chest infection explain why he was off his baseline when he went into hospital.
46. Mr M had a further assessment with the physiotherapy team on 23 February. The physiotherapist noted he was able to stand and walk 12 metres with a Zimmer frame. The records show he then had physiotherapy sessions on 23 February, 9 March, 10 March, 13 March, 15 March, and 16 March. They note that, outside of these sessions, the Trust was supporting Mr M with movement by repositioning him in bed and helping him to sit upright or in a chair.
47. We understand from our physiotherapist adviser that Mr M’s operation on 28 February and other procedures while he was in hospital would very likely have affected his mobility. They explained that, for a frail patient recovering from a serious infection and an operation, energy is likely to be very limited.
48. Based on the evidence available to us and advice from our independent physiotherapist adviser, we consider the physiotherapists from the Trust acted in line with HCPC standards because their treatment plan balanced the need to support Mr M alongside the risk of causing him to become too tired to do anything after the session.
49. We recognise Mrs L’s concern that Mr M did not have physiotherapy while he was in hospital because of the extreme deterioration in his mobility. We can see from our independent advice that Mr M’s frailty would have been a contributing factor to this deterioration.
50. We hope we have been able to reassure Mrs L in our independent role that the evidence available shows that Mr M did have physiotherapy while he was in hospital. We have seen no evidence the Trust failed to act in line with applicable standards of care or that the available guidance shows it should have done more to prevent the decline in Mr M’s mobility during his time in hospital.
51. Mrs L was also concerned the Trust did not offer Mr M further physiotherapy sessions when she requested this during the complaint meeting. We listened to the recording of the meeting and acknowledge Mrs L asked staff at the meeting if physiotherapy was an option for Mr M. Mrs L and the Trust discussed the physiotherapy Mr M had been provided upon his discharge in March 2023, and then the discussion appears to move to a different topic. It seems from the recording Mrs L did not ask about physiotherapy again.
52. The Trust confirmed to us that in Bedfordshire, a different NHS organisation is responsible for providing physiotherapy in the community. The Trust was unable to offer this service to Mr M, so we have seen nothing to suggest it did not act according to his best interests or departed from HCPC standards here in not providing further physiotherapy.
53. Our Principles of Good Administration set out what public bodies should do to be open and accountable. They say public bodies should give people clear and relevant information when they need it. With this in mind, we have considered whether the Trust should have explained it could not provide physiotherapy care in the community. However, as we have seen, it appears Mrs L did not ask about physiotherapy again, so we can see the Trust may have understood she was not making a request for physiotherapy, rather that she was enquiring whether it was a possibility. On balance, we think not providing that clarification is not so serious as to indicate a failing in service on the part of the Trust.