Falls risk assessment
13. Miss C believes nurses failed to assess her mother’s risk of falling. She says staff should also have given her support when using a commode. She says her mother needed one-to-one support when mobilising.
14. The Falls Guideline says clinicians should ask older people in their care whether they have fallen in the past year. Older people who need medical attention because of a fall, or report recurrent falls in the past year, or demonstrate gait or balance abnormalities should be offered a multifactorial assessment.
15. The Nursing Standards say nurses should use evidence-based, best practice, approaches for meeting the needs of patients for mobility and safety by accurately assessing the person’s capacity for independence and self-care.
16. The Toilet Access Guideline refers to the ‘Behind Closed Doors’ campaign. This aims to raise awareness that people, whatever their age and physical ability, should be able to choose to use the toilet in all care settings. It stresses this is an important marker of human rights and dignity.
17. The clinical records show a clinician in the emergency department assessed Mrs C’s risk of falling at 8.45pm on 1 June 2023. They noted she had not experienced a recent fall and had no falls risk factors. They recorded she was mobile and independent.
18. On 3 June 2023 a nurse completed a care plan which noted Mrs C needed assistance from one person for her personal care and hygiene needs because of shortness of breath. Mrs C could communicate effectively.
19. We can see Mrs C had a falls care plan in place. This stated that her call bell was in reach, and she could transfer from her bed to a chair with assistance from one person. Physiotherapy records show she could use a commode without support and had been doing so at home. On 14 June 2023 a physiotherapist assessed Mrs C’s mobility in preparation for a potential discharge from the Hospital. They noted she would be able to transfer between bed, commode and sofa at home, but could only take a few steps because of breathlessness. Nurses assessed her capacity for independence and self-care.
20. The Nursing Adviser told us Mrs C was at risk of falls because of her age. Nurses established she had a moderate risk of harm from falling. Mrs C did not have a history of recent falls or demonstrate abnormalities with her gait or balance. There was an enhanced care plan in place, and she was in view of nurses within a bay on the ward. Nurses checked on Mrs C every hour. There was no need for a full multifactorial assessment.
21. The Nursing Adviser told us it is usual practice to give people privacy when they are using a commode. This is to preserve their dignity. There is nothing to suggest this was a significant risk for Mrs C based on her ability to transfer and evidence that she could use a commode.
22. We find the nurses assessed Mrs C’s falls risk in line with the relevant standards. The evidence suggests Mrs C’s fall could not have been prevented. Nurses followed the Falls Guideline, the Nursing Standards and the Toilet Access Guideline.
23. We recognise Miss C believes her mother should have been offered more support. We hope she is reassured we have seen no evidence of any failings by staff at the Hospital in this respect.
Response to the fall
24. Miss C says nobody knows how long her mother was left on the floor after her fall on 20 June 2023. She says clinicians then lifted her mother back into bed despite her broken hip and did not consider the bruise on her temple. She believes staff caused her mother pain when they lifted her into bed and questions whether it was right to move her. She also asks why it took so long to arrange scans after the fall.
25. The NPSA Report says organisations should have a protocol setting out what should happen following a patient fall. The protocol should ensure that, after a fall, healthcare professionals check for signs and symptoms of fracture or the potential of spinal injury before moving a patient. It says they should use safe manual handling techniques for patients who may have signs of such an injury.
26. QS86 also says each NHS trust should have a post-falls protocol. It says a medical examination should be completed within twelve hours or thirty minutes if fast-tracked.
27. The Trust Policy contains information about how staff should respond to patients when they find they have fallen. This is in line with the recommendations in the NPSA Report and QS86. The Trust Policy says that if clinicians suspect a spinal injury they should not attempt to move the patient. If there is no sign of significant injury and the patient is responsive they should assess the situation and then assist the patient to a chair or bed.
28. The clinical records show Mrs C was in an observed bay at the time of her fall. A health care assistant, nurse and doctor attended immediately after the incident. It is unclear how they moved Mrs C from the floor to her bed. The Nursing Adviser told us they would not expect the moving and handling technique to be documented unless there were any problems when transferring.
29. The evidence suggests a doctor attended Mrs C immediately after the fall to carry out a medical review. The Medical Adviser told us this was a comprehensive review. Mrs C complained of pain in her right hip and that she was unable to fully raise her leg. A doctor requested X-rays of her head and hip around five hours after the fall. The results of these were available in the early hours of the next morning. The X-ray of the head showed no signs of injury. The X-ray of the right hip confirmed a fracture.
30. The evidence does not show Mrs C was left on the floor following her fall. At that time there is no evidence to suggest she was unable to return to bed with assistance following the fall. Neither is there anything to suggest clinicians used inappropriate techniques to lift her back into bed. We can see that clinicians were conscious of suspected injuries to her head and right hip, and they took appropriate action to investigate these.
31. We find clinicians followed the NPSA Report, QS86 and the Trust Policy when caring for Mrs C following her fall. We recognise Miss C considers the ward staff did not respond appropriately to her mother’s fall. Clearly, this has been a source of distress for Miss C. We cannot see any evidence of failings in this respect.
Nursing care after the fall
32. Miss C says nurses failed to provide her mother with basic hygiene care. She says her mother was left in wet clothing after the fall and the health care assistant responsible for this failed to record the incident. She also says she found medication on her mother’s bed after the fall, which meant her mother had not taken the tablets she needed.
33. The NMC Code contains the professional standards for nurses. It says nurses should listen to people and respond to their preferences and concerns. It says they must respect, support and document a person's right to accept or refuse care and treatment. The NMC Code also says nurses must deliver the fundamentals of care. This include ensuring people are cared for in clean and hygienic conditions.
34. The clinical records show that a HCA and a nurse attended to Mrs C after her fall. They noted her bedding was wet. The first member of staff noted they could not move Mrs C. The second said staff attempted to change Mrs C’s gown, but she refused because of the pain from her hip. A nurse notified the team coming on duty for the next shift that the gown needed to be changed.
35. The Nursing Adviser told us that nurses must obtain a patient’s consent before any intervention. This is set out in the NMC Code. Mrs C refused attempts to assist her to remove wet clothing. The nurses were right not to remove her clothing without her consent. We can see no evidence to suggest this incident was not properly recorded.
36. We can find no evidence in the clinical records about the incident relating to medication being found on Mrs C’s bed. It is not possible for us to say what happened or what the medication was. However, the Trust has accepted Miss C’s account of this incident in its complaint responses. We find this fell below the expectations in the NMC Code.
37. Mrs C had a short life-expectancy because of her existing health problems, which were worsening, and her severe frailty. The Medical Adviser told us her fall, which was not preventable, may have contributed to her death. It is unlikely the issues with missing medication had a significant effect on Mrs C. We recognise this continues to be a source of distress for Miss C.
38. We do not ask the Trust to take any further action about this issue. The Trust has acknowledged this failing and apologised to Miss C. It has clearly discussed the incident with the nurse concerned and confirmed they understand their obligations relating to ensuring they administer prescribed medication. We are satisfied this is an appropriate response to this issue.
DNACPR
39. Miss C is unhappy that doctors put a DNACPR order in place. She says they told her that her brother gave permission when this was not true. She says staff did not take her mother’s, or her family’s, views into account. She said doctors caused her mother distress by frequently trying to get her to sign a form, despite her objections.
40. The Resuscitation Guideline stresses the importance of discussing resuscitation (CPR) with families in advance of the events. However, it clearly says resuscitation is a medical decision. Even if a patient demands to be resuscitated, the medical team is not obliged to deliver treatment they consider to be clinically inappropriate. It is not necessary to obtain the patient’s consent, or permission from their relatives, for a decision not to resuscitate someone in the event that their heart stops working or they stop breathing.
41. On 3 June 2023 doctors completed a DNACPR form. They said CPR was unlikely to be successful because of Mrs C’s pulmonary hypertension, COPD and heart problems. They recorded that this followed a discussion that a junior doctor, a consultant and a nurse had with Mrs C’s son. They documented how they explained what CPR is and the chances of success. They noted the son understood and said he wanted a discussion with his family. The clinicians confirmed this did not mean they would stop active treatment.
42. We recognise Miss C, and her family strongly dispute the discussion with her brother took place as documented in the records. There is nothing we have seen to suggest this was an error in the records or that it applied to a different patient. There is no alternative explanation for the clinician making a record of the discussion.
43. The records also show a doctor also discussed resuscitation with Mrs C before completing the form. They explained how it was likely to be unsuccessful and traumatic in her situation. They noted Mrs C said her son and daughter wanted her to be resuscitated.
44. Early on 20 June 2023 a nurse met with the family. The family was concerned about the DNACPR order being in place. They said this decision was not discussed with them. The nurse arranged for a doctor to meet with them. They told the doctor it was untrue that someone had discussed the decision with Miss C’s brother. The doctor noted Miss C disagreed with the DNA-CPR decision. They said they had to act in the patient's best interests.
45. Another doctor discussed the family’s concerns with them later that night. They explained how CPR was unlikely to be successful because of Mrs C’s lung disease and frailty. The family agreed with the decision, but said it was untrue that there had been a discussion with Miss C’s brother, as stated on the DNACPR form. The doctor said this was inappropriate if that was the case. But they were clear the decision had been correct, and the order would remain in place.
46. On 21 June 2023 a doctor met with the family and explained how the focus would be on providing supportive care at home for Mrs C. They stressed she was very unwell and there was a high risk of her dying on the way home.
47. The Medical Adviser said it appears clinicians made every effort to communicate the decision with the family. There were clear and appropriate discussions with Mrs C who had the capacity to understand what was being said. The doctors clearly noted her family’s view, that she should be resuscitated. The doctors made a decision based on their understanding of Mrs C’s best interests.
48. We find the clinicians followed the Resuscitation Guideline. As we have explained above, there is no requirement for doctors to obtain permission from family members or consent from a patient, when implementing a DNACPR order. But doctors had conversations with Mrs C and her family and took account of their views. We recognise these discussions were distressing, particularly for Mrs C. We can see no evidence of any failings in this respect.
Records
49. Miss C says there are records missing from the day of her mother’s fall. She also says other records were ‘scribbled out.’ She believes there has been a deliberate attempt to conceal what really happened.
50. Good Medical Practice says doctors must make records that are clear, accurate and legible. The NMC Code says nurses must keep clear and accurate records.
51. The Medical Adviser told us the medical records appear to be complete. The Nursing Adviser said there are no national guidelines about how often nurses should record their observations. However, nurses would usually summarise the care given at least once during their shift and also record any significant issues, such as a fall.
52. The records the Trust sent to us contain copies of paper-based and electronic records. Miss C’s concerns relate only to the paper-based records. They show there were regular nursing entries on 19 and 20 June 2023. The Nursing Adviser told us these were generally completed in line with the NMC Code.
53. The records relating to Mrs C’s fall contain a few words that have been ‘scribbled out.’ These are mostly readable and are clearly just a rewording of the same information. The Nursing Adviser told us that clinicians should cross out errors with a single line so the record beneath is still legible. There are some errors in the notes where words have been crossed out and are not completely readable. These are individual words or short phrases which do not suggest anything is being covered up. Ideally, these should have been crossed through with a single line.
54. We can also see that drug charts from 19 and 20 June 2023 have been crossed through with a single line. These are still readable. The Nursing Adviser told us clinicians cross through drug charts with a single line to show they are no longer in use.
55. We find record keeping was in line with Good Medical Practice and the NMC Code. We can see no evidence that records were completed and are now missing. The information we would expect to see is contained in the copies of the records we have seen. It is unfortunate that some phrases in the records relating to Mrs C’s fall have been ‘scribbled out.’ We do not consider record keeping falls significantly below the relevant standards.
Conclusion
56. We appreciate Miss C believes there were failings in her mother’s care that contributed to her mother's death. This is not what we have seen. We recognise her mother’s hospital admission was distressing for her, and her family, to witness. We cannot see any evidence that clinicians fell below the relevant standards or that they have attempted to ‘cover up’ what happened.
57. We do not uphold Miss C’s complaint.