Nottinghamshire Healthcare NHS Foundation Trust

3. Mrs A complains about the district nurse care provided to her husband, Mr B, from 29 June to 4 August 2023 by the NHS Trust (the Trust). Specifically:

• there was inadequate care for Mr B from the District Nursing Team between 29 June and 4 August 2023.

4. Mrs A says that as result of inadequate care from the District Nursing Team, Mr B had to spend 7 weeks in hospital including his birthday. He did not know what day of the week it was and did not see his grandson for 5 weeks. Mr B now walks with a frame and has no quality of life. Mrs A says she was told by a paramedic that if they waited any longer for the District Nursing Team, Mr B may have died.

5. As an outcome, Mrs A wants a face-to-face meeting with the manager at the Trust who authorised cancellation of Mr B’s district nurse appointments. She also wants a financial remedy.

6. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

7. Mr B is 73 years old and suffers from some mild cognitive impairment which can affect his ability to follow processes. He suffered some urine retention whilst on holiday, so went to see his GP. A nurse measured Mr B’s urine output and recommended that he needed a catheter. Mr B went to hospital on 29 June 2023. They said he had an infection. A referral was made for him to the District Nursing Team (DNT) at the Trust and he was given a catheter.

8. Unfortunately, Mrs A says the planned visits by the DNT never happened and her husband was unable to leave the house apart from for hospital appointments. Over the next five weeks, Mr B only received one visit from the DNT on 5 July 2023. Mr B was at home, but his wife was not, so she told the nurse to come back at a later date to discuss matters, but they never did.

9. After approximately 5 weeks, Mrs A says she contacted the Trust and spoke to an outreach nurse who came to change Mr B’s catheter the following day. Mrs A says that because her husband did not receive appropriate care including how to manage his catheter, he ended up in hospital from 4 August 2023 and was in and out of hospital until November 2023.

10. Mrs A says her husband was close to death when he was in hospital between August and November 2023 due to sepsis, pneumonia, kidney failure and urosepsis. She feels he would not have developed these conditions or needed to be hospitalised if care from the DNT had been appropriate.

District nurse care

15. Mrs A says the care provided to her husband by the DNT from 29 June to 4 August 2023 was inadequate.

16. We can see from Mr B’s records that there were two home visits by the DNT during this episode of care. The first one was on 5 July 2023 when care was provided to Mr B regarding the management of his catheter. The second visit on 7 July 2023 was just to drop off supplies (short tube leg bags).

17. Given that Mr B had recently had an infection and needed to use a catheter, we have asked our nurse adviser if they consider the volume of home visits by the DNT was appropriate for a patient like Mr B.

18. Based on the RCN Catheter care guidance which encourages self-care where possible, our nurse adviser says the amount of home visits by the DNT for Mr B was appropriate. It is documented in the records from the home visit on 5 July 2023 that Mr B was aware of how to empty his bag and had been shown how to change his leg bag. It is also documented that Mr B was independent with his hygiene and mobile around the house.

19. We have also considered if the overall care from the DNT for Mr B was appropriate during this period. Our nurse adviser says Mrs A called the DNT on 21 July 2023 to report that Mr B’s leg bag had not been changed for over 3 weeks since it had been put in place at the end of June 2023. This is despite the DNT explaining to Mr B on 5 July 2023 how to change it. This was reiterated on 7 July 2023.

20. Given this, our nurse adviser says Mrs A’s phone call should have served as a red flag for the DNT. If Mr B’s bag had not been changed for over 3 weeks despite advice and demonstrations about how to do this, the situation should have been investigated further. There is no evidence this happened.

21. Furthermore, on 4 August 2023, we note that Mrs A called the DNT again. This time she reported that Mr B’s legs/feet were all red and he was confused. Our nurse adviser says these symptoms should have alerted the district nursing team to the possibility of sepsis. Although the advice from the DNT was to contact Mr B’s GP or 111 which is appropriate, there is no evidence they considered the possibility of sepsis which they should have done in the circumstances.

22. Page 33 of the RCN guidance states: ‘to minimize risk of complications and infections, consider, who will be responsible for emptying/changing the bag? Have they been trained appropriately.’

23. NHS Patient Information Leaflet (PIL) on Catheter care states: ‘you will be referred to the district nurses who will arrange to see you to ensure you can care for your catheter, manage any problems that may occur with your catheter if needed‘. It is recommended you change your leg bag every 5-7 days’.

24. The NICE guidance on suspected sepsis states: section 1.1.1 ‘think ‘could this be sepsis’ if a person presents with signs or symptoms of infection’. Section 1.1.3 ‘pay particular attention to concerns expressed by the person and their family or carers, for example, changes from usual behaviour’. Section 1.1.6 when assessing remotely ‘factors that increase risk for sepsis’. Section 1.2.1 Such as ‘older people’, ‘people with indwelling catheters’.

25. We consider there were some failings by the Trust regarding the district nurse care provided to Mr B, contrary to the relevant RCN, NHS and NICE guidance. We consider this causes Mrs A distress about some of the care provided to her husband which is emotionally upsetting for her. We have made some recommendations about this.

Impact

26. Mrs A believes that her husband ended up in hospital for 7 weeks with sepsis, pneumonia, kidney failure and urosepsis due to inadequate care from the DNT from 29 June to 4 August 2023. Given the failings we have identified with Mr B’s care, we have asked both our advisers for a view on any related impacts for Mr B.

27. Our nurse adviser says that a combination of having a catheter in-situ every day and Mr B’s age meant he was more susceptible to infection as both are risk factors. In other words, he may have ended up in hospital anyway due to these factors.

28. While this is noted, we felt we needed to consider what happened to Mr B in more detail. Therefore, we obtained Mr B’s hospital records from August to November 2023 alongside some additional clinical advice from a urologist.

29. Our urology adviser says that Mr B was admitted to hospital on 4 August 2023 with urinary tract infection (catheter related), klebsiella organism isolated on urine culture. He was also diagnosed with delirium secondary to the infection and exacerbation of COPD.

30. Mr B’s admission on 27 September 2023 was due to balanitis and urinary infection/ urosepsis – klebsiella organism isolated. Mr B was also diagnosed with hyponatraemia which is low blood sodium.

31. When Mr B was admitted to hospital on 11 October 2023, he was vomiting and generally unwell. This may have been antibiotic induced vomiting. Mr B was also found to have urinary infection (pseudomonas organism isolated), as well as acute kidney injury probably secondary to sepsis and vomiting/dehydration.

32. Therefore, our urology adviser says that although Mr B’s condition was serious when he was in hospital at these times, at no time did he require care on a high dependency unit or intensive care unit.

33. As for whether the failings we have identified by the Trust caused Mr B to be hospitalised, our urology adviser says his age alone is unlikely to be a significant factor. He was only 71 (at the time of the first admission) which is not old for a man to be having prostate issues. More likely, we note that Mr B is diabetic, and this combined with an indwelling catheter for more than 6 weeks, would have been very significant in his susceptibility to urinary infections and consequent hospital admissions.

34. According to the NHS England guidance on the management of bladder outlet obstruction, within 6 weeks of having an indwelling catheter the lower urinary tract is colonised with bacteria. In other words, the fact that Mr B had an indwelling catheter meant he was more susceptible to infections.

35. Overall, we consider there is insufficient evidence that the failings we have identified by the Trust caused Mr B’s urinary infections and hospitalisations. As previously explained, Mr B having a long-term indwelling catheter is the main factor in contributing to recurrent urinary infections, balanitis and urosepsis alongside his known diabetes. At the time of the home visit by the DNT on 5 July 2023, the records indicate that Mr B knew how to manage his catheter. Appropriate advice was reiterated two days later, but by 21 July 2023, the records indicate that Mr B and his wife were unsure how to change his bag. While we agree that the DNT should have investigated further at this point perhaps with another home visit, there is insufficient evidence for us to say this would have prevented Mr B getting infections and having to go to hospital, initially on 4 August 2023.

1. We have seen failings by the Trust regarding its management of Mr B after Mrs A contacted the District Nursing Team on 21 July and 4 August 2023. We consider this causes Mrs A distress about some of the care provided to her husband which is emotionally upsetting for her. We do not consider these failings caused Mr B’s subsequent infections and hospitalisation.

2. Therefore, we will partly uphold Mrs A’s complaint about the Trust. These are our recommendations:

• the Trust should acknowledge the failings in its management of Mr B, as summarised in paragraph 25, and apologise to Mrs A for the distress and emotional upset this causes her about her husband’s care • the Trust should develop an action plan to address the failings summarised in paragraph 25. It should identify any specific reasons for these failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, as well as how these will be monitored.

36. In considering our recommendations, we have referred to the ‘NHS complaint standards.’ The Complaint Standards support organisations to provide a quicker, simpler, and more streamlined complaint handling service. They have a strong focus on:

• early resolution by empowered and well-trained people • all staff, particularly senior staff, regularly reviewing what learning can be taken from complaints • how all staff, particularly senior staff, should use this learning to improve services.

37. Therefore, in accordance with the NHS complaints standards, we recommend the following action by the Trust within the next six weeks:

• the Trust should acknowledge the failings in its management of Mr B, as summarised in paragraph 25, and apologise to Mrs A for the distress and emotional upset this causes her about her husband’s care • the Trust should develop an action plan to address the failings summarised in paragraph 25. It should identify any specific reasons for these failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, as well as how these will be monitored.

38. This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.

Findings leading to recommendations

What we are asking the Trust to do for Mrs A

Complaint issue What we found What the organisation should do What we need to see and when Inadequate management of Mr B by the DNT at the Trust as concerns raised by Mrs A were not thoroughly investigated or considered.

We have seen failings by the Trust regarding its management of Mr B after Mrs A contacted the DNT on 21 July and 4 August 2023. We consider this causes Mrs A distress about some of the care provided to her husband which is emotionally upsetting for her.

Apologise to Mrs A.

Sight of written apology.

By: Six weeks after issue of final report.

What we are asking the Trust to do to improve its services:

Complaint issue What we found What the organisation should do What we need to see and when Inadequate management of Mr B by the DNT at the Trust as concerns raised by Mrs A were not thoroughly investigated or considered.

We have seen failings by the Trust regarding its management of Mr B after Mrs A contacted the DNT on 21 July and 4 August 2023. We consider this causes Mrs A distress about some of the care provided to her husband which is emotionally upsetting for her.

Create an action plan.

Sight of action plan.

By: Six weeks after issue of final report.