SCAS
24. Mr B complains ambulance crew from SCAS raised a false and unaccountable safeguarding concern about his behaviour towards his wife. He says their false testimony led to a witch-hunt against him and to hospital staff not consulting him about his wife’s care.
25. SCAS records say the ambulance crew members who attended Mr and Mrs B’s home on 5 September to transport her to hospital were concerned about Mr B’s behaviour. They documented he was aggressive to them and towards his wife, and that Mrs B appeared to be distressed. Due to concerns about Mrs B’s safety, they completed a safeguarding referral to the Adult Services safeguarding team.
26. We have referred to the SCAS safeguarding policy. The policy refers to the Care Act 2014 which says adults at risk include those in need of care and support and are therefore unable to protect themselves from either the risk or experience of abuse or neglect. It describes adults who are ‘elderly and frail’ as more likely to be vulnerable.
27. In terms of a threshold for safeguarding, the policy says, ‘there is no precise definition of what should be categorised as a safeguarding issue’, and ‘if in doubt [staff should] always complete a safeguarding referral’. The policy says all SCAS staff are responsible for safeguarding adults at risk who cannot protect themselves.
28. We recognise Mr B’s view the account of his behaviour is false, and SCAS should have recognised this. We acknowledge we were not present at the time of events, and so it is not possible for us to reach a view on what took place. However, the records show SCAS staff were concerned about Mrs B’s safety. We do not have reason to dismiss their concerns.
29. The SCAS policy makes it clear that if any staff are concerned a vulnerable adult may be at risk, they should make a safeguarding referral. The ambulance crew were concerned for Mrs B and we therefore consider they acted in-line with the policy to make a safeguarding referral. For this reason, we have not seen anything went wrong here.
30. We recognise how distressing this issue has been for Mr B, and how he feels it affected staff then involving him in his wife’s care. We hope we have been able to clearly explain why we will not take this concern any further.
The Trust
Nursing care
31. Mr B complains nurses did not understand or meet his wife’s personal needs and this contributed to her deterioration through her admission. He says the team did not engage with him and feels he was side-lined and not listened to. His wife spoke limited English and Mr B helped translate for her. We are sorry to hear of his distress and frustration during this very difficult time.
32. The NMC’s ‘standards of proficiency for registered nurses’ says to manage personal care needs, nurses should, ‘observe, assess and optimise skin and hygiene status and determine the need for support and intervention’. They should, ‘provide appropriate assistance with washing, bathing, shaving and dressing’.
33. The records show Mrs B had a comprehensive geriatric assessment on her admission on 5 September 2022. This says her condition had been declining throughout August which led to her admission.
34. The doctor assessed Mrs B as being doubly incontinent and of having a history of reduced mobility with ‘previous regular falls’. Due to being more recently unwell, she had been immobile but had previously been able to mobilise with a Zimmer frame with some assistance from Mr B. She was ‘reported to stay in her nightdress all day’, and Mr B assisted with all her care needs. She required a soft diet.
35. On review of her clinical needs, the medical team referred Mrs B to several specialist teams: orthopaedics and rheumatology, haematology, Speech and Language Therapy (SALT), occupational therapy (OT) and physiotherapy (PT) teams.
36. Nursing care plans showed Mrs B needed assistance with her hygiene needs from two members of staff. She wore continence pads, and had a urinary catheter from 25 September so staff could monitor her output. She also needed support from staff to help her change her position in bed.
37. The records support the nursing team regularly attended to Mrs B during her admission, assessing her skin, mobility, level of confusion, nutrition, urinary/ bowel output and her observations. There are a few occasions when Mrs B declined nursing care, such as turning down having a wash, but the records support staff offered her this care.
38. Our nurse adviser has commented the nursing charts show the team responded to and maintained Mrs B’s personal hygiene needs. In consideration of the advice we have received, we consider the nursing team met Mrs B’s needs, in-line with the NMC guidance we have referred to above.
39. In terms of consulting with Mr B about his wife’s care, we have referred to the NMC’s ‘The Code’. This says nurses should, ‘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’.
40. The records contain references to the nursing team speaking to Mr B about his wife’s care and needs, both when he was attending the hospital, and in phone calls to him.
41. Staff consulted Mr B before giving his wife a catheter. They discussed boils on her back that Mr B was able to explain the history of. There were discussions about her medications and how they were trying to manage her constipation. There are documented conversations of the nursing team answering Mr B’s questions about his wife and discussing the plans for her care. Our nurse adviser has commented the team involved Mr B in all aspects of his wife’s care.
42. We recognise Mr B does not feel the nursing team consulted him as they should have. On review of the records, we have seen indication the team involved him in discussions about the management of his wife’s care throughout her admission. We consider this meets with the NMC’s guidelines referred to in paragraph 39.
43. In terms of Mrs B’s nutritional needs, Mr B complains the nursing and dietitian teams did not identify what his wife liked to eat and did not listen to his advice. He says this led to her losing a lot of weight and starving while in hospital. We are sorry to hear of his significant concerns.
44. NICE guidelines for ‘nutritional support for adults’ say healthcare professionals should screen all hospital patients for malnutrition on admission. It says the Malnutrition Universal Screening Tool (MUST), may be used to do this, and ‘nutrition support should be considered in people at risk of malnutrition’.
45. The NMC’s ‘The Code’ says nurses should, ‘deliver the fundamentals of care effectively’ and recognise ‘individual choice’. It says nurses should help ‘those who are not able to feed themselves or drink fluid unaided’.
46. The SALT team assessed Mrs B on 8 September. They recommended she have a soft and bite-sized diet, that she needed supervision with meals and verbal prompts to swallow.
47. The SALT team re-reviewed Mrs B again on 12 September and she told the therapist she had been declining food because she had lost her appetite. They made recommendations for the nursing team to encourage eating and drinking and to give food supplements.
48. The nursing team were monitoring Mrs B’s oral intake on food charts. They completed a MUST review on 21 September, however, we note this refers to ‘updating’ her MUST score implying there had been a previous assessment but we have not seen this. The nursing team assessed Mrs B as being at high risk of malnutrition.
49. The SALT team re-reviewed Mrs B on 21 September and noted she had on-going low intake of food and reported a ‘strong dislike of soft hospital food’. They recommended she could now have a regular diet, the nursing team should offer snacks throughout the day, encourage Mr B to bring in her preferred meals and to give her plenty of time to eat before clearing her tray away.
50. The food charts show Mrs B often declined meals, and often did not finish a meal. The notes refer to her only liking soup and coffee. A note from 30 September says she was declining prescribed supplements and had minimal fluid intake, often refusing water and requesting hot coffee ‘but does not drink it’.
51. The nursing team used red trays for Mrs B’s meals which hospitals use to indicate when a patient may need support or assistance with eating and drinking. Mrs B continued to struggle with her intake and so the nursing team referred her for a dietician review.
52. The dietic team reviewed Mrs B and made further recommendations for the supplements and the types of foods she preferred. An assessment on 30 September refers to a note left by her husband explaining she liked cornflakes, brown toast with butter and soup with every meal. The team said Mrs B should be supported to have these food choices.
53. In October, dietician notes say Mrs B reported having little appetite. On 25 October a nurse documented she was taking very small amounts of food, mostly soup, coffee and milk. A doctor noted she had been offered a variety of supplements throughout her admission. The dietician concluded they were ‘likely reaching the ceiling of dietic care’ for her.
54. Our nurse adviser has commented that Mrs B’s nutritional intake was poor throughout her admission and the steps taken by the nursing team to monitor her intake and to try to encourage her to eat were appropriate.
55. In terms of staff discussing Mrs B’s food preferences with Mr B, we have seen references in the records to staff documenting suggestions he made for foods she liked, and to discussing this with him. The SALT and dietician recommendations include the advice from Mr B on what his wife preferred to eat, and encouraging nursing staff to support her with these options. There are references to the nursing team offering her the choices of food and drink her husband suggested.
56. Mr B said he would take in the soups to his wife that she liked to eat. The records say Mr B was allowed to visit during mealtimes to help her eat. We note she would still refuse meals even when he was present.
57. On review of the records, we can see staff assessed Mrs B using the MUST, and identified she was at risk of malnutrition. While we could not see a MUST assessment from her admission date, there is reference to this earlier assessment. Our nurse adviser has also commented staff had identified early on in Mrs B’s admission her risk of malnutrition and her need for assistance with eating and put appropriate interventions in place.
58. In consideration of the advice we have received, we consider the records support the nursing, SALT and dietician teams reviewed and supported Mrs B with her nutritional needs. We have seen indications staff listened to Mr B’s advice on what she liked, offered her suitable options, and respected her choices. Mrs B struggled with her appetite, and often refused the options given to her.
59. In summary, we have not seen indication the nursing team acted outside of the NICE or NMC guidelines we have referred to. We recognise Mr B was very concerned his wife was not getting the nutrition she needed. We are sorry for how distressing this was for him.
Physiotherapy
60. Mr B complains his wife did not receive the physiotherapy support she needed during her admission, and this led to her condition declining and to her not recovering her mobility.
61. The BGS launched a ‘Sit Up, Get Dressed and Keep Moving’ campaign in July 2020. The purpose of the campaign was to help healthcare professionals recognise the impact of deconditioning, to help prevent this and educate carers and patients on the importance of staying active in hospital and following discharge.
62. The BGS explains ‘deconditioning syndrome is the condition of physical, psychological and functional decline that occurs as a result of a series of complex physiological changes induced by prolonged bed rest or inactivity’. The impact of deconditioning on older people can be ‘more rapid, more severe and irreversible’. Deconditioning can lead to complications such as: • muscle stiffness and weakness leading to an inability to walk and an increased risk of falls • increased confusion, increased risk of swallowing problems leading to pneumonia • constipation and incontinence, and, • an impact on appetite and digestion.
63. The BGS campaign says healthcare professionals should assess patients, provide relevant support to assist with their needs and encourage their independence.
64. On admission, Mrs B was noted to be doubly incontinent, as staying in her nightdress all day, to having mobility issues, a history of suffering increasing falls and to her husband assisting with her personal care needs. During her admission, Mrs B had constipation and pneumonia.
65. Our physician adviser has commented the records support Mrs B was deconditioned, and this was likely the case before she came into hospital.
66. As noted above, through her assessment on 5 September, the clinical team identified Mrs B needed input from the OT and PT teams.
67. On 7, 10 and 12 September, there are notes from the OT and PT team saying they were unable to complete a therapy review due to their caseload and time constraints.
68. On 14 September, the OT and PT team attended to do a mobility review, but Mrs B declined this. The team documented they tried to explain this would help get her home, but she said no. She then declined a further review on 16 September. The therapy team planned to review her with her husband present.
69. The therapy teams reviewed Mrs B on 21 September. They described her as being in ‘a lot of pain’ when they assisted her moving from lying down to sitting up. She needed help from two people to stay upright and was unable to use standing aids. The PT team planned to give her bed exercises to do.
70. The OT team discussed discharge with Mr and Mrs B and said she may be bedbound on return home. They said she was deconditioned and was experiencing pain when attempting to mobilise.
71. There are references in the records to the PT team continuing to visit Mrs B to assist with her bed exercises. There are accounts of her sometimes declining to take part in this therapy, for example when she was tired or in pain. Therapy also would not have taken place while she was too medically unwell.
72. On 30 September, Mr B raised concerns with staff that he did not think his wife was getting the care she needed and asked if he could be present at her PT sessions to help encourage her. The PT team later noted she did better when her husband was there. We consider the records show the team regularly attended to provide physiotherapy support through her admission.
73. Guidance from the Department of Health & Social Care on ‘hospital discharge’ says planning for discharge' should ‘start on admission’. Multi-disciplinary teams should work across hospitals to plan post-discharge care, and to assess long term needs. Our physician adviser has explained OT and PT input is vital for safe discharge planning.
74. It took over two weeks for the PT team to review Mrs B. Our physician adviser has said this wait was too long, and it should have happened sooner. By this time, Mrs B was in pain and unable to engage with the session. While we recognise Mrs B declined a review on 14 and 16 September, there are several accounts before this of the review not going ahead due to a lack of time and staff availability. We therefore consider there were earlier missed opportunities to review her.
75. We consider the delay in the therapy team assessing Mrs B’s needs does not meet the Department of Health guidance we have referred to. This indicates a failing in Mrs B’s care.
76. Mr B has told us he considers the lack of physiotherapy contributed to his wife’s decline in health, and ability to recover. This has been a considerable source of distress for Mr B.
77. The records say Mrs B had gradually lost her mobility in the weeks before her admission. Our physician adviser has commented earlier intervention from the PT team would have given Mrs B the best opportunity to regain her mobility. It would have been an opportunity for the team to put an early plan in place, and she may have been able to engage better earlier in her admission.
78. However, we also recognise Mrs B was very unwell, she was deconditioned on admission, and did not always agree to participate in therapy when she did not feel able to. On balance, our physician adviser has commented it is not possible to say if an earlier PT review would have led to Mrs B being able to regain her mobility, or if it would have changed the overall outcome.
79. We consider the uncertainty of the impact to Mrs B is an injustice to Mr B who has suffered distress and concern his wife was not receiving the care she needed.
80. To address a complaint, our ‘NHS Complaint Standards’ say organisations should ‘identify suitable and appropriate ways to put things right for people who raise a complaint’. Where failings are identified, the organisation should apologise and offer a suitable remedy to address the impact caused.
81. We contacted the Trust to ask if it would agree to write to Mr B to apologise. The Trust had already commented in its complaint response it had been working on improving patient pathways and its discharge process. We therefore also asked if it could share an update with Mr B on the difference this work is making to ensure relevant teams are involved in the discharge process from an early stage.
82. The Trust confirmed it would be willing to complete this work. Mr B agreed he would like to receive this letter from the Trust. We are pleased we have been able to reach a resolution for this part of Mr B’s complaint, and hope this brings some reassurance to him.
Discharge and safeguarding
83. Mr B complains the Trust delayed discharging his wife home despite them both asking for this. He says this was in part due to waiting for his wife to have a safeguarding assessment, and staff should have dismissed the concerns raised by SCAS.
84. Mr B says the delays led to his wife’s condition deteriorating while she was in hospital, and she was not able to live her final days in peace at home as they had wished. He says the safeguarding assessment caused his wife unnecessary distress.
85. We have considered these parts of the complaint together because they closely interlink.
86. Guidance from the Department of Health & Social Care on ‘hospital discharge’ says ‘people should be supported to be discharged to the right place, at the right time, and with the right support’. It says people should be discharged who no longer need hospital care, and when it is safe to do so.
87. As noted above, the OT team assessed Mrs B on 21 September. By this time, she was medically fit for discharge, and the team was assisting with the discharge planning.
88. The OT team discussed with Mr B his wife could return home with a hospital bed, and they would come to the home to assess the property for equipment needs. They discussed physiotherapists could visit to assist with Mrs B’s therapy when she returned home to work on her mobility.
89. The OT team visited Mr B the following day to assess the property. Mr B was concerned whether a hospital bed would fit because he had a lot of furniture that would make this difficult. The OT team suggested they could arrange for a ‘discharge to assess’ bed for Mrs B, this is discharge from hospital to a nursing home where her needs could be further assessed. Mr B was initially unsure but then agreed to this suggestion.
90. Mrs B became more unwell on 24 September when she suffered an upper GI bleed. She then went on to suffer aspiration pneumonia. While being treated for these conditions, doctors determined she was not fit for discharge.
91. Doctors assessed Mrs B as medically fit for discharge again on 5 October. A doctor discussed this with Mr B on 6 October, and he was now keen to have his wife come home and he could move furniture to allow space for a bed.
92. The OT team spoke to Mr B on Friday 7 October and he confirmed he wanted the assessment bed in a nursing home cancelled, and for his wife to come home. Mrs B said she was ‘keen to get home’.
93. Mr B planned to clear a room and update staff about this on the Monday. The team noted there would also need to be a ‘stretcher risk’ assessment, this is required when a patient needs a stretcher to be transported home to make sure this can be done safely.
94. On 10 October, the Adult Services safeguarding team visited Mrs B in hospital to attempt to complete a safeguarding assessment following the referral from SCAS. This team is part of the local authorities, not the Trust. They could not complete the assessment due to a language barrier in speaking to Mrs B, and recognised they needed an interpreter to be present.
95. On 11 October, the OT team documented they needed to know the outcome of the safeguarding referral to ensure Mrs B would be safe to return home with her husband.
96. We note ward staff did not have safeguarding concerns based on their observations of Mr and Mrs B. For this reason, the safeguarding team within the Trust was not taking any action, and acknowledged Adult Services were managing the concerns raised by SCAS.
97. Adult Services completed the safeguarding assessment on 21 October with an interpreter present. Mrs B assured the team she wanted to return home with her husband and said the concerns raised were ‘stupid’. The team were satisfied she could be discharged home safely.
98. Guidance from the Department of Health & Social Care on hospital discharge says ‘safeguarding protocols should be followed’ if staff have any concern about the risk of family members or carers playing a role in the patients care following discharge. It further says, ‘no person should be discharged until it is safe to do so’.
99. We consider, in-line with this guidance, it was appropriate for the staff planning Mrs B’s discharge to wait for the safeguarding assessment outcome before their planning could continue. This is because it would have determined where Mrs B was going to be discharged to.
100. A note from the ‘complex discharge team’ from 26 October says Mr B had contacted a local charity that supports older people with living in the home for assistance in making preparations for his wife returning home. Mr B spoke to staff and said he was desperate to get his wife home and he felt they were delaying matters.
101. The following day, the OT team spoke to Mr B who said the room at home was clear for his wife’s return. The team member explained they needed to arrange for the equipment to be put in place, and for transport to be arranged to ensure Mrs B could be safely discharged.
102. The OT team ordered the equipment for the home on Friday 28 October, expecting this to be delivered early the following week. An SCAS risk assessment was booked for Monday 31 October to check what equipment the ambulance team would need to safely transfer Mrs B. Staff noted these steps were ‘essential’ before discharge could occur.
103. On 1 November, Mr B spoke to a nurse to advise the bed and equipment had arrived and he was ready for his wife to come home as soon as possible. SCAS completed its assessment and advised they had booked a four-person crew to attend on Monday 7 November to take Mrs B home.
104. SCAS advised they needed four crew members to attend as the limit on space in the house meant they could not use a trolley and would need a sling to carry her inside which required four people to do. Due to staffing and resourcing, this could not happen earlier.
105. There is a note on 2 November of Mr B being angry the Trust and SCAS were delaying his wife coming home, and did not agree with the plan. At a meeting on 3 November with hospital staff, Mr B confirmed he had all the equipment his wife needed in place and he would like her to come home before the weekend. Staff explained this would not be possible due to the requirements for moving her safely.
106. Our physician adviser has commented there were several teams involved in assessing Mrs B as part of the discharge process, and they all needed to complete their work before this was possible. This included resolving the safeguarding concerns that staff had a responsibility to consider as part of the discharge process.
107. In consideration of the sequence of events and the advice we have received, we think staff were acting in-line with the Department of Health and Social Care guidance that says people should be discharged home when they have the relevant support in place, and when it is safe to do so. It took time for each of the necessary actions to be completed and we are sorry for how this affected Mr and Mrs B.
108. We recognise Mr B’s frustration his wife was not able to come home earlier. We are sorry for how upsetting this was. We hope we have been able to clearly explain why we have not seen indications anything went seriously wrong in the discharge process.
109. We recognise how much this complaint means to Mr B, and we are sorry for the frustration and upset the events we have considered caused him. We thank him for bringing this to us for our consideration. We understand our decision may be disappointing, but we hope we have shown how seriously we have considered his concerns and that we may have in part brought some resolution for what he has been through.