NWA Trust
Failed to take appropriate measures to prevent her father suffering multiple falls whilst in hospital
17. Miss D says her father suffered multiple falls in hospital and she believes as a result of one of those falls he suffered a fractured thumb. This point of complaint does not include the fall Mr D suffered on 8 December 2022 as we will be looking at this fall separately later in our report.18. The NICE falls prevention guidance says: ‘Preventing falls in older people
Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context, and characteristics of the fall/s.
Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.’
19. The NICE falls prevention guidance also says falls interventions should promptly address the patient's identified individual risk factors for falling in hospital and take into account whether the risk factors can be treated, improved or managed during the patient's expected stay.
20. The NWA Trust’s policy for the prevention and management of slips, trips, falls and the use of bedrails says:
‘All patients over 65, under 65 with underlying health conditions and all adult patient with Learning Difficulties are risk assessed for falls within six hours of admission (see Appendix 1). Prevention strategies implemented and the correct level of observation put in place. This is established by completing enhanced risk assessment (associated document enhanced care policy.)
All patients identified at risk of falls should have at a minimum hourly intentional rounding with a reason implemented. Enhanced Care score to be reviewed daily in line with care plans to ensure timely review of any escalation or de-escalation of the level of observations required
If bed rails are in place a bed rail assessment should be completed and consent documented for all patients. If the patient is unable to consent and using the low rise /hybrid bed in the lowest position with no bed rails has been assessed as not appropriate.
Mental capacity must be ascertained if patient assessed as lacking capacity, deprivation of liberty safeguarding need to be put in place.’
21. The bed rails guidance says:
‘When medical devices (bed rails, mattresses and others) are prescribed, issued or used, it is essential that any risks are balanced against the anticipated benefits to the user. The process of understanding, evaluating, addressing and recording these risks is known as risk management.
The points to consider during a risk assessment include:
• Is it likely that the bed user would fall from their bed?
• If so, are bed rails an appropriate solution or could the risk of falling from bed be reduced by means other than bed rails (see Alternatives to rigid bed rails)?
• Could the use of a bed rail increase risks to the occupant’s physical or clinical condition? (See Case Study 1) • Has the bed user used bed rails before? Do they have a history of falling from bed, or conversely of climbing over bed rails?
• Do the risks of using bed rails outweigh the possible benefits from using them?’
22. The records indicate NWA Trust completed a ‘Multifactorial Risk Assessment and Action Plan for the Prevention of Falls’ which identified Mr D had a history of falls. He was suffering confusion, had poor vision, wore glasses and used a stick to mobilise. NWA Trust completed a mobility assessment and put in place a care plan for Mr D which included a walking frame and close supervision when mobilising due to him being unsteady on his feet. NWA Trust completed an ‘Enhanced Care Risk Assessment’ which concluded Mr D required cohort care (where a patient is nursed in a bay where they are always within the line of sight of nursing staff).
23. On 2 October 2022 Mr D became aggressive with the medical staff and NWA Trust arranged 1:1 care during the evening as they noted Mr D’s agitation seemed to increase at night. NWA Trust repeated the ‘Enhanced Care Risk Assessment’ after this incident which recommended it continued to provide 1:1 care whilst on the cohort bay. The records indicate there were times when 1:1 care was not available, this was when Mr D was in a side room by himself and could not therefore be nursed in a cohort bay. The records indicate at these times, hourly, or more frequent observations were documented by the nursing team.
24. The records indicate from admission on 28 September 2022 NWA Trust used bed rails to reduce the risk of Mr D suffering harm from a fall from his bed. NWA Trust reassessed this on 7 October 2022 and decided to remove his bed rails and keep his bed at a low level with a crash mat next to the bed instead. Our nurse adviser said this was appropriate and consistent with the NICE falls prevention guidance, the Trust’s policy and the bed rails guidance. Our nurse adviser said using bed rails where a patient is suffering confusion but is still able to mobilise independently increases the risk of severe injury from climbing over the bed rails and falling from a greater height or becoming entrapped in the bed rails.
25. Our nurse adviser said the records support the view NWA Trust performed all the necessary risk assessments and put in place appropriate care plans to reduce the risk of Mr D suffering harm from falls. Despite this the records indicate Mr D suffered falls on the following dates:
• 14 October 2022 • 15 October 2022 • 16 October 2022 • 21 October 2022 • 26 October 2022 • 29 October 2022 • 2 November 2022 • 3 November 2022
26. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. It is clear Mr D suffered a significant number of falls during his admission.
27. We acknowledge falls cannot be 100% prevented even with the best risk management measures being taken. We also acknowledge there were times during this admission when NWA Trust were unable to provide Mr D with 1:1 care. However, we have seen that even when 1:1 care was provided Mr D still suffered falls due to his poor mobility combined with his symptoms of confusion, aggression and agitation.
28. We found NWA Trust acted in line with the NICE falls prevention guidance, the bed rails guidance and its own policy in assessing the risk of Mr D suffering harm from a fall and putting in place measures to reduce this risk. We found no evidence to indicate there was anything more that NWA Trust could have done to reduce the risk of Mr D suffering harm from a fall. We do not consider it a failing on the part of NWA Trust that Mr D suffered falls whilst in hospital. It seems his falls were due to his symptoms and condition and happened despite appropriate mitigation measures being put in place by NWA Trust.
29. Miss D says her father suffered a fractured thumb as a result of one of the falls. Having reviewed the records we have seen no evidence so far that Mr D suffered a fractured thumb as a direct result of a fall. There is no such injury identified in the records immediately after any of the reported falls. We found no evidence which would enable us to comment on how or when Mr D suffered an injury to his thumb.
Failed to prevent her father from contracting covid whilst in hospital
30. Miss D says her father had chronic obstructive pulmonary disease (COPD) and breathing problems. She says the covid infection had a negative impact on his COPD and worsened his symptoms of dementia and psychosis.
31. The GMC guidance says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
b. promptly provide or arrange suitable advice, investigations or treatment where necessary.’
32. The records indicate NWA Trust tested Mr D for covid on admission and the test came back negative. Mr D developed a chesty cough and a repeat test was performed on 2 October 2022 which returned a positive result for covid. As a result of the positive test NWA Trust isolated Mr D in a side room to prevent the spread of infection on the ward.
33. Our physician adviser said it is impossible to determine the source of Mr D’s covid infection or when he contracted it. It is equally possible he could have become infected prior to arrival at NWA Trust, during transfer from ambulance to hospital, from a visitor or on the ward from another patient or staff member. Our physician adviser said it is not possible to determine whether the infection was spread through any poor care or infection control measures from NWA Trust.
34. The records indicate Mr D’s suffered with a chesty cough but he did not suffer with fever and his oxygen levels did not fall at any point. Our physician adviser said whilst covid was sometimes associated with deterioration in frail individuals, such deterioration was much more likely to effect people who suffered with more severe covid illness such as a cough, with a fever and reduced oxygen levels. Mr D had multiple other medical problems which our physician adviser says make it impossible to assess the single impact covid had on his condition at this time, however the evidence in the records supports the view that on balance of possibilities, the impact of his covid infection is likely to have been minor.
35. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge how distressing it would have been for Miss D to learn of her father’s covid infection at this time.
36. We found no evidence Mr D contracted covid as a result of failings in NWA Trust’s care, treatment or infection control measures. We found no evidence which would enable us to comment on when or how Mr D contracted covid. We found the action taken by NWA Trust to test Mr D for covid on admission and again when he displayed symptoms, and to isolate him after he tested positive, was in line with the GMC guidance.
Failed to provide appropriate medication and treatment for his dementia and psychosis
37. Miss D says NWA Trust over sedated her father at times and as a result he would display slurred speech and drowsiness.
38. The NICE delirium guidance says:
‘If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, manage the delirium first.
If a person with delirium is distressed or considered a risk to themselves or others, first use verbal and non-verbal techniques to de-escalate the situation. Distress may be less evident in people with hypoactive delirium, who can still become distressed by, for example, psychotic symptoms.
If a person with delirium is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term haloperidol (usually for 1 week or less). Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms.’
39. The records indicate Mr D had displayed features of dementia during the previous two years. Whilst in hospital Mr D experienced episodes of worsening confusion, agitation with aggression and features of psychosis such as hallucinations and NWA Trust diagnosed Mr D with dementia.
40. Our physician adviser said it is sometimes difficult to distinguish between the causes of such symptoms in older people. The appropriate approach to take, in line with the NICE delirium guidance, is to test for potential medical causes of delirium such as dehydration or infection first. This is because delirium caused by these medical conditions can resolve or at least improve with treatment of the underlying cause.
41. The records indicate NWA Trust followed this approach and carried out initial urine and blood tests to look for potential medical causes for Mr D’s delirium which could be treated. The records indicate NWA Trust went on to perform further tests on several occasions during his admission to look for any treatable causes of his delirium.
42. The BNF guidance provides information about the use of medicines including information on the selection, prescribing, dosing and administration of medicines. It says:
‘Haloperidol for acute delirium in elderly patient Initially 0.5 mg, dose adjusted gradually according to response up to maximum 5 mg daily.
Lorazepam for anxiety in elderly patient 0.5 to 2 mg daily in divided doses.
Benzodiazepines Indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness. Treatment (should be limited to the lowest possible dose for the shortest possible time.’
43. NWA Trust treated Mr D with 0.5 mg doses of haloperidol (an antipsychotic medication primarily used to treat acute psychosis) to help reduce the effect of his psychotic symptoms and lorazepam (medication primarily used to treat anxiety) to help reduce his agitation and aggression. The records indicate NWA Trust occasionally treated Mr D with a low dose of midazolam (a benzodiazepine medication generally used for sedation and anxiety relief) when his anxiety and aggression increased.
44. Our physician adviser said these medications were appropriate for NWA Trust to use to help ease Mr D’s symptoms of delirium. As these medications can have a sedative effect the BNF guidance recommends they only be provided in small doses. Our physician adviser said the medication provided to Mr D by NWA Trust for his mental health symptoms was done with close co-ordination between medical and psychiatric staff and the records indicate the doses provided by NWA Trust to Mr D were consistent with the recommendations in the BNF guidance.
45. Our physician adviser said the fluctuating nature of Mr D’s behavioural challenges and his moments of insight into his behaviour and greater lucidity made these problems extremely difficult for clinicians to manage and treat. Our physician adviser said there is no evidence in the records to indicate Mr D was being over-sedated due to the medication provided to him by NWA Trust.
46. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge how distressing this aspect of her father’s condition and treatment was for Miss D and her father.
47. We found no evidence NWA Trust failed to provide appropriate medication and treatment for Mr D’s symptoms of dementia and psychosis. We found no evidence to indicate there was anything more NWA Trust could have done to manage these symptoms. We found NWA Trust managed Mr D’s delirium in line with the NICE delirium guidance and provided medication in line with the BNF guidance.
Failed to provide appropriate support with his nutrition
48. Miss D says her father lost weight during this period. She says his weight was already low when he was admitted but he didn’t improve during the time he was in hospital. She says her father ate the food provided by the family during visits as though he had not been given enough food by NWA Trust.
49. The NICE nutrition guidance recommends:
• Food and fluid of adequate quantity and quality should be provided in an environment conducive to eating • Appropriate support should be provided, for example, modified eating aids, for people who can potentially chew and swallow but are unable to feed themselves • Screening for malnutrition should be carried out by healthcare professionals with appropriate skills and training • All hospital in-patients should be screened on admission and screening should be repeated weekly or when there is cause for clinical concern (for example; unintentional weight loss fragile skin and poor wound healing) • Nutrition support should be considered for people who have eaten little or nothing for more than 5 days and /or are likely to eat little or nothing for the next five days or longer.
50. NWA Trust’s malnutrition action and prevention policy states if after 3 days of a review the patient is managing less than half of their meals and/or drinks they should be moved to a high risk care plan.
51. The records indicate NWA Trust assessed Mr D on numerous occasions following his admission on 28 September 2022 and he was initially assessed to be at medium risk of malnutrition. As his clinical condition declined and he suffered low magnesium levels from poor dietary intake, NWA Trust provided nutritional support with dietary supplements on 23 November 2022 (Fortijuice, prescribed and given on one occasion). Following further assessment NWA Trust recorded Mr D as at high risk of malnutrition from 27 November 2022.
52. The records indicate that although NWA Trust referred Mr D to its dietitian on 27 November 2022 there is no evidence to indicate the dietician had any input into his care following this referral.
53. The food and fluid charts in the records indicate Mr D suffered with poor food intake from the outset, managing less than half of his meals and less than seven cups of fluids during the days following his admission. The records indicate as Mr D was not taking on sufficient nutrition and fluid, in line with its own policy NWA Trust should have moved Mr D to a high risk care plan earlier on in his admission. In line with the NICE nutrition guidance NWA Trust should have considered providing him with additional nutritional support sooner.
54. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge how distressing this aspect of her father’s care was for Miss D to witness and for her father to experience.
55. We fund NWA Trust did not provide adequate support to help Mr D with his nutrition in line with its own policy and the NICE nutrition guidance. We consider this to be a failing. NWA Trust should have identified Mr D as at high risk of malnutrition, put in place a high risk care plan and referred him to the dietician much sooner after his admission.
56. The records indicate Mr D would refuse his meals and required encouragement to eat and drink. It is not possible for us to say whether his nutrition would have improved if NWA Trust had put in place a high risk care plan sooner as he may have continued to refuse meals and supplements. However a high risk care plan earlier in his admission may have provided Mr D with additional support with his food, encouraged him to eat more and provided him with some degree of comfort.
Inappropriately restrained him during an incident on 19 October 2022
57. Miss D says NWA Trust failed to take into consideration her father’s mental state when restraining him which caused him to suffer injuries to his hands and damage to his glasses. She says NWA Trust were overly aggressive and forceful with her father and failed to understand that he was experiencing psychosis and not acting as he normally would.58. In its response NWA Trust said:
‘During his admission Mr D was very aggressive both verbally and physically towards staff. Throughout his stay there were reports of increased aggression and unpredictable behaviour towards individuals. In some instances his behaviour required intervention from the Hospital Security Team to manage and calm the situation.On 19 October 2022 he assaulted one of the Trust’s healthcare assistants holding their neck up against a wall. When he experienced episodes of extreme agitation they were managed in line with the Trust’s policies and procedures to maintain the safety of everyone involved. There was no evidence of fracture on his hand afterwards.’
59. The DOH restraint guidance says:
‘Following any occasion where a restrictive intervention is used, whether planned or unplanned, a full record should be made. This should be recorded as soon as practicable (and always within 24 hours of the incident).
The record should allow aggregated data to be reviewed and should indicate: • The names of the staff and people involved • The reason for using the specific type of restrictive intervention (rather than an alternative less restrictive strategy) • The type of intervention employed • The date and the duration of the intervention • Whether the person or anyone else experienced injury or distress • What action was taken.’
60. NWA Trust’s Security & Management of Violence & Aggression policy says all alleged physical assaults must be reported using the incident reporting system. There is no evidence in the records to indicate an incident report was completed on this occasion.
61. It is not clear from the information in the records exactly what happened at this time. As there is no incident report and no CCTV evidence we can review, it is impossible to say whether the restraint or the force used by the security team was inappropriate. This is due to NWA Trust not completing a report for this incident, which we consider to be a failing.
62. Our MH nurse adviser said the records do provide information about Mr D’s pattern of behaviour and NWA Trust’s consideration of his mental state throughout this admission and during his episodes of aggressive behaviour. It is clear and consistent throughout the records that NWA Trust understood Mr D’s behaviour was due to his symptoms of psychosis and it recorded he did not have capacity to make informed decisions due to his condition from the outset.
63. When considering whether the method of restraint was appropriate for Mr D given his lack of capacity, it is important to note NWA Trust’s Security & Management of Violence & Aggression policy indicates the method of restraint would be the same for patients with capacity as it would be for patients without capacity.
64. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge how distressing this incident was for both her and her father.
65. We cannot say whether the level of restraint was excessive or inappropriate. However we acknowledge that this is due to the failure of NWA Trust to complete an incident report in line with DOH restraint guidance and its own policy. This has left doubt about how the restraint was carried out which we cannot now resolve. This in itself is a significant injustice for Miss D.
Failed to consistently maintain his dignity whilst he was in hospital
66. Miss D says her father was often found naked on his bed with the curtains open. She says the 1-1 care should have prevented this from happening and he should have been kept covered, with the curtains closed or placed in a private room. In its response NWA Trust said:
‘The documentation reflects that the ward staff would cover him and attempt to maintain his dignity. Staff were not always welcomed by him attempts to cover him would not last.’
67. The NICE patient experience guidance says people using adult NHS services should be treated with empathy, dignity and respect. The CQC guidance says staff should be trained to ensure patients can maintain dignity even when they may be confused or able to advocate for themselves due to dementia.
68. Our nurse adviser said the records indicate that even immediately after being covered by the nursing team, Mr D would uncover himself. Our nursing adviser said 1:1 care was unable to prevent this as Mr D was often in a confused state and became aggressive when support was attempted. Our MH nurse adviser said the records indicate attempts to maintain his dignity often led to an increase in his aggressive behaviour.
69. Our MH nurse adviser said the records that document this behaviour do not provide a great deal of detail. There is very little evidence in the records to indicate NWA Trust considered any other possible options to try and maintain Mr D’s dignity, such as closing curtains or placing him in a side room.
70. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received.
71. We acknowledge the nature of Mr D’s condition caused his behaviour to be unpredictable and difficult to manage. We acknowledge communicating with him and attempting to support him with personal care was also difficult and often led to an increase in his aggressive behaviour. However as he resisted the attempts to cover him we think it would have been in line with the NICE patient experience guidance and the CQC guidance for NWA Trust to consider possible alternative measures.
72. We acknowledge that any additional possible measures may have been very limited and we cannot say that any additional measures would have been more successful in maintaining his dignity. However we think they should have been considered.
Failed to prevent him from suffering a fall on 8 December 2022
73. Miss D says her father was on 1-1 care at this time but was left unattended and fell, injuring his head. In its complaint response NWA Trust said Mr D had a fall that was unwitnessed whilst he was supposed to be having 1-1 care. It said the ward was short staffed that day and the staff member left his room to assist another staff member as Mr D appeared settled. NWA Trust said following the fall a CT scan was required to rule out a head injury but Mr D declined.
74. The records indicate at this time Mr D was in a low bed with bedrails in place. Prior to the fall he is noted to be unsettled and trying to get out of bed. Our nurse adviser said in this situation the bedrails are not recommended as they should only be used to prevent accidental rolling or falling out of bed. If a patient is mobile enough and confused enough, bedrails pose a greater risk of harm due to falling from a greater height over the rails or entrapment within the rails.
75. To minimise the risk of Mr D suffering harm from a fall if he attempted to climb out of his bed NWA Trust should have placed Mr D in a low bed without bedrails and with a falls mat in line with the NICE falls prevention guidance and the bed rails guidance and as they had done previously. The records indicate despite Mr D needing 1:1 care he was left alone and unsupervised at this time.
76. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge how distressing it was for Miss D to learn about her father’s fall. We found NWA Trust failed to take appropriate falls prevention measures prior to this specific fall. It was inappropriate to use bed rails and leave Mr D unsupervised whist he needed 1-1 care.
77. We acknowledge that Mr D had suffered falls earlier in his admission despite appropriate measures being put in place to minimise the risk. For this reason we cannot say for certain that he would not have suffered a fall whilst attempting to leave his bed even if the Trust had put the appropriate measures in place on this occasion. However we think his risk of harm from suffering a fall was increased due to the failings we have identified.
78. Miss D says this fall contributed to her father’s death. We acknowledge Miss D’s view on the impact this fall had. We understand why she has this view given her father suffered a head injury during the fall and sadly died the next day.
79. After Mr D died a post mortem examination was carried out and the coroner said:
‘There is a bruise over the right forehead but no evidence of intracranial injury. In my opinion the fall has not caused or contributed to his death’.
80. In the post mortem report the coroner says the cause of Mr D’s death was pneumonia on a background of vascular dementia with contributory factors being severe ischaemic heart disease and damage to kidneys from long term high blood pressure.
81. Having reviewed the post mortem report, the coroner has been very clear on the impact the fall had and the cause of Mr D’s death. We found no evidence to indicate this fall contributed to Mr D’s death.
C&P Trust
Failed to provide appropriate support with his nutrition
82. Miss D says her father lost weight during this period. She says his weight was already low when he was admitted but he didn’t improve during the time he spent in the mental health centre.
83. In addition to the standards set out in the NICE nutrition guidance, the NHS nutrition guidance has specific standards for the provision of food and drink for vulnerable patients such as those with dementia. This includes routine screening and monitoring for the risk of malnutrition.
84. The NICE dementia guidance says clinicians should encourage and support people living with dementia to eat and drink, taking into account their nutritional needs. This would include the use of food and drink charts to monitor the patient’s nutritional intake and referral to Speech and Language Therapy (SALT) when required.
85. The records indicate whilst in the mental health centre C&P Trust recorded Mr D’s nutritional intake using food and fluid charts and referred him to the SALT team to explore whether his poor intake was due to any swallowing difficulties.
86. Our MH nurse adviser said the records support the view C&P Trust provided Mr D with nutritional care in line with the NICE nutrition guidance. His nutrition intake and needs are referred to and reviewed regularly throughout the records. The nursing team appropriately completed the daily food and fluid charts and the records indicate C&P Trust offered Mr D a choice of food and drinks and referred him to the appropriate specialists to help support him with his nutrition.
87. The nursing team documented the occasions when Mr D refused attempts to support him with his eating and drinking and the records indicate the nursing team considered the context of his refusal such as his poor cognition, dementia and the impact this was having on him during these occasions.
88. Our MH Nurse adviser said weight loss is common in dementia patients and evidence suggests around 40% of dementia patients lose weight due to the impact of the condition has on their cognition and mental capacity.
89. The NICE nutrition guidance states:
‘Nutrition support should be considered in people who are malnourished, as defined by any of the following:
• a BMI of less than 18.5 kg/m2
• unintentional weight loss greater than 10% within the last 3 to 6 months
• a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3 to 6 months.
Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following:
• have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
• have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.
Healthcare professionals should consider using oral, enteral or parenteral nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition, as defined above. Potential swallowing problems should be taken into account.
Enteral tube feeding refers to the delivery of a nutritionally complete feed via a tube into the stomach, duodenum or jejunum. Healthcare professionals should consider enteral tube feeding in people who are malnourished or at risk of malnutrition, as defined above and have:
• inadequate or unsafe oral intake and
• a functional, accessible gastrointestinal tract.’
90. Our MH nurse adviser said there is no evidence in the records to indicate Mr D’s clinical picture was severe enough to warrant C&T Trust considering the possibility of NG feeding whilst in the mental health centre.
91. Tube feeding in patients suffering with dementia poses risks to the patient. The NICE tube feeding guidance states:
‘People living with severe dementia often develop problems with eating and drinking. They may have swallowing problems. If this happens food or saliva may go down their windpipe and cause an infection in their lungs (aspiration pneumonia). This can be serious or even fatal. They may also have a reduced appetite, and in their final weeks or days they may stop eating or drinking altogether.
Tube feeding usually involves either passing a tube through a person’s nose and down into their stomach or making a cut in the person’s abdomen and passing a tube into their stomach that way. Liquid food can be put directly into the person’s stomach through the tube.
NICE recommends that tube feeding should not normally be used for people living with severe dementia.’
92. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received.
93. We found C&P Trust provided appropriate support to help Mr D with his nutrition in line with the NICE and NHS nutrition guidance and the NICE dementia guidance. We found no evidence to indicate there were any further measures C&P Trust could have taken to help improve Mr D’s nutrition or that his condition worsened due to inadequate nutritional care and support from C&P Trust.
Failed to prevent him from suffering a fall on 25 November 2022
94. Miss D says the fall resulted in her father suffering a broken hip which required an operation. She says this contributed to his deteriorating condition and his death.
95. The incident report completed by C&P Trust after the fall states:
‘Patient was walking with a staff member to the communal area, patient started to become aggressive towards the staff member. Patient tried to hit staff, patient became unsteady on their feet, patient tried to grab the support railing on the wall, patient missed the grab railing and fell on the floor on his right side.
Staff called for help, informed the nurse in charge and the doctor. Physical health observations were recorded, BP - 148/70, SATS - 98, TEMP - 36.3, RESPS - 20 and HR - 94. Doctor came and examined patient and reported that the patient is in discomfort and appears patient got pain at hip/leg area. Right elbow appeared to have skin tear and has bruised. Doctor told staff that patient need to go to PCH for a x-ray. Ambulance was called immediately. Patient was escorted by staff to hospital.’
96. We acknowledge falls cannot be 100% prevented even with the best risk management measures being taken. The records indicate Mr D’s risk of falls was identified from the outset by C&P Trust and the factors that raised this risk were his history of previous falls, his medication, his poor mobility and his dementia.
97. The records indicate prior to his fall on 25 November 2022 Mr D’s falls risk assessments were up to date and comprehensive and at the time of the fall he was receiving 1:1 care whilst moving to the communal area. However we have seen throughout this period that even when 1:1 care was provided Mr D still suffered falls due to his poor mobility combined with his symptoms of confusion, aggression and agitation.
98. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records and the guidance. We acknowledge how upsetting it was for Miss D to learn of her father’s fall on this occasion and the hip injury he sustained. We acknowledge that as a result of this fall her father suffered a fractured hip which required surgery.
99. We found no evidence to indicate Mr D’s fall on this occasion was due to C&P Trust failing to appropriately assess the risk of him suffering harm from a fall and put in place measures to reduce the risk as much as possible. We found no evidence to indicate C&P Trust failed to act in line with the NICE falls prevention guidance prior to or during this incident.
100. At the time of the fall Mr D was being supported by care staff whilst walking and became aggressive which resulted in him becoming unsteady on his feet and falling. We found Mr D fell due to his symptoms and not due to any failings from C&P Trust.
Failed to arrange suitable transfer from the specialist mental health centre to hospital at NWA Trust
101. Miss D says C&P Trust did not arrange appropriate transfers for her father when he needed to be taken from the mental health centre to the hospital. She says on one occasion her father was left sitting in an ambulance for several hours with the back doors open when it was freezing cold. She says on another occasion the carer who accompanied her father ignored him when he asked for help. She says the manner in which C&P Trust managed these transfers was detrimental to her father’s condition and contributed to his death.
102. The records confirm Mr D was transferred from the mental health centre to hospital for medical treatment five times during this period. However the records do not provide a great deal of information about how the transfers were carried out. The records show he was transferred on:
• 7 November 2022 to the A&E department for treatment for his acute kidney injury • 16 November 2022 to the A&E department for treatment for his low magnesium level • 17 November 2022 to a hospital outpatient appointment • 17 November 2022 to the A&E for IV treatment for suspected chest infection • 25 November 2022 to the A&E department for investigations and treatment following his fall and hip injury.
103. Having reviewed the information available to us in the records at the time of all five of the transfers we have not identified any evidence of difficult circumstances such as long waits or exposure to cold weather during any of the transfers. However we acknowledge that as most of the transfers were to take Mr D to A&E it is likely he will have experienced delays on some occasions before he could be assessed by an A&E clinician. We acknowledge that any possible delay when they arrived at A&E would have been out of the control of the C&P Trust staff.
104. Our physician adviser said there is no evidence in the records which would indicate the circumstances of his transfers or the manner in which they were carried out had a detrimental impact on Mr D’s condition on any of these occasions. There is no evidence in the records to indicate the transfers themselves caused his condition to deteriorate. He received treatment from the hospital and on each occasion, other than following the transfer on 25 November 2022, the medical condition which prompted his transfer improved and he was able to return to the mental health centre.
105. When we discussed this aspect of her complaint with Miss D she provided additional information relating to two specific transfers, one on 16 November 2022 when her father was transferred to hospital due to low magnesium levels and one on 25 November 2022 when he was transferred for investigations and treatment after his fall and hip injury.
106. The additional evidence provided by Miss D for the transfer on 16 November 2022 is an excerpt from the records and was included in the records provided to us by NWA Trust. It states:
‘Patient suffering with low magnesium, gradual decline despite oral magnesium replacement, transfer to hospital Medical Assessment Unit for IV infusion. Ambulance arranged for transfer. On arrival, patient sat in chair, care staff accompanied patient, fully alert, in good spirits, handover given. Patient wheelchaired to ambulance for further assessment. All observations within normal range, patient feels well in themselves, recent diarrhoea, none today. Plan, Patient transported to A&E, no beds, patient eating and drinking – coffee, soup and sandwiches, talking with nurse, daughter and son-in-law and crew. Patient continuously monitored.’
107. We acknowledge Miss D’s views on this specific transfer. We found no evidence to indicate this transfer was inappropriately managed or that it had a detrimental impact on her father’s condition. The records indicate after he was assessed in A&E Mr D was admitted to hospital and treated for low magnesium. His condition improved and he was discharged back into the care of the mental health centre on 24 November 2022.
108. The evidence provided by Miss D for the transfer on 25 November 2022 is also included in the records provided to us by NWA Trust. It includes the assessment from the hospital A&E clinician following the review of Mr D. It gives a full summary of the A&E assessment and then states:
‘Patient asking carer for help, carer ignored patient and continued. I asked her to pay attention to her patient, she said she was sending a text as I saw her scrolling through her photos which I pointed out to her. Told her to keep an eye on her patient’.
109. We acknowledge Miss D’s view on this incident and we understand how upsetting it was for her to read about the carer not responding to her father’s request for help whilst he was being treated in A&E. We do not condone this conduct and we think it was appropriate for the A&E clinician to address it with the carer at the time to ensure they provided Mr D with appropriate support whilst he remained in A&E.
110. We found no evidence to indicate this incident had a detrimental impact on Mr D’s condition and the records show that he was admitted to the orthopaedic ward at the hospital for investigations and treatment a short time later. We found no evidence to indicate this incident resulted in an unremedied injustice for Mr D and we think suitable action was taken by the A&E clinician at the time to address the issue directly with the carer and to ensure Mr D received the support he needed.
111. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we received. We found no evidence to indicate C&P Trust failed to arrange suitable transfer from the specialist mental health centre to hospital at NWA Trust.
112. We found the transfers were arranged promptly when Mr D required medical intervention. We think C&P Trust acted in line with the GMC guidance in arranging the transfers to ensure Mr D could undergo the necessary investigations and receive the medical treatment he needed.
Failed to transfer him from the specialist mental health centre to the hospital at NWA Trust with his medication
113. Miss D says as C&P Trust transferred her father to hospital on 16 November 2022 without his medication he became agitated which led to hospital staff restraining him. Miss D says this was difficult for her father and could have been prevented if he had been sent with his medication.
114. The NHS complaint standards state that where poor service or maladministration has led to injustice the organisation responsible should take steps to put things right. In its response C&P Trust said:
‘His anti-psychotic medication was to be taken at night and, therefore, it was expected that he would be given a dose at hospital. Unfortunately, staff have been unable to confirm whether his medication was sent to hospital and it is not documented. Staff will be reminded to document all items transferred with a patient.’
115. The failure to record all items transferred with Mr D has led to doubt about whether or not he was transferred with any of his medication which we cannot now resolve. This in itself is a significant injustice for Miss D. We think the response from C&P Trust is appropriate to address this failing and the doubt that now remains. We have looked to see whether this failing led to any additional unremedied injustice for Mr D.
116. The records do not provide any information about staff needing to restrain Mr D during any of the transfers from the mental health centre to the hospital. However the records do confirm he was often agitated and displayed challenging behaviour at these times including aggression towards staff and refusing medication and care interventions.
117. Our physician adviser said there is no evidence in the records which would indicate the circumstances of his transfers had a detrimental impact on Mr D’s condition on any occasion. As C&P Trust has said in its response it understood Mr D’s medication would be provided by the hospital after he was transferred.
118. The records indicate Mr D’s medication was continued by the hospital when he was admitted after transfer from the mental health centre. The A&E records for the specific transfer on 16 November 2022 indicates the hospital staff provided Mr D with medication in A&E to help calm him. The record of this attendance at A&E says ‘we gave patient’s prescription risperidone and a PRN (‘pro re nata’ meaning medications that are taken ‘as needed’) haloperidol at 01.30 due to agitation.’
119. We carefully considered Miss D’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we received. We acknowledge the failure to document all items transferred with Mr D identified by C&P Trust. We think the action it has taken is in line with the NHS complaint standards and appropriate to address the injustice resulting from this failing.
120. Having reviewed the records prior to, during and after each of the transfers from the mental health centre to the hospital we have seen no evidence to indicate this failing has led to any additional unremedied injustice for Mr D. There is no evidence to indicate his condition deteriorated immediately after transfer and during the transfer on 16 November 2022, appropriate medication was provided in A&E by the hospital team to help ease Mr D’s agitation.