Nutrition
24. Miss F told us nursing staff did not follow the plan a dietician put in place for her father. She says she and her family brought in extra food and drinks for him, but staff did not bring them to him and left them in the fridge. She explained seeing food left on trays out of his reach, or in packages he could not open. She feels her father would have starved if she and her family had not been there to help him.
25. NICE guidance CG32 ‘Nutrition support for adults’ says unless a person is at low risk of malnutrition, they should be screened for malnutrition ‘weekly’. It says to do this, clinicians can use the Malnutrition Universal Screening Tool (MUST) which assesses body mass index (BMI), any unintended weight loss, the time over which this has occurred and the likelihood of any future issues with nutritional intake.
26. The guidance also says the volume of nutritional intake should be monitored for someone receiving nutritional support. A person should be weighed, ‘daily if concerns regarding fluid balance, otherwise weekly reducing to monthly’.
27. A dietician reviewed Mr G on 30 December 2022. They noted he had lost weight over the previous year and had a BMI that meant he was underweight. During his admission, he weighed 69.6kg on 3 December and 58kg on 29 December. The dietician spoke with his family and commented they were bringing in meals and snacks he liked.
28. The dietician concluded Mr G was malnourished due to multiple hospital admissions over the year and poor health. The aim was to stabilise Mr G’s weight and the dietician left instructions for the nursing team to support him by providing nutritional support drinks, to encourage him to snack and to have a hot milky drink at bedtimes. They advised the nursing team should keep a ‘strict food chart’ to monitor his intake.
29. The Trust commented in its complaint response the dietician discussed the option of a feeding tube with Mr G, but due to a previous negative experience of this, they did not take this any further.
30. The dietician reviewed Mr G again on 6 January 2023. They noted there was no new weight recorded for him. They reviewed his food charts and saw he was managing to eat a reasonable amount of around 1200 calories a day. The dietician saw Mr G had been refusing one of the nutritional drinks offered and so recommended an alternative.
31. Mr G had a further dietician review on 12 January. They could not access the system to check his recorded weight. Mr G’s intake was noted to be ‘variable’. They did not consider he was likely meeting his nutritional requirements and asked the nursing team to continue the food charts, to encourage snacks and to weigh him weekly.
32. A nurse assessed Mr G’s risk of malnutrition on 28 January using the MUST. The form does not document Mr G’s weight, BMI, weight loss or overall risk score, but it does document his weight as 57.75kg and that he was at high risk of being or becoming malnourished.
33. A nurse re-assessed Mr G’s risk of malnutrition again on 4 February. His MUST score was higher than in January, meaning his risk of malnutrition was higher (although the lack of detail recorded on the entry for 28 January means we do not know why he had a lower score then). His weight had gone up slightly to 58.40kg. This is the last weight we can see documented during his admission.
34. On review of the records, our nursing adviser has commented the food charts the nursing team completed are reasonably detailed and indicate the nursing team was offering Mr G snacks and nutritional drinks, in-line with the dietitian’s plan. We also note there are references to Mr G refusing meals and snacks or only eating part of his meals.
35. However, we have not seen food charts covering the full period of Mr G’s admission through January and February 2023. The last chart we have seen is dated 15 January. The care rounding charts have some information on his nutritional intake, but the level of detail varies. Our nursing adviser has commented the charts do not consistently document the quantity of food Mr G was eating.
36. There do not appear to have been concerns about Mr G’s fluid intake, and so in-line with the NICE guidance and the dietician’s instructions, the nursing team should have been recording his weight each week. We have not seen evidence the team was doing this, or that it re-assessed his risk of malnutrition weekly. Our nursing adviser has said due to this, it was not possible for the dietician to fully assess if their plan was working.
37. On review of the NICE guidelines and the advice we have received, we find staff at the Trust did not assess Mr G’s MUST score weekly, despite being a risk of malnutrition. We also find staff did not weigh Mr G weekly or document his nutritional intake consistently and in the necessary detail. We consider these are failings in care.
38. In terms of the impact of this, Miss F has told us she and her family could not trust staff were giving him the food he needed while they were not there. She considers this level of care contributed towards her father’s overall decline in health when he was already unwell. We are sorry to hear of how upsetting and frustrating this was for Miss F.
39. Mr G was at risk of malnutrition and the lack of monitoring means it is not possible to determine if the dietitian’s plans were working. From the documented weights, we can see Mr G lost just over 10kg throughout December. His weight then remained largely the same from the end of December to the start of February. There are no further weights documented after 4 February and so it is not possible to say if he went on to gain or lose weight.
40. We consider it is possible a lack of adherence to the plan could have contributed to Mr G losing weight, although we cannot say to what degree. We also recognise that when he was offered food and drink, he would sometimes refuse this or not consume it all. For this reason, on balance, we cannot say what impact the failings had on Mr G. We recognise this uncertainty will cause distress to Miss F.
41. The Trust has since taken action to improve its service by explaining it has provided further education to the nursing team, this has included dietic training and ensuring staff know how to identify if a patient’s intake is not adequate. It has introduced a process to prepare patients for mealtimes including sitting patients up properly and getting their tables ready. We recognise the work it has done in response to this concern.
42. However, we have found specific concern Mr G was not weighed or assessed weekly for malnutrition, in-line with NICE guidance, and we have not seen information to show the Trust has addressed these points. We have also not seen clear actions to explain how the lack of accurate recording of nutritional intake will be improved.
43. We have therefore made recommendations to fully address these points, set out in detail at the end of our report. We hope this will bring some reassurance to Miss F of the difference her complaint will make.
Butrans patches
44. Miss F complains the medical team prescribed her father Butrans patches to manage his pain, but when reading about this medication, she could see her father met all the criteria that meant this was an unsuitable choice for him. She says the patches caused her father to suffer side effects, and the medical team did not recognise this.
45. Butrans patches slowly release the drug buprenorphine through the skin into the body. Buprenorphine is an opioid mediation used to treat chronic and acute pain.
46. The Trust’s pain team assessed Mr G on 28 December 2022 because he had increasing hip pain. Mr G was taking paracetamol to manage this. The pain team suggested he trial taking a low dose of oxycodone, this is an opioid medication used to treat severe pain.
47. At a further review on 29 December, the pain team documented Mr G’s hip pain was severe and it was affecting his sleep. The clinician recommended a regular low dose of oxycodone, but they could re-assess this if necessary. They noted he could benefit from a Butrans patch as an alternative.
48. The pain team reviewed Mr G again on 3 January 2023 because he was now taking oxycodone but was still struggling with pain. The clinician recommended the medical team consider giving him a Butrans patch of the ‘lowest dose’ instead of the regular oxycodone.
49. A clinician from the pain team spoke with a ward doctor on 4 January who agreed to prescribe 5mg Butrans patches to be applied once a week. The pain team spoke with the medical team on 6 January due to a concern they had raised that Mr G was also taking sertraline, this is an antidepressant medication. The pain team discussed this with the ward pharmacist and they confirmed there was no significant interaction between the drugs.
50. The pain team documented Mr G was showing no side effects and he said the patch was controlling his pain well. The team advised he should continue having the patches and once discharged, his GP should monitor him for any side effects.
51. Our physician adviser has referred to the BNF, this is a UK pharmaceutical reference resource that contains information for healthcare professionals on prescribing and administering medications. They have confirmed that with reference to the BNF, there were no absolute contraindications for Mr G being able to have buprenorphine. Contraindications are factors that mean a treatment may be of more harm than benefit to a patient.
52. Our adviser has further commented it is not unusual for an older person with health conditions who is already taking other medications to meet the warnings for a new drug. This does not mean a new medication is not appropriate if clinicians fully consider the risks and benefits.
53. In Mr G’s case, he had already tolerated a low dose of opioids well and he did not meet the contraindications for buprenorphine listed in the BNF. Our physician adviser has said it was therefore appropriate for the team to trial the low dose of buprenorphine.
54. In consideration of the advice we have received and the information in the BNF, we have not found concern with the decision to prescribe Mr G Butrans patches.
55. Miss F has further complained her father started to show side effects because of the Butrans patches, but the staff did not make the link. She says he was calling her in the early morning not making sense and hallucinating, he then believed he could walk despite not having done so for weeks and suffered a fall.
56. Miss F complains that when she raised her concerns with staff, they did not listen or fully investigate the cause of his symptoms. She considers they only tested him for an infection on her prompting, and said he may have dementia which she knew was wrong.
57. The BNF lists common/ very common side effects of buprenorphine as including confusion, drowsiness and hallucinations.
58. The records from 7 January say a doctor spoke to Miss F who was concerned about her father’s hallucinations and that he appeared to be in distress. The doctor requested blood tests to check for infection and completed a confusion screen, this is a short cognitive test to check for mental impairment. The test revealed no concerns about Mr G’s capacity.
59. The following day Mr G suffered a fall, he banged his head and cut his finger. A doctor spoke with Mr G’s family and said they did not know the cause of his confusion and his blood tests were normal, ruling out an infection. A CT head scan also did not show abnormalities.
60. The records show Miss F and her family raised further concerns with staff about her father’s episodes of confusion and hallucinations. Clinical staff also reference episodes of these symptoms including a physiotherapy note on 18 January saying he thought there was a dog in the room, and on 21 January he thought someone was sitting by his bed.
61. On 21 January, Mr G’s daughter’s queried if the Butrans patches could be causing side effects. A consultant completed a medication review at the end of January and stopped the prescription.
62. Our physician adviser has referred to NICE guidelines on delirium. The guidelines say delirium can present as a change in cognitive function, including confusion, and ‘visual or auditory hallucinations’. To prevent delirium, the guidelines say doctors should ‘carry out a medication review for people taking multiple drugs’. A person showing signs of delirium should have a confusion screen.
63. The medical team did a confusion screen which was appropriate, but they did not consider the drugs Mr G was taking. Our physician adviser has said in recognition Mr G was showing signs of delirium; this should have been done in-line with the NICE guidance. If this had happened, it is likely doctors would have identified the Butrans patches were causing his symptoms and stopped these three weeks earlier.
64. In consideration of the advice we have received, we consider Mr G was showing side effects from the Butrans patches by at least 7 January. The medical team should have recognised Mr G had signs of delirium and in-line with the NICE guidelines, they should have carried out a medication review. This did not happen for a further three weeks, and we find this a failing.
65. We are sorry for how upsetting it was for Miss F and her family to feel staff were not listening to them while they were raising their concerns about the impact they thought the patches were having on Mr G.
66. The Trust has since acknowledged hallucinations can be a side effect of Butrans patches and has apologised doctors did not make this link. It also agreed they could have contributed towards him suffering a fall.
67. Our physician adviser has agreed with the Trust’s conclusion, further advising the medication could also have affected his appetite and to him therefore becoming weaker and more vulnerable. We consider that had the patches been stopped earlier, it could have reduced his side effects.
68. While the Trust has apologised for what happened, it has not yet explained what learning has been taken from this concern to help prevent this happening again. We have therefore set out our recommendations to address this at the end of this report.
Nephrostomy tube
69. Miss F says when her father had the nephrostomy tube inserted in December 2022 (this is a tube that allows a blocked kidney to drain externally), doctors told the family this was something he urgently needed and it was a matter of life and death. She questions why when the tube fell out on 30 January 2023, there was no urgency to re-insert it again.
70. Mr G’s nephrostomy tube fell out overnight. A doctor assessed Mr G the following day and did not consider he was showing any signs of sepsis. They contacted the urology team for advice. If a kidney does not drain properly, the person is at risk of infection and sepsis.
71. A urology consultant advised Mr G should have daily monitoring of his renal function and blood tests to check his urea and electrolytes. He should also have an urgent CT scan. The urologist said if Mr G became septic, he should be transferred directly to the urology team at the acute hospital.
72. Mr G had a CT scan of his kidneys, ureters and bladder on 1 February. A doctor reviewed the results and spoke again with the urology team. The urologist advised they should continue to monitor him for any signs of sepsis and they would arrange for him to have a new nephrostomy tube.
73. A doctor reviewed Mr G on 2 February and noted there were no signs of sepsis. On 3 February, the urology team had a multidisciplinary team meeting (MDT) to discuss Mr G’s case and they reviewed his scan results.
74. Mr G had hydronephrosis of his left kidney, this is when the kidney becomes swollen. He was admitted with this condition and the CT scan report documented this was worse than it had been on a previous scan from December. The MDT considered he had a ‘resolving psoas collection’. This is a collection of urine outside of the urinary tract.
75. The MDT determined Mr G had stable renal function and re-insertion of the nephrostomy would be arranged if he showed any clinical deterioration in future, but it did not need to immediately go ahead.
76. The urology team shared this decision with the clinical team. They advised he should have a repeat CT scan every two weeks and blood tests three times a week to check for signs of worsening renal function and any inflammatory response. Inflammation is part the body’s immune response and can indicate sepsis.
77. Our urologist adviser has said that from the records, there are no indications Mr G had sepsis and he did not have acute renal dysfunction (his left kidney was still functioning). In the context of the urology team being satisfied Mr G’s renal function was stable and he was showing no signs of sepsis, our adviser has said the decision to provide safety-netting advice to the medical team with instructions to observe him and carry out regular monitoring was reasonable.
78. While there are no specific guidelines to say when a person should have a nephrostomy tube inserted, we have referred to the GMC’s Good Medical Practice. This says doctors who treat patients must ‘adequately assess the patient’s conditions’ and ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’. It also says doctors must ‘consult colleagues where appropriate’ and ‘provide effective treatments based on the best available evidence’.
79. In consideration of the advice we have received, we consider the decisions made about Mr G’s nephrostomy tube were appropriate and in-line with GMC guidance. We have therefore not found failing in this part of the complaint.
80. We recognise Miss F feels strongly about what happened and continues to question the decision made by the MDT. We are sorry for the distress this causes her and her family. We hope we have been able to clearly explain how we have reached our view for what happened.
81. Miss F also told us the clinical team did not tell her and the family about the change in the decision to not immediately replace the tube and so believed the team delayed arranging this. We recognise this was very unhelpful for their understanding what was happening and why and led to them questioning if the Trust was providing an appropriate level of care. We hope it has been helpful for us to explain when we consider the plan to monitor her father was clinically appropriate.
Monitoring and observations
82. Miss F complains that when the urology team said her father needed to be monitored closely after his nephrostomy tube fell out, the ward staff did not do so. She says she and her family had supported her father through nine previous occasions of having sepsis and so knew the signs to look out for, but felt staff did not listen to them.
83. The Trust has said Mr G had frequent blood tests and the nursing and medical staff monitored him for any signs of infection and sepsis. It said blood tests on 17 February showed he was more anaemic and so he was transferred back to the medical ward at the acute hospital for a blood transfusion. It did not consider he was showing signs of sepsis at this time.
84. The Trust did highlight a lack of sufficient nursing documentation for the dates 15, 16 and 17 February to confirm if Mr G was passing sufficient urine. The Trust has said this meant there was a missed opportunity for the team to consider sepsis at an earlier time.
85. Our urologist adviser has explained any signs of declining renal function, sepsis or worsening pain affecting his left-hand side would have indicted Mr G needed the nephrostomy tube re-inserting. We have reviewed the records from 30 January to 17 February to identify when he started to show signs of deterioration.
86. In terms of monitoring Mr G’s fluid output, there is reference in the nursing notes to him drinking and to his catheter draining well, but there are there are no formal fluid balance charts. The information the team captured about fluid output is incomplete, with volumes of fluid only recorded on some dates.
87. Our nurse adviser has said it was important for the team to be strictly monitoring Mr G’s urinary output. This would have indicated any deterioration in his renal function and the medical and urology team’s would have wanted to be aware of this. As noted above, if a person is unable to sufficiently pass urine, they are at risk from developing an infection and sepsis.
88. The NMC’s The Code says nurses should ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’ and ‘keep clear and accurate records’.
89. The lack of monitoring records does not support that the nursing team appropriately monitored Mr G’s fluid output and this does not meet with NMC guidelines. We therefore find failing here and we have considered the impact linked to this at the end of this section of the report.
90. In terms of showing signs of sepsis, our physician adviser has considered Miss F’s account of her father on 16 February. She explained when visiting that day, he was shaking badly, he was weak and ‘there was no output from his urinary catheter’. She says she was frightened by what she saw and reported her concerns to staff that she thought this was sepsis, but they told her he was fine and they were waiting for the results of blood tests.
91. There is no record of this conversation in the records, but we have not seen reason to dispute the account Miss F provided.
92. Mr G had been having regular blood tests throughout his admission and our physician adviser has commented his results were abnormal throughout his admission, but they started to worsen by 16 and particularly by 17 February.
93. The medical notes from 16 February say Mr G’s haemoglobin level was decreasing, haemoglobin carries oxygen from the lungs to the body’s cells. This indicates anaemia, something people with kidney disease are particularly at risk of. His creatine level was high, indicating a problem with the kidneys. His C-reactive protein (CRP) level had also increased, indicating inflammation or infection in the body.
94. Staff noted Mr G was ‘muddled’, had reduced blood pressure and a higher-than-normal heart rate. These can all be signs of sepsis. A consultant had decided Mr G should have a repeat blood test.
95. The results of the blood tests on 17 February showed worsening results and led to Mr G being transferred back to the medical ward at the acute hospital. On arrival, the team identified he needed treatment for urosepsis and was started on antibiotics
96. NICE guidelines for ‘suspected sepsis’ say if a person presents with signs or symptoms of an infection, medical professionals should think, ‘could this be sepsis?’. People most vulnerable to sepsis include those with catheters and older people over the age of 75. Mr G met both these criteria.
97. The NICE guidance says clinicians should take into account ‘non-specific, non-localised presentations’, such as feeling very unwell, but the person may not have a high temperature. It also says, ‘pay particular attention to concerns expressed by the person and their family or carers, for example changes from usual behaviour’.
98. Our physician adviser has explained the records and the account of Mr G shaking, being weak and confused on 16 February indicated a deterioration in his condition. While he did not have a high temperature, his abnormal test results along with the concerns raised by the daughter of his changing condition should have led to consideration of sepsis. Our adviser considers there was sufficient indication to start treating him for sepsis on 16 February, and this was a missed opportunity.
99. Mr G was vulnerable to developing sepsis. In consideration of the advice we have received and the NICE guidance on sepsis, we consider there was a delay in the team identifying he was showing signs of sepsis and starting treatment on 16 February. We find this a failing and have considered the impact stemming from this below.
100. Our urologist adviser has reviewed Mr G’s records from 17 February. A repeat CT scan showed Mr G’s kidneys and ureter were enlarged. The report says there had been ‘significant progression’ in the build-up of fluid since the last scan.
101. His observations showed he had a high heart rate of 100 beats per minute, a low oxygen saturation level of 94% and worsening confusion.
102. An arterial blood gas test from 17 February showed Mr G had a high potassium level. The kidneys regulate potassium levels in the body. Further tests showed his CRP level had risen further and he had a high white blood cell count indicating infection and/or inflammation. Mr G’s eGFR level (this shows how well the kidneys are working) had also worsened from the last test on 15 February.
103. Mr G also had minimal urine output. On review of the records, our urologist adviser has said this was likely due to an infected and obstructed kidney.
104. On 18 February, the urology team decided Mr G needed the nephrostomy tube to be re-inserted and planned for this to take place on 20 February. Sadly, Mr G became too unwell for the procedure and died on 21 February.
105. Our urologist adviser has said there are no specific guidelines for when to insert a nephrostomy tube, but they have highlighted relevant clinical papers that consider this.
106. A study called ‘Emergent percutaneous nephrostomy for the diagnosis and management of pyonephrosis’ (pyonephrosis is an infected and blocked kidney) emphasises the importance of prompt drainage. It says the main indication for an emergency nephrostomy tube is to relieve an infected and obstructed system ‘due to the risk of rapidly developing sepsis’. It says in the cases of patients with one kidney, ‘more urgent drainage may be indicated’. Our urologist adviser has said Mr G essentially had one functioning kidney.
107. The clinical paper ‘Emergency percutaneous nephrostomy’ says a patient with high potassium levels is a further indication for an emergency nephrostomy. As noted above, Mr G had increasing potassium levels.
108. Our urologist adviser has commented Mr G’s test abnormal test results from 17 February were the indications the urology team were looking for to decide when to intervene and carry out the procedure. The results appear to have been noted but not acted on. We consider the clinical articles referred to support Mr G met the criteria for the procedure.
109. Our urologist adviser considers the team should have identified on 17 February Mr G’s kidney needed to be unblocked and this should have been the reason for his transfer to the acute hospital. The urology team should have planned to carry out the re-insertion of the nephrostomy tube without delay.
110. In consideration of the advice we have received, and the clinical studies we have reviewed, we find failing the urology team delayed identifying Mr G required re-insertion of the nephrostomy tube on 17 February. We carefully consider the impact of this below.
Impact
111. Miss F says she considers the lack of monitoring caused her father to develop sepsis. She and her family were used to recognising when her father was showing signs of infection. We are sorry to hear of their frustration and distress staff did not seem to listen to them when they raised their concerns.
112. As noted above, the Trust has already recognised that if staff had consistently monitored and documented Mr G’s urinary output, particularly between 15 and17 February, they could have had an earlier opportunity to recognise sepsis and to escalate this accordingly.
113. Our nurse adviser has agreed with the Trust’s conclusion the lack of documented monitoring was a missed opportunity to escalate concerns about Mr G at an earlier time. However, we recognise that because this information was not recorded, it is not possible to say what this would have showed, and therefore what action should have occurred and when. We consider the medical and urology teams were without all the relevant information they needed to monitor Mr G’s condition.
114. On review of the available evidence, we consider Mr G started to show deterioration from 16 February. It is not possible for us to say if he had reduced urinary output before this date, but in consideration of the advice we have received, this was a missed opportunity for earlier action. We are sorry for how distressing it is for Miss F and her family to question the difference these actions could have made.
115. As set out above, it is our view medical staff should have recognised on 16 February that Mr G was showing signs of sepsis. This was a missed opportunity to start treating Mr G, including IV antibiotics, and to transfer him to the medical ward for acute care.
116. Our physician adviser has commented early treatment of sepsis is known to improve outcomes and any delay can affect the prognosis. However, we also recognise Mr G was frail and very unwell. For this reason, our adviser has commented it is not possible to say what difference earlier treatment would have made. Overall, we consider this was a missed opportunity, and we recognise the significant distress this uncertainty will cause Miss F and her family.
117. Miss F has said she considers the delay in re-inserting the nephrostomy tube led to her father deteriorating, developing sepsis and being too unwell to then have the procedure.
118. We consider the urology team should have identified on 17 February that Mr G required re-insertion of the nephrostomy tube without delay.
119. In terms of whether the delay caused him to develop sepsis, we recognise Mr G was vulnerable to sepsis. We note the clinical studies referred to above list sepsis and death as complications that can occur as a result of a nephrostomy. We recognise Mr G developed urosepsis after he had the tube initially inserted in December.
120. In consideration of the urologist advice we have received, we have not seen earlier indication the clinical teams should have arranged for re-insertion of the nephrostomy tube before 17 February. Mr G had already started showing signs of sepsis on 16 February. This means we cannot say the delay in arranging the nephrostomy tube re-insertion can be linked to him developing sepsis.
121. Miss F considers that had the team arranged for the nephrostomy tube to be re-inserted earlier, her father would have been in a better condition to under-go this and this may have given him more time.
122. Our urologist adviser has said earlier arrangement of the procedure may not have affected the overall outcome for Mr G. This is because of the risks of the procedure, and because he was already very unwell. However, this it was a missed opportunity to try and treat his condition which could have made a difference. We recognise the uncertainty about the difference this delay may have caused will be significantly distressing to Miss F and her family.
123. We recognise and are pleased to see the Trust has taken some actions in response to this complaint. It has apologised the nursing team did not monitor Mr G’s urine output appropriately, and that Miss F did not feel staff listened to the family’s concerns.
124. It also arranged further training for the ward team on the identification and management of sepsis, and on the management of complex urological conditions. It also addressed the lack of documentation with the nursing team ‘for further teaching and education’.
125. The Trust did not find staff missed signs of sepsis, or that there was a delay in identifying Mr G needed the nephrostomy tube re-inserting. We cannot therefore say the Trust’s actions address these issues. Our physician adviser has also commented the actions taken so far focus on the staff based at the rehabilitation ward. The Trust does not appear to have reviewed its pathways for managing complex urological patients between the community and acute hospitals.
126. In terms of the documentation to monitor Mr G’s urinary output, the Trust says it has addressed this with the nursing team but there is no detail around what this entailed, how it would monitor this or who would be responsible for this. We consider this is a gap in its actions to address what happened.
127. We consider the Trust should take further actions to address the impact of these events to Miss F. We have therefore set out our recommendations below.
128. We thank Miss F for bringing her complaint to us for us to consider, we have been sorry to hear of her serious concerns. We recognise she wants to see positive changes as a result of her complaint and we hope our recommendations will assure her of the difference her complaint has made.