Failure to manage skin care
15. Ms Y complains that the Trust failed to manage her husband's skin which resulted in a pressure ulcer on his sacrum (triangular bone at the base of the spine). Ms Y has provided a chronology of how Mr X’s pressure sore developed from his admission.
9 16. The Trust said an ED nurse should have flagged up Mr X’s requirements as soon as he was identified as high risk of deterioration of his grade 2 sore on admission. The Trust said the deterioration of the pressure sore from a grade 2 to grade 3 indicated the best management was not fully implemented. It was also considered inappropriate that Mr X that he had been on a trolley for two days while waiting for a pressure relieving mattress and this would have contributed to further deterioration of the sore.
17. The relevant guidance that applies here is NICE ‘Pressure ulcers: prevention and management’. Our nursing adviser explained that in accordance with this guidance Mr X should have had a risk assessment on admission to hospital, using a validated assessment tool such as Waterlow. If he was deemed high risk, he should then have had a skin assessment by a trained healthcare professional.
18. If deemed at risk of developing pressure damage, then preventative measures should be used or put in place such as; • Regular repositioning • Pressure redistributing devices • Barrier creams
The management of developed pressure ulcers includes; • Ulcer measurement and categorisation • Nutritional supplements and hydration • Pressure redistributing devices • Use of dressings 19. On the day of his admission, it was noted that Mr X’s skin was dry and fragile, and that he already had an area of concern on his sacrum.
20. Another document dated 17 August states that Mr X had a grade 2 pressure sore to his sacrum, for which a Datix report had been submitted, barrier cream applied and a dressing put into place. However, there is another document for the same day indicating his skin was intact.
21. It is also documented on a nursing handover note from the 18 August at approximately 8am that Mr X’s pressure areas are intact but that he has a grade 2 pressure sore on his sacrum. It is noted that he is being nursed on a Talley mattress.
22. Our nursing adviser said all the above information would indicate that Mr X already had some pressure damage to his sacrum on admission, possibly a grade 2 pressure sore. However, some of the nursing documentation is conflicting, therefore it is difficult to assess the level of damage from the early part of his admission. However, we note the Trust said in its response dated 21 December 2023 that the skin was intact on 17 August. This reflects Ms Y’s account of the events as she said her husband’s skin was intact on his admission and we acknowledge that.
23. A tissue viability nurse (TVN) reviewed Mr X on 23 August for a grade 2 pressure sore. A TVN is a specialist in wound and pressure ulcer care who provides expert advice, assessments, and education to healthcare professionals and patients to promote healing and prevent complications. The TVN graded the pressure sore as unstageable, probably grade 3 but noted that Mr X was correctly being nursed on pressure relieving mattress and cushion on chair. The TVN put a plan in place which included;
• Encourage to change position every 2 hours, providing assistance if necessary • Complete SKIN bundle • Complete Waterlow daily • Limit time sat out to less than an hour. Encourage to stand every 20-30 minutes to off load pressure • TVN follow up 7-10 days
24. Our nursing adviser has said it is not clear if this plan was adhered to, as we have been unable to see the SKIN bundle charts within the notes and any evidence that these plans were put into action.
25. We note that although some of the recommendations from the above guidance appear to have been followed, Mr X developed further pressure damage whilst an inpatient in hospital. Our nursing adviser said there could have been many contributory factors for this, but due to lack of clarity from within the documentation about nursing actions, we cannot rule out that pressure damage occurred due to guidance not being followed. Evidence of this includes, a pressure relieving cushion only being ordered on the 22 August, 5 days after admission, when due to his high risk status, this should have been ordered on the day of admission.
26. We further note that the Trust has acknowledged in its response that there were shortcomings in care which would have contributed to the deterioration in Mr X’s pressure sore from a grade 2 to grade 3.
27. We have found the management of Mr X’s skin was not fully in line with guidance and this was failing on the part of the Trust. Therefore, we uphold this part of the complaint.
The Trust has apologised to Ms Y for the poor care provided to Mr X with regard to his skin care. It has also set out improvements that it made as a result of this complaint. These include, • Regular Waterlow assessments • TVN training for all staff • The introduction of the Airway, Breathing, Circulation, Disability. Exposure (ABCDE) handover tool • The TVN has introduced educational information about suitable pressure relieving devices to be used on beds and chairs.
28. We recognise that it is a source of distress to Ms Y that her husband’s skin was not managed fully in line with guidance. She was caused worry and distress at what was already a worrying time for her and her husband.
29. We welcome the actions the Trust has taken to improve the care provided by nursing staff regarding pressure sores. However, we consider that the Trust’s actions do not fully recognise the impact on Ms Y. We have therefore made recommendations below to address this.
Failure to manage bowel movements and communication
30. Ms Y complains that the Trust did not manage her husband's bowel movements leading to an impacted bowel. Ms Y said her husband had gone nine days without opening his bowels. She considers this was gross negligence.
31. The Trust said in its response dated 25 October 2023 that suppositories were administered by the nursing staff but this seemed to have little effect. In its further response dated 21 December 2023 the Trust explained the care it had provided regarding Mr X’s bowel management. The Trust said that a consultant involved in Mr X’s care said the management of Mr X’s bowel care was poor. It said there were many contributory factors including decreased mobility, use of opioid painkillers and high calcium levels.
32. The Trust said Mr X was noted to be constipated on the day after his admission and was started on laxatives. These were increased in an attempt to correct his bowel problems. The consultant said in hindsight the medical team were too slow in making those changes and offered his sincere apologies.
33. Within the NMC code of conduct, Read The Code online - The Nursing and Midwifery Council, it states that Registered nurses should treat people as individuals, upholding their dignity. This includes;
1.2 make sure you deliver the fundamentals of care effectively
The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions. It includes making sure that those receiving care have adequate access to nutrition and hydration, and making sure that you provide help to those who are not able to feed themselves or drink fluid unaided.
34. Therefore, in line with the above guidance, the nursing team should have ensured that they were monitoring Mr X’s bowel movements and escalating this to the medical team if there were any concerns. They should also have been administering any medication prescribed to help him open his bowels.
35. Our nursing adviser said from the records it appears the nursing staff were compliant with administering the medication to help Mr X’s constipation including oral laxatives, suppositories, and enemas. The nursing staff also appear to have been monitoring Mr X’s bowel movements during the period 20 to 27 August.
36. The indication is the medical team prescribed laxatives and suppositories to try and resolve Mr X’s bowel problems. This was in line with NICE guidance ‘Constipation in adults’. The guidance says if oral laxatives are inadequate or too slow consider suppositives or a mini enema. The laxatives and suppositories were not effective and an enema was prescribed. This resulted in Mr X opening his bowels on 30 August. A consultant involved in Mr X’s care said that the medical team were too slow in making these changes. We consider that if this had been done sooner it is likely this problem may have been resolved earlier.
37. We have found there was a failing on the part of the Trust in the management of Mr X’s bowel problem. Therefore, we uphold this part of the complaint.
38. Mr X suffered discomfort and pain due to the lack of bowel movement. We recognise that it is a source of distress to Ms Y that her husband’s care was suboptimal. Again she was caused further worry and distress at what was a worrying time for her and her husband.
39. The Trust has not fully recognised the impact of the above failings on Ms Y. We have therefore made recommendations below to address this.
Poor communication
40. Ms Y complains there was poor communication regarding her husband's lack of bowel movements.
41. The relevant guidance here is NICE ‘Patient experience in adult NHS services: improving the experience of care for people using adult NHS services’. This states,
“1.13.10 Involvement of family members
Clarify with the patient at the first point of contact whether and how they would like their partner, family members and/or carers to be involved in key decisions about the management of their condition (or conditions). Review this regularly. If the patient agrees, share information with their partner, family members and/or carers”.
42. In accordance with the above NICE guidance, it should have been discussed with Mr X on admission whether he would like his wife involved in the management of his condition and about which aspects, he would like her updated on. As he had capacity, this is a decision that he could have made himself, and the nursing team should have complied with this.
43. It is worth noting that Mr X was deemed as having capacity, though there was some cognitive impairment, therefore he was able to discuss with or answer questions from Ms Y regarding having his bowels open. Also, it is documented within the medical records that Ms Y had requested a daily update from the medical team. Therefore, it does appear she did have regular opportunities to discuss Mr X’s bowel movements with the nursing and medical team.
44. It appears from the available evidence that Ms Y discussed Mr X’s bowel movements with the nursing and medical team during the period 25 to 30 August. This resulted in an increase in laxative medications, suppositories and then an enema.
45. In view of the above our decision is that overall there is no evidence of failings regarding communication. Therefore, we do not uphold this part of the complaint.
Failure to manage mobility
46. Ms Y complains that the Trust did not encourage her husband's mobility. She said that this led to his mobility worsening while he was in hospital. The Trust said that at the time of admission Mr X was having increasing difficulty mobilising because of pain. The Trust said that when a consultant saw him on 17 August he was able to mobilise 10 metres with a frame.
47. Our nursing adviser said the records indicate Mr X’s mobility was adequately assessed in line with the above NMC code, as he was referred to the therapy team on admission for expert assessment and evaluation. From the records it appears that the nursing team took guidance from the therapy team and adhered to the plans they formulated.
48. Mr X was regularly reviewed by the therapy team and guidance provided to the nursing team regarding the plan for his mobilisation. On 27 August, the therapist has recorded Ms Y confirmed she felt that Mr X’s mobilisation was much improved to what it was prior to admission. Our nursing adviser said this indicates that appropriate plans and management of Mr X’s mobilisation were in place.
49. The records show some of the entries as follows,
• 17 Aug - Mobilised by physio - Able to mobilise with supervision and frame • 18 Aug – Mr X and Ms Y note significant deterioration in mobilisation recently • 18 Aug - OT Note- on arrival to pt, nurse and HC transferring pt out of bed. Mobilised by OT • 18 Aug - Walks with Zimmer frame or stick but very slow with assistance of 1 • 19 Aug - Patient unsteady, mobilising with Zimmer frame. Mobilised by Physio-plan to sit out daily • 20 Aug - Patient sat out in chair • 21 Aug - Mobile with ZF. Assistance of 1. From bed to chair • 22 Aug - Mobile transferring from bed to chair with assistance of 1 and Zimmer frame • 24 Aug - Mobilising with ZF. Assistance of 1 transfers. To stand every 30 minutes to relieve pressure areas.
50. These entries continue within the records. The records indicate that the therapy team was involved in Mr X’s care to help with his mobility.
51. We recognise that Ms Y believes the Trust should have done more for Mr X regarding his mobilisation. However, taking into account the available evidence including the advice from our nursing adviser, our decision is there were no failings on the part of the Trust. Therefore we do not uphold this part of the complaint.
PET scan
52. Ms Y complains that the medical team referred Mr X for a PET scan at another hospital on 30 August 2022 when he was not well enough due to an impacted bowel. Ms Y said she had contacted the hospital the night before as she did not consider Mr X was well enough for the procedure. She said the scan caused him stress and discomfort.
53. The Trust addressed this issue in its December 2023 response apologising for the lack of communication about this. It also explained that it was considered the PET should have gone ahead despite any concerns as it was considered important for the management of Mr X's care.
54. The relevant standards which apply here are the General Medical Council’s (GMC) Good Medical Practice (2014). These state,
“15 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 c refer a patient to another practitioner when this serves the patient’s needs”
55. Our physician advise explained a PET CT scan is a detailed scan looking at the whole of the body to identify any disease or condition that requires further investigation. There are no absolute contraindications for a PET CT scan as it did not pose a serious or potentially life threatening risk to Mr X.
56. In this case, the decision to perform the scan was taken and the scan arranged. It is noted that Mr X had not opened his bowels for a few days prior to this scan – however it appears the patient was comfortable, not in pain but mobility was limited to transferring from bed to chair with assistance of 2 people.
57. Our physician said it seems Mr X was suitable for the scan and that it was an appropriate investigation to be carried out. Mr X had a number of medical issues and a unifying diagnosis had not been made at this stage. In the circumstances, the PET CT seems to have been a reasonable investigation. This would have been in line with the above GMC guidance.
58. Having considered the available evidence, our decision is there are no indications of failings regarding this aspect of Mr X’s care. The medical team were trying to establish an underlying cause for Mr X’s condition. Therefore, we do not uphold this part of the complaint.
Discharge
59. Ms Y complains about that there were unnecessary difficulties and delays in arranging her husband's discharge and care package from 7 September 2022.
60. The Trust addressed this in its response dated 23 October 2023. It explained the process for arranging the discharge and the involvement of social services and the clinical commissioning group. The Trust acknowledged in its response that there had been some miscommunication between the ward and the clinical commissioning group (CCG) which caused Ms Y and Mr X stress.
61. The relevant guidance here is NICE ‘Transition between inpatient hospital settings and community or care home settings for adults with social care needs’.
62. Our nursing adviser informs us the documentation indicates Mr X’s discharge was managed in line with guidance, although it is evident that there were some delays due to the Trust having to order equipment and a package of care being agreed with the CCG. The discharge flow coordinator and the occupational therapists appear to have had communication with Ms Y about Mr X’s fast track discharge, the provision of equipment and what care he would require at home. This is in line with point 1.5 of the above guidance which deals with ‘Discharge from hospital’. This includes appointing a discharge coordinator, communication and information sharing and involving carers which appears to have been met by the Trust.
63. Having considered the available evidence including our nursing adviser’s advice our decision is that, whilst there may have been some miscommunication between the ward and the CCG, overall the discharge was managed in line with guidance. Therefore, we do not uphold this part of the complaint.
Hospital Acquired Pneumonia
64. Ms Y complains that Mr X suffered a heart attack on 3 September 2022 driven by hospital acquired pneumonia (HAP). The Trust said that Mr X was started on antibiotics for suspected HAP on 2 September 2022.
65. The relevant guidance here is NICE – Healthcare-associated infections. Our physician adviser explained that healthcare acquired infections (HCAIs) are an unfortunate consequence of prolonged hospital inpatient stays for patients. Mr X had been in over 2 weeks at this stage, had been unwell and physically deconditioned with reduced mobility. He had several medical issues and was frail.
66. Our physician adviser said there is no evidence that Mr X developed a HCAI as a result of failings on the part of the Trust. The importance of good nutrition, early mobilisation and rapid discharge all play a role in reducing HCAI incidence as well as infection prevention measures. It appears that the patient needed an admission to hospital due to being unwell and developed HCAI due to prolonged stay and the need for ongoing inpatient assessment and investigations.
67. Our physician adviser said Mr X was frail and had been declining in health a few weeks prior to admission. He presented with high calcium, pain, constipation and reduced mobility – these all contributed to increasing frailty and pressure sores and subsequently development of a HCAI. Extensive investigations and treatment was needed resulting in a prolonged hospital stay. The sequence of events was an unfortunate result of the need for being in hospital for assessment and treatment.
68. Having considered the available evidence our decision is there is evidence of failings on the part of the Trust which indicates it was responsible for Mr X’s infection. Therefore, we do not uphold this part of the complaint.