Weight loss
25. Mr L complains the Trust did not take action to monitor or address his father’s profound weight loss in a short time frame during this admission. He says this is despite his father’s MUST score being zero on admission. MUST is a tool used to identify malnourished patients or patients at risk of malnutrition in the hospital setting.
26. In response to this part of the complaint, the Trust said Mr Y’s oral intake reduced following contracting COVID-19, which is a common symptom of this infection. The Trust acknowledged it missed opportunities to take Mr Y’s weight and to complete a dietician referral on two occasions as requested by the tissue viability nurse (TVN).
27. The NICE guidance for nutrition support for adults advises healthcare professionals should ensure:
• food and fluid of adequate quantity and quality in an environment conducive to eating • screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training • all hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients.
28. We can Mr Y lost a significant amount of weight during this admission (more than half his body weight). Our nurse adviser said the nurses caring for him did not monitor his weight in line with the NICE guidance. The guidance suggests nurses should weigh patients on admission to hospital and every week during admission.
29. The records indicate Mr Y went six weeks without the treating team weighing him (between 31 October and 6 December). This is the period in which he appears to have lost a lot of weight.
30. Our nurse adviser said nurses should also carry out a weekly MUST score. Mr Y had this done on admission, scoring zero, but the nursing team did not complete the MUST score on several occasions following this. The Trust also did not complete Mr Y’s referral to a dietician on two occasions when requested by the TVN.
31. Taking this advice into account, we found the Trust failed to take action to monitor and subsequently address Mr Y’s weight loss during this admission in line with the NICE guidance for nutrition support for adults. The Trust has already acknowledged some of these failings in its response to Mr L’s complaint. We have considered the impact of this failing in the impact section of this report.
Pressure sore
32. Mr L complains the Trust did nothing to prevent, identify and treat a pressure sore. He says the Trust did not identify this until 6 January 2021 by which the time it had already developed into a grade 4 pressure sore.
33. In its response to this complaint issue, the Trust found several areas for learning regarding Mr Y's care. It said staff had not completed daily and weekly assessments in line with the Trust's policy. It said there was documentation in the records to support that nurses regularly turned Mr Y. However, it said there were two occasions where there is no documented information regarding repositioning. It also said someone with advanced training, experience and knowledge in tissue viability or nutrition did not undertake an expert assessment in a timely manner.
34. The NICE guidance on pressure sores recommends treating teams should:
• be aware that all patients are potentially at risk of developing a pressure ulcer • carry out and document an assessment of pressure ulcer risk for adults admitted to secondary care • a trained healthcare professional should offer adults who are at high risk of developing a pressure ulcer a skin assessment. They should take into account any pain or discomfort reported by the patient and the skin should be checked for skin integrity in areas of pressure and colour changes or discolouration.
35. The Trust’s tissue viability policy also says the treating team should identify patients at risk of pressure ulcers early and should carry out risk and skin assessments within four hours of admission to hospital or transfer between wards. It says the team should repeat the risk assessment weekly when there is a concern about risk. It also says staff should assess a patient’s skin at every applicable patient contact (such as during washing and repositioning).
36. Our nurse adviser said the Trust did not act in line with this guidance or its own policy. Nurses assessed Mr Y as being high risk for pressure ulcers on admission. This was because he had significant loss of sensation, a previous pressure ulcer, and significantly limited mobility. He also had a bad hip with an abscess on it meaning the nursing team could not reposition him as much as they wanted.
37. Our nurse adviser said the nursing team followed the guidance initially by assessing and implemented pressure relieving equipment and regularly repositioning Mr Y as documented in the charts in the medical records.
38. However, whilst nurses assessed Mr Y’s skin on admission, they did not complete the daily and weekly skin assessments required in line with the Trust’s policy. Our nurse adviser said this might have helped them identify the pressure sore at an earlier stage.
39. Our nurse adviser also said nurses did not refer Mr Y to the TVN until much later in the admission. This is despite staff uploading a photo of the injury as early as 3 December. Our nurse adviser explained the nursing team should have referred Mr Y to the TVN sooner given his high risk.
40. Taking this advice into account we consider the Trust did not act in line with the NICE guidance for pressure sores or in line with its own policy. We consider there were failings in this aspect of Mr Y’s care which the Trust has already acknowledged. We have considered the impact of this in the impact section of our report.
COVID-19
41. Mr L says his father contracted COVID-19 on Lamport Ward after the Trust exposed him to a positive patient (patient A) whose status was unknown.
42. In its response to this complaint, the Trust said when it admitted Mr Y to Lamport Ward there was an outbreak. It said Patient A was asymptomatic initially but on further swabs had a positive result and started showing symptoms. It said the patient was unable to be isolated due to their medical condition and so Mr Y was exposed to the virus, as he was in the same bay as Patient A.
43. In NHS England and NHS improvements letter to all NHS trusts, this outlined hospitals should be testing patients on admission and to reconduct the test between five to seven days after the admission.
44. The Trust was acting in line with the NHS England and NHS improvement guidance as it was swabbing on admission, on day 3, on day 5, and every other day. We can see that, unfortunately, the swabs of the patient who contracted COVID-19 had initially shown they were negative. This was a common occurrence during the pandemic as patients would often test negative only then to test positive a few days later.
45. The Trust’s policy for cohorting COVID-19 patients also advised to:
• cohort patients with suspected COVID together (red pathway) • cohort patients with confirmed COVID together (red pathway) • cohort patients that are negative but exposed to COVID together (amber pathway) • cohort patients that are negative but not exposed to COVID together (green pathway) 46. The Trust completed a SI investigation into this outbreak which concluded in January 2021. This identified Patient A swabbed positive on 12 November 2020 (which was day six of their admission to the ward). An infection prevention control (IPC) nurse reviewed them and noted their day 0 and day 3 swabs were negative but the ward medical team had still suspected COVID-19. The medical team had requested a respiratory view of Patient A but had not isolated them as they were unsafe for a side room.
47. The SI investigation confirms the IPC nurse supported the ward to move the patient to a red pathway bed and advised to swab the rest of the bay (who were now considered amber patients as they had negative tests but had been exposed).
48. We consider the Trust did not act in line with its policy here as it did not isolate patient A immediately on suspicion of COVID-19. The SI investigation confirms patient A remained on the bay for 48 hours following suspicion of COVID-19. In line with its own policy, the Trust should have moved Patient A to a red pathway if he was unsuitable for a side room. We consider this to be a failing.
49. We considered whether this resulted in Mr Y contracting COVID-19 and if this could have been avoided. We now cannot say whether this failing directly led to Mr Y contracting COVID-19. This is because Mr Y had been on the ward since 30 October and so will have likely already been exposed to Patient A at the time they became symptomatic. Nonetheless, we recognise that failing to move patient A will have prolonged the length of time Mr Y’s was exposed.
50. We recognise this now leaves Mr L with some uncertainty around whether his father’s COVID-19 infection could have been avoided. We can see at the time of the events, the Trust carried out some actions as part of the SI investigation to address the issues it had identified. This included strengthening the COVID-19 pathway and sharing this with colleagues. We consider this is enough to help ensure similar mistakes do not happen again in future and so we have not made any recommendations to the Trust for further learning here.
51. However, the Trust has not acknowledged any failings relating to this in its handling of the complaint. We have made some recommendations to the Trust to address this.
C-difficile
52. Mr L says his father contracted C. diff whilst an inpatient due to poor care and non-adherence to infection prevention and control polices. We understand why Mr L is so concerned about his father contracting this infection.
53. In its response to this part of the complaint, the Trust said Mr Y had several different antibiotics both prior to and during his admission. It said as such, Mr Y was at increased risk of C. diff.
54. The NHS England website explains who is at risk of getting C. diff. This explains a patient is more likely to get C-difficile if:
• they are over 65 years • they are taking, or have recently taken, antibiotics • they are staying in hospital or a care home for a long time • they have a weakened immune system – for example, from having a long-term condition like diabetes or kidney failure, or treatment like chemotherapy • they are taking a proton pump inhibitor, such as omeprazole, or other medicines that reduce stomach acid • they have had a C. diff infection in the past
55. Our nurse adviser explained C. diff lives inside the body as harmless bacteria. However, they explained when a patient has antibiotics it can flare up. In line with the advice from NHS England, Mr Y was at risk as he was over 65, was on antibiotics, and was residing in hospital.
56. On the balance of probabilities, it is more likely Mr Y got C. diff in this way rather than through poor infection prevention control measures. Our nurse adviser explained it is difficult to contract C-difficile in this way. We have therefore not identified any failings in this area of the complaint. We hope this provides some reassurance to Mr L about this aspect of his father’s care.
Fluid balance
57. Mr L complains about poor fluid balance management. He says on 28 December, a nurse informed him his father had not passed urine for 48 hours.
58. In its response to this part of the complaint, the Trust said there is evidence nurses completed fluid balance charts and recorded the outputs of his catheter. It also said there was evidence nurses regularly changed his catheter bags and there was no documented evidence to suggest a reduced urinary output.
59. The Trust’s oral nutrition and hydration policy in place at the time says a nurse should review fluid balances and oral intake every four hours. It also says the patient will have a daily fluid record placed in the nursing booklet and completed with all fluid intake and output. It says it is the nurses’ responsibility to add up the fluid intake and output continually throughout the 24-hour period. It explains they should discuss any concerns with negative or positive balance with the doctors responsible for the overall care of the patient.
60. Our nurse adviser said initially, it appears the Trust completed the daily fluid balance charts in line with national guidance. However, from around 10 December onwards we could not see evidence in the records to show nurses recorded fluid output (although there is evidence of nurses completing food charts).
61. We cannot see anything recorded on 28 December where Mr L said his father did not pass urine for 48 hours. It is possible these records are missing. However, if nurses did not complete this documentation, this was not in line with the Trust’s policy which says nurses should complete it daily. We again consider this to be a failing.
62. We considered the impact the failings to properly monitor Mr Y’s fluid balance had. Our physician adviser said fluid balance charts help the team measure what fluid is going in and the fluids which are coming out. This can help determine a patient’s hydration status. Our physician adviser said they could not see any evidence Mr Y was not having enough fluid or that he was dehydrated.
63. Our physician adviser explained the medical records throughout December show Mr Y’s kidney function was normal and his blood tests did not indicate he was dehydrated. As such, whilst nurses should have monitored Mr Y’s fluid balance carefully, it does not appear there was a significant clinical impact from this.
Mental Health referral
64. Mr L complains his father’s mental health referral was not progressed.
65. In its response to this part of the complaint, the Trust said the treating team referred Mr Y to Liaison Psychiatry for Older People (LPOP) on 7 December. It said LPOP reviewed him on 9 December 2020 but deemed him not medically fit for review. LPOP advised the ward to re-refer Mr Y once he was medically fit. The Trust said sadly Mr Y did not recover sufficiently before it transferred him to a hospice on 13 January 2021, and so the ward did not make another LPOP referral.
66. The GMC guidance which was in place at the time of these events says doctors must:
• 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 • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.
67. On the day the ward referred Mr Y to LPOP on 7 December, he had a urinary tract infection (UTI), and doctors had only just commenced him on antibiotics. The medical records show he was confused which our physician adviser said was likely in part due to his UTI. Our physician adviser said he had raised inflammatory markers (these are blood tests that go up with inflammation, most usually caused by infections), which supports the evidence he had an infection.
68. When the psychiatrist visited Mr Y on 9 December, he still had an acute medical illness. There are multiple entries showing he was confused and delirious. Our physician adviser said the decision not to assess Mr Y at this point was in line with the GMC guidance as it did not serve his needs at the time.
69. Our physician adviser said following the initial visit from the psychiatrist on 9 December, it does not appear he was ever well enough to be re-referred. They explained it is difficult to manage any psychiatric illness when the patient is so unwell that the physical illness (and the impact it is having on cognition etc) and any psychiatric illness cannot be differentiated between. They said this is why the psychiatrist did not want to see Mr Y on 9 December and advised the ward to re-refer him once medically fit.
70. Taking the above into account, we have found no failings in the Trust’s handling of this referral. We again hope this provides some reassurance to Mr L.
Pain control
71. Mr L complains about ineffective pain control including on one occasion he could hear his father screaming in pain on a call. From the information provided, this appears to have been on or around 30 December.
72. In response to this part of the complaint, the Trust said there is documentation throughout Mr Y's medical records regarding the assessment of his pain and provision of pain relief. It said this meets the standard of assessment and pain relief expected. It said his pain was well managed with clear documentation it was fluctuating. It said when he reported pain, staff adjusted his medication and escalated at appropriate times.
73. We firstly considered whether doctors managed the prescriptions for Mr Y’s pain in line with national guidance. The NICE guidance for pain advises a stepwise approach for clinicians prescribing pain relief. The steps are:
• step 1: non-opioid analgesic such as paracetamol and/or nonsteroidal anti-inflammatory drug (NSAID) - mild pain • step 2: weak opioid such as codeine, dihydrocodeine, or tramadol, with or without a non-opioid analgesic – mild to moderate pain • step 3: strong opioid such as morphine, with or without a non-opioid analgesic - severe pain.
74. Mr Y was taking a blood thinning medication (DOAC) as he had an irregular heartbeat. Our physician adviser said when a patient is on blood thinning drugs NSAIDs should only be used with caution as the combination of DOAC and NSAID significantly increases the risk of bleeding, including gastrointestinal bleeding. Therefore, doctors correctly did not prescribe these to Mr Y.
75. Initially, doctors prescribed Mr Y co-codamol (which is a combination of codeine and paracetamol). This means Mr Y was initially on step 2 of the pain ladder. This advises using a non-opioid analgesic and combining this with a weak opioid such as codeine.
76. As the admission went on, we can see doctors prescribed Mr Y as required morphine (5-10mg up to every two hours) in line with step 3 of the pain ladder. They appear to have prescribed this throughout November up to mid-December. Our physician adviser explained the records show Mr Y was not using this much. He explained if Mr Y had been requiring this more frequently, the doctors may have decided to change this to a regular tablet dose.
77. The medical records also show on 15 December, doctors prescribed Mr Y a buprenorphine patch to replace the morphine. Buprenorphine is a different type of opiate which provides more long-standing pain relief. Doctors prescribed this alongside paracetamol and codeine. Our physician adviser again said this was in line with step 3 of the pain ladder.
78. Overall, the prescriptions for Mr Y’s pain relief were in line with the NICE guidance for pain. We have found no failings in relation to this aspect of Mr L’s complaint.
79. We also considered whether nurses administered Mr Y’s pain relief as prescribed. The NICE guidance for patient experience says if a patient is unable to manage their own pain relief:
• do not assume that pain relief is adequate • ask them regularly about pain • assess pain using a pain scale if necessary (for example, on a scale of 1 to 10) • provide pain relief and adjust as needed.
80. Our nurse adviser said the records indicate the nursing team frequently assessed Mr Y’s pain every few hours using a numerical scoring system and he usually scored ‘0’ indicating he was not in pain.
81. The records also show the nursing team acted when Mr Y was in pain in line with national guidance by giving him his medication as prescribed. They also referred Mr Y to palliative care to help manage his pain.
82. We can see nothing documented in the records regarding the incident on 30 December where Mr Y says he heard his father screaming in pain. We are in no way disputing his account. Overall, our view is the nursing team acted in line with the NICE guidance for patient experience in managing Mr Y’s fluctuating pain. We have found no failings in this aspect of care.
Impact of failings regarding nutrition and pressure sore
83. We have found failings in the care the Trust provided to Mr Y. This relates to nurses monitoring his weight loss adequately and taking action to address this. It also relates to the failure to identify and address Mr Y’s grade 4 pressure sore.
84. On the balance of probabilities, we consider that had these failings not happened, the Trust could have identified Mr Y’s pressure sore sooner and prevented it from developing to the level it did. Our nursing advice also indicated that if the Trust had acted sooner, Mr Y may not have lost as much weight as he did. We can therefore see that these issues caused avoidable harm to Mr Y. We have also considered if these failings contributed to Mr Y’s death and whether his death could have been avoided.
85. Mr Y's death certificate noted frailty as his cause of death, alongside several other conditions which were listed as contributing to this frailty.
86. Our physician adviser said the weight loss will have contributed to Mr Y’s frailty (and death). However, they advised it is clear there were also several other contributing factors to Mr Y’s frailty alongside this. They said it is therefore difficult to estimate how much the weight loss contributed. Our physician adviser said the weight loss will have been a significant factor, however the other factors are also significant.
87. Our physician adviser said even if the treating team had referred Mr Y to a dietician sooner and properly monitored his weight loss, on the balance of probabilities it is likely he still would have continued to lose weight. This is because we can see Mr Y was frequently refusing oral intake throughout the admission. However, as above, interventions may have helped prevent Mr Y from losing as much weight as he did.
88. Although nutritional supplements could have been prescribed sooner, our physician adviser said these are not the optimal way of providing nutrition. Once the treating team prescribed these, we can see Mr Y also frequently refused those too.
89. Our physician adviser said a feeding tube would not have been indicated for Mr Y as he was able to swallow. He explained emerging evidence over the years is that people on feeding tubes do not live any longer and so this would not have solved the problem.
90. Similarly, our physician adviser said the pressure sore would have been a contributing factor to Mr Y’s death, however, it is now difficult to quantify to what extent this played a role either. They explained the infections Mr Y sustained during the admission will have contributed to his poor mobility, loss of appetite, and frailty and so all these different factors are interlinked.
91. Taking the above advice into account, we cannot say, on the balance of probabilities, the failings of the Trust caused Mr Y’s death or that his death was avoidable had the failings not occurred. It is possible, Mr Y still may have died even if these failings had not occurred. However, we recognise these failings may have contributed.
92. This represents a missed opportunity to provide Mr Y with the best chance to survive. We recognise the knowledge of this will be incredibly distressing to Mr L. We also recognise that knowing these failings contributed to his father developing a grade 4 pressure sore and him losing weight will also be distressing.
93. As part of its SI investigation. We can see the Trust created an action plan to address the failings identified relating to nutrition and the pressure sore. This action plan outlined what actions the Trust would take to ensure similar mistakes do not happen again in future. We consider the Trust has done enough to take learning from these issues.
94. We can also see the Trust has acknowledged the care it provided with regards to Mr Y’s nutrition and pressure care fell below the expected standard as part of its complaint responses. However, we have made a further recommendation to it to acknowledge the Trust missed opportunities to give Mr Y the best chance to survive and to apologise for the impact on Mr L.