Nursing care
18. Ms A complains that the nursing care provided to Mrs B was not to an expected standard. She says she had to attend the hospital three to four times daily to feed Mrs B and provide fluids, as the nursing staff were not doing this. Ms A also says Mrs B’s personal care was neglected. She says her mother’s nails were filled with faeces, that her toothbrush used to complete mouth care was dirty, that faeces were no cleaned up, and that her nails were painted to cover up the faeces/dirt.
19. In response to the complaint the Trust says the medical records indicate interventions were provided to address Mrs B’s hygiene and nutrition needs. However, it acknowledges the photographs provided show some aspects of Mrs B’s care were unacceptable. The Trust provided an apology during a local resolution meeting (LRM) for this and told them the pictures had been shared with the ward team to highlight that the care provided fell below an acceptable standard.
20. During the LRM, the Trust also provided reassurances that the environment on the ward has much improved since the time Mrs B was an inpatient. It explained that at the time, the ward was short of substantive staff and was relying on locum/agency staff. Additional staff have since been recruited and all nurses working on the ward are substantive members of staff. The Trust says this ensures all staff are familiar with procedures on the ward and leads to greater continuity of care.
21. We have considered this aspect of the complaint with our nursing adviser and will address each matter in turn.
Nutrition
22. NICE CG32 says healthcare professionals should ensure that care provides the following: • Food and fluid of adequate quantity and quality in an environment conducive to eating • Appropriate support, for example, modified eating aids, for people who can potentially chew and swallow but are unable to feed themselves (point 1.1.2) 23. The NMC’s standards says nurses should use evidence-based, best practice approaches for meeting needs for care and support with nutrition and hydration. They should assess the patient’s capacity for independence and self-care, determine the need for intervention and support, and assist with feeding and drinking as required, including the use of appropriate aids (Section 5, points 5.1 and 5.3).
24. The NMC’s Code says nurses should make timely referrals to other practitioners when any action, care or treatment is required (point 13.2), and that they should ask for help from suitability qualified/experienced professionals to carry out any actions or procedures beyond the limits of their competence (13.3).
25. At the point of admission, Mrs B had been unwell for a few weeks prior. She was documented to be bedbound, drowsy, and with a reduced food and fluid intake.
26. The fluid balance charts in the medical records show us a good level of fluid intake for the first week of the admission. From this point on, Mrs B required additional help with hydration by way of intravenous (IV) fluids. Despite this, the fluid charts show us that Mrs B continued to be offered drinks orally in addition to the IV input throughout her admission. We consider this is in line with the NMC’s standards.
27. With regards to food intake, Mrs B’s nutritional intake was poor. It is noted her food intake was moderate for the first week of the admission. After this, Mrs B began refusing most meals. There is evidence within the medical records that the nursing team were encouraging Mrs B to eat and prompting nutritional intake.
28. We can see the doctor reviewed Mrs B and had a discussion with the family to explain she was not actively eating or drinking despite active encouragement. The option of NG feeding was discussed on 30 July, and a suggestion was made for a referral to the dietitians for nutritional support.
29. The referral to the dietitian for NG feeding was not completed until 8 August, which was over a week after this was first advised. We consider this was not in line with the NMC’s Code in relation to making referrals in a timely manner.
30. Our nursing adviser explained that there does not appear to have been any impact on Mrs B from the delay in referring her to the dietitian and starting NG feeding. Mrs B was declining physically and cognitively prior to her admission, and during her admission. This meant she had a reduced ability to recover from her illness, and nutrition alone would not have addressed this.
31. Despite this, we recognise the family’s concerns that the lack of adequate nutrition during this period had an impact on Mrs B, and we recognise this caused them significant concern as it led them to conclude she was being neglected. We can see from the information submitted to us that this contributed towards their stress at an already distressing time.
32. In conclusion, there are indications that the nursing team acted in line with the NICE guidance and NMC standards quoted above when encouraging and assisting Mrs B to eat and drink throughout the admission. However, Mrs B was not referred to the dietitians in a timely manner and this was not in line with the NMC’s standards.
33. We cannot see that the Trust has addressed this matter in any of its complaint correspondence so far. We spoke with the Trust, and it advised that whilst an apology was provided in the LRM for the oversights in nursing care, it did not specifically apologise in relation to nutrition.
34. The Trust has acknowledged there was a delay in the dietitian referral being made and attributed this delay to a lack of senior nursing input into Mrs B’s care. The Assistant Divisional Director of Nursing, Emergency, and Urgent care has agreed to review the processes currently in place on the ward and produce an action plan to ensure this area of care is improved going forwards.
35. We consider once this action plan is complete, the Trust will have provided a response to the complaint in line with the NHS Complaint Standards with regards to giving a fair and accountable response and promoting a learning culture. For this reason, we will not be taking any further action on this part of the complaint.
Hygiene
36. NICE CG138 says healthcare professionals should ensure a patient’s personal needs (for example, relating to continence, personal hygiene, and comfort) are regularly reviewed and addressed. They should regularly ask patients who are unable to manage their personal needs what help they need and address their needs at the time of asking (point 1.2.9).
37. The NMC’s standards says nurses should observe, assess, and optimise skin and hygiene status, whilst determining the need for support and intervention and providing assistance with washing, bathing, shaving, and dressing (points 4.1, 4.3).
38. We understand from reviewing the medical records that from the point of admission Mrs B was bedbound and needed full assistance in meeting her hygiene needs. We can see she had two hourly intentional rounding in place, which meant the nurses carried out checks of her needs every two hours as a minimum. It is documented that during these checks, Mrs B’s hygiene needs were assessed.
39. We can see Mrs B’s stool frequency was being monitored from early in her admission, and there was a period where Mrs B had frequent loose stools. The records indicate to us that her incontinence pads were being changed accordingly. From this, we consider there are indications that Mrs B’s hygiene provision was in line with the guidance outlined above.
40. Despite this, we can see from the pictures submitted by the family that here were some occasions where Mrs B’s hygiene needs had not been met. We have not seen any wider evidence to indicate this was the case throughout the admission.
41. We recognise how distressing and concerning it must have been for Mrs B’s family to see her prior to her needs being met. We can see the Trust has acknowledged this was unacceptable, and that it has shared the pictures with the team on the ward to raise awareness of what happened, and to ensure service improvements take place. We can also see the Trust has provided an apology to Ms A for these omissions in care.
42. We consider the actions taken by the Trust are in line with the NHS Complaint Standards with regards to giving fair and accountable responses and promoting a learning culture. In our view, the response from the Trust is proportionate to what went wrong in Mrs B’ care, and for this reason, we do not consider there are any indications this part of the complaint requires further investigation.
Communication
43. Ms A says that despite having weekly meetings with the doctors, it was not explained how they knew Mrs B was at end of life and the reasons for her deterioration were not explained to them. Ms A also says the family were not given an explanation of the cause of death.
44. During the LRM with the Trust, the medical consultant present explained to Ms A that Mrs B had several chest infections and had received various courses of antibiotics, however, she continued to deteriorate with long admissions to hospital. She had also had Covid-19, which left her prone to chest infections. The consultant explained that during Mrs B’s final admission, it was clear she was very unwell. The Trust also explained that advice was taken from the geriatricians, neurologists, and palliative care team and it was agreed Mrs B was approaching the end of her life and that the focus should be on ensuring she was as comfortable as possible.
45. NICE G42 recommends using systems to identify adults who are likely to be approaching the end of their life. This enables practitioners to start discussions about advanced care planning, provide the care needed, and to support people’s preferences for where they would like to be cared for and die (point 1.1.1).
46. It also says practitioners should also identify the patient’s carers and other people important to them (point 1.1.2), and that they should think about what practical and emotional support can be provided to them (point 1.3.1).
47. The GMC’s guidance on treatment and care towards the end of life says those close to a patient may want or need information about the patient’s diagnosis and about the likely progression of the condition or disease in order to help them provide care and recognise and respond to changes in the patient’s condition (point 19). It says when providing information, doctors must do their best to explain clinical issues in a way the person can understand (point 20).
48. It also says doctors should explore treatment options with patients (and with those close to them if appropriate) focusing on the goals of care, and explaining the likely benefits, burdens, and risks. The guidance goes on to say that doctors should bear in mind that patients and those close to them may not always have a clear or realistic understanding of the diagnosis or benefits, burdens, and risks of a treatment option (point 28).
49. It further explains that patients and those close to them may also draw incorrect conclusions from the terminology used by healthcare staff about the risks or expected outcomes of these treatments, and so they should explain the options in a way they can understand, explaining any medical or other terminology used (point 29).
50. From the medical records available to us, we have seen regular documentation of communication with the family by the treating medical team and the ward nursing team.
51. Our geriatrician adviser observed that many efforts were made to treat Mrs B and to identify any reversible causes of illness, despite her deterioration. There is evidence that various specialists were involved in her care, including the geriatricians, neurologists, the mental health team, the speech and language therapy team (SaLT), the dietitians, and the palliative care team.
52. We recognise that in any situation like this, it is difficult to judge from written notes as to whether explanations given around the causes of decline and death were clear and understood by all those present. We acknowledge we were not present at the time to independently know what, and how, things were said. We also recognise in some instances, each person involved in the same conversation can come away with a different perception of its contents and what happened.
53. We can see regular and frequent documentation of updates given to the family by these teams, and from what is recorded of these updates and discussions, the clinical teams provided explanations of the care provided and the investigations undertaken.
54. We can also see that the team spoke to the family about Mrs B’s significant frailty and guarded prognosis. As the situation developed, the teams explained it was likely she would deteriorate further and that this was an irreversible situation, in which she was approaching the end of her life. We consider this terminology was appropriate to the situation, and we observe that it is documented on several occasions that the family understood the conversations and the severity of the situation.
55. Overall, we have not identified any indications of service failure when considering the standard of communication with the family, and we will not be investigating this part of the complaint further.
56. We do not intend this decision to diminish Ms A’s feelings, nor the experience she had. We recognise these conversations were likely emotional and challenging, and that she has a different view of events that outlined in above our statement.