16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. If we see any indication things did not happen as they should have done, we consider the impact this had and what the organisation has already done to put things right.
First hospital admission: Mrs J’s clinical care and treatment
17. Mr J complains the Trust did not investigate, diagnose, or treat his wife appropriately.
What happened:
18. The Trust admitted Mrs J with worsening shortness of breath, significant swelling, reduced mobility, reduced kidney function, double incontinence, a rash and likely infection. Following admission, doctors diagnosed hypothyroidism which is where the thyroid gland does not produce enough hormones. Common causes include autoimmune diseases. They also diagnosed several other issues including low calcium, low albumin (a vital protein), low vitamin D and protein/blood in the urine.
19. Doctors initially thought Mrs J had a chest infection or a urinary tract infection which had led to sepsis. Sepsis is a life-threatening condition where the body’s response to infection causes it to attack its own tissue and organs. Doctors thought sepsis had then caused Mrs J’s reduced kidney function and other issues.
20. However, doctors also considered whether Mrs J was having an inflammatory response unrelated to an infection. Blood tests showed her white cell count was raised, as was her C-reactive protein and other proteins that can indicate an autoimmune disease. An antinuclear antibody test was also positive. This detects antibodies that mistakenly attack the body.
21. Autoimmune diseases are conditions where the body’s immune system mistakenly attacks its own tissues. Symptoms vary but often include fatigue, inflammation, and pain. Treatment focuses on managing symptoms and can involve immunosuppressants. These are medications that supress the body’s immune system, so it stops attacking itself.
22. Doctors treated Mrs J’s suspected infection with an antibiotic and gave her medication for her underactive thyroid, fluid retention and high blood pressure. They also gave her replacement calcium and vitamin D.
23. They arranged several scans and tests, including MRI and CT scans (scans that takes detailed pictures of the inside of the body), electromyography (a test that measures the electrical activity of muscles), kidney biopsies, muscle biopsies, skin biopsies (a biopsy is where a small tissue sample is looked at under a microscope) and various urine and blood tests.
24. Doctors also got input from several specialisms, including nephrology (the branch of medicine focused on the kidneys), rheumatology (inflammatory conditions), dermatology (skin), endocrinology (hormone production), haematology (blood), microbiology (microorganisms) and cardiology (heart and blood vessels).
25. Rheumatology reviewed Mrs J on 14 July and believed she had anti-synthetase syndrome. This is a rare chronic autoimmune disease associated with muscle inflammation, lung disease and specific immune cells that damage the body. It primarily affects women. They recommended some tests and advised doctors to start Mrs J on corticosteroids. This is a medication used to treat conditions that cause swelling, like autoimmune diseases.
26. On 15 July, an MRI was consistent with myositis. This is an inflammatory muscle disease associated with muscle weakness and inflammation. Various conditions can cause myositis, including autoimmune diseases like anti-synthetase syndrome. Doctors stopped Mrs J’s antibiotic but restarted it on 20 July as tests suggested she also had a chest infection.
27. Dermatology reviewed Mrs J on 15 July. They believed her rash was red and inflamed areas of skin that can be caused by various underlying conditions. They also thought she had a superficial bacterial infection of the skin or dermatomyositis.
28. Dermatomyositis is a rare form of myositis causing inflammation in both the skin and muscles. The cause is unknown, but the body’s immune system begins to attack the muscles and skin. It is known to affect women more than men and is more common in adults over 50 (Mrs J was in her 60s).
29. In dermatomyositis, a skin rash usually appears before the muscle weakness starts and people sometimes feel tired and run down. It usually affects the muscles involved in movement such as the neck, arms, or hips. The muscles become weak, stiff, sore, and tender due to inflammation.
30. Rheumatology reviewed Mrs J again on 22 July and 26 July. They noted her muscle power had improved, her legs were much less swollen, she no longer had a rash, and her blood test results were improving. They advised doctors to continue corticosteroids and recommended physiotherapy.
31. Doctors were later concerned Mrs J was not improving and may need an immunosuppressant. Rheumatology reviewed Mrs J on 2 August and advised against this whilst she was still in hospital, especially as she had an infection. They said although her mobility had not improved, blood tests showed her condition was getting better. They explained physical recovery can be slow and unpredictable with this condition.
32. Mrs J’s muscle biopsy results on 10 August also pointed to myositis. Rheumatology reviewed her again later the same day and asked doctors to continue corticosteroids. Mrs J then continued this treatment alongside physiotherapy to regain her muscle strength.
What should have happened:
33. Mrs J presented with various symptoms and multi-organ involvement. The Trust started treatment by prescribing antibiotics, intravenous (directly into the vein) fluids and medications to reduce swelling and help restore her various imbalances. It also started investigations into what was causing Mrs J’s symptoms consulting with different specialities.
34. Our rheumatology adviser explained the Trust appropriately managed Mrs J’s initial symptoms and carried out all the relevant tests and investigations they would expect to see in a case like this.
35. The main diagnosis was anti-synthetase syndrome leading to dermatomyositis. Mrs J’s presentation and test results, as well as the input from other specialists, supports this diagnosis. The Trust did further investigations to confirm the diagnosis including testing an antibody and proteins that can indicate autoimmune diseases.
36. The BSR guideline recommends corticosteroids to treat dermatomyositis. The Trust started these within three days of admission. Mrs J’s condition then improved on this medication as her muscle enzymes decreased. These enzymes help chemical reactions in muscle tissue, and levels often increase with some active autoimmune problems.
37. The BSR guideline says doctors should consider immunosuppressants. Mrs J’s doctors did this, but rheumatology advised against it while she was in hospital and being treated for an infection. This is because patients can often pick up infections in hospital and immunosuppressants make it harder to fight off infection. Our rheumatology adviser agreed they were not needed while Mrs J was still unwell in hospital.
38. GMC professional standards say doctors must adequately assess a patient’s conditions. They must provide or arrange suitable advice, investigations or treatment where necessary, and do so promptly. They must also refer patients to another practitioner when this serves their needs.
39. Overall, Mrs J had a complicated presentation with various symptoms and interrelated conditions. The Trust’s main diagnosis was a rare autoimmune condition with related dermatomyositis. From what we have seen, the Trust appropriately investigated, diagnosed, and treated Mrs J in line with the GMC professional standards and the BSR guideline.
40. We hope our consideration answers Mr J’s concerns and can bring some closure to the understandable distress he has experienced.
First admission: Mrs J’s heart issues
41. Mr J complains the Trust missed signs his wife had heart issues. He is particularly concerned about this as the post-mortem found she had several heart problems.
42. When the Trust saw Mrs J as a day case in June, doctors noted her new heart murmur and considered a possible heart issue. Mrs J had an electrocardiogram (ECG) on 27 June. This is a test that records heart activity over a period of time. This found a murmur and a second ECG on 30 June found she had a fast heartbeat.
43. A cardiologist then did an echocardiogram on 8 July which found no issues. This is an ultrasound scan used to look at the heart in more detail. The cardiologist thought the earlier murmur may have been caused by slightly elevated blood flow. They thought this was due to the left ventricle (one of the four chambers of the heart) bulging into the aorta (the artery that starts in the left ventricle), which can happen as people age.
44. The Trust also did B-type natriuretic peptide (BNP) blood tests on 22 June and 15 September. This is a test that measures the levels of a hormone called BNP. This is released when the heart is under stress and particularly when it is struggling to pump blood effectively.
45. Both our clinical advisers said Mrs J’s BNP was only slightly raised and the results did not indicate a heart issue. Our physician adviser felt the changes seen on the earlier ECGs were more likely due to Mrs J’s autoimmune condition than a heart problem. Both our clinical advisers confirmed the results of the Trust’s investigations did not point to a heart problem.
46. Our rheumatology adviser explained dermatomyositis can sometimes affect the heart muscle. The BSR guideline says patients should be screened for heart involvement and doctors should consider blood tests, ECGs, echocardiograms and MRIs. In terms of the type of blood test, it recommends a troponin test. Troponin is a protein which is released when the heart muscle is damaged.
47. We can see the Trust carried out ECGs, an echocardiogram and BNP blood tests. Both our clinical advisers felt a troponin test would have been helpful. However, Mrs J’s clinical investigations did not point to a heart issue. Therefore, we do not believe the lack of a troponin test falls below the BSR guideline which says doctors should consider it.
48. Overall, it appears the Trust considered a possible heart issue and carried out appropriate tests to investigate this. Both our clinical advisers said these investigations showed no obvious signs of heart involvement or heart failure. From what we have seen, the Trust acted in line with GMC professional standards and the BSR guideline.
49. We hope this provides Mr J with some reassurance around this part of his wife’s care.
First hospital admission: Mrs J’s physiotherapy
50. Mr J complains the Trust did not provide appropriate physiotherapy input during his wife’s first admission and this affected her recovery. We can see from Mrs J’s clinical records he raised these concerns at the time.
51. Our rheumatology adviser explained how some patients with dermatomyositis need extensive rehabilitation. They said Mrs J’s illness and time in hospital had led to a significant reduction in physical activity which meant she lost muscle strength and fitness. This is known as becoming physically deconditioned.
52. Mrs J’s notes show rheumatology recommended physiotherapy on 22 July. Our rheumatology adviser said it would not have been appropriate to start physiotherapy or occupational therapy before this as Mrs J was too unwell with significant swelling and inflammation. Occupational therapy helps people overcome challenges completing everyday tasks and activities.
53. We can see Mrs J had 19 therapy sessions during this admission. She also declined therapy on 9 occasions and was unable to participate on four occasions due to a muscle biopsy. From what we have seen, the Trust offered Mrs J regular therapy once she was well enough to do this though she did not always engage.
54. We consider the Trust referred Mrs J to therapy to help her recover once she was well enough. This is in line with the GMC professional standards set out in paragraph 38. From what we have seen, therapists visited her regularly and respected her wishes when she did not want to engage.
First hospital admission: Mrs J’s nursing care
Mrs J left in chair:
55. Mr J complains physiotherapy staff told his wife she needed to sit in her chair everyday starting with 15 minutes. He says they left her in her chair for four hours on the first day and she was in agony. He also told us his wife did not want to sit in her chair after this, but staff insisted on hoisting her into her chair causing her pain.
56. We have checked Mrs J’s records to see what happened. A physiotherapist first saw Mrs J on 24 July, but she declined to engage. She then had occupational therapy sessions on 26 and 27 July. The notes for 26 July say she did not get out of bed and the notes for 27 July suggest she was assessed in bed.
57. Mrs J then had an occupational therapy session at 2.38pm on 30 July lasting around an hour. The notes say staff hoisted her into her chair to sit out for one hour to start with. They left her comfortable and nursing staff were to hoist her back into bed after one hour. The nursing notes indicate they transferred Mrs J back into bed at around 4.43pm.
58. Mrs J then had a physiotherapy therapy session on 31 July. The notes say she had found her chair comfortable the day before, but they left her in bed as she said Mr J was due to visit. She said nursing staff would hoist her into her chair once Mr J had left but we cannot see anything in the notes to suggest this happened.
59. At the next physiotherapy session on 4 August, Mrs J told staff she had not sat out in her chair since 31 July due to investigations and tests she had been having. They did not transfer her into her chair as she told them she had been told to rest for three days following a biopsy.
60. On 9 September a physiotherapist noted nursing staff had been attempting to hoist Mrs J out into her chair, but she had been refusing. Mrs J told them she had got out of bed on 7 September though they said this did not match the records. They noted, as far as they were aware, Mrs J had not yet sat out in her chair for more than three hours.
61. Overall, we have not seen anything in Mrs J’s records to show therapy staff left her in her chair for a prolonged period when they first saw her. We have also not seen any clear evidence this happened on another day or that Mr and Mrs J raised concerns about this at the time. We do not think we can add anything further here.
Mrs J pushed into chair:
62. Mr J says his wife was unable to bend her legs and she told a nurse she was unable to sit in a chair. He complains the nurse pushed his wife down by her shoulders which caused her pain. He told us his wife had an X-ray, and a doctor examined her to see if this had caused her any damage.
63. We cannot find any reference to this incident within Mrs J’s records. From what we can see, the only scan she had on her legs was an MRI before she started sitting out in her chair. The reason this was requested is also recorded as being for pain, weakness and swelling of the lower limbs possibly due to myositis.
64. We can see references to Mrs J reporting pain in her knees and having limited movement due to pain and stiffness of her joints. This was first recorded on 10 August by a physiotherapist. We have seen nothing to suggest this was due to a nurse pushing Mrs J into her chair. We do not think we can add anything further here.
Mrs J’s perfume:
65. Mr J complains nursing staff used Mrs J’s perfume. The Trust said this should not have happened and sincerely apologised if this occurred and for the upset caused. The Trust explained it had discussed this issue with all staff on the ward to stop it happening again.
66. We have looked at the impact this had and whether the Trust has done enough to put things right. Our Principles say organisations should acknowledge when things go wrong and take steps to put things right. This can include an apology and making service improvements to stop the same issue happening again.
67. This was clearly a concerning incident for Mr and Mrs J and something that caused them some upset at the time. We have considered whether the Trust responded to this part of Mr J’s complaint in line with our Principles.
68. We can see the Trust has already acknowledged this should not have happened, apologised and taken steps to stop it from happening again. We are satisfied the Trust has done enough to resolve this issue.
Nursing staff restricting Mrs J’s access to personal items:
69. Mr J complains nursing staff would put his wife’s personal items out of reach and tell her they were too busy to help if she asked for them. We recognise the frustration this must have caused Mr and Mrs J at an already difficult time.
70. The Trust said nursing staff should have placed Mrs J’s belongings on the windowsill during care or therapy but returned them afterwards. It apologised this did not happen and said it had discussed this with staff.
71. Again, we have considered whether the Trust has responded to this part of Mr J’s complaint in line with our Principles. We can see it has already acknowledged this should not have happened, apologised and taken steps to stop it from happening again. We are satisfied the Trust has done enough here.
First hospital admission: Mrs J’s discharge on 17 September
72. Mr J complains the Trust rushed his wife’s discharge because it needed her bed. He feels she was not ready to leave hospital.
73. The Trust decided Mrs J was ready for discharge on 1 September and started planning this on 8 September. It then discharged her to the Centre on 17 September. Intermediate care centres provide health-related care and support for people who do not need hospital-level care but need more assistance than what is available at home.
74. The DH guidance sets out how premature discharge can leave patients with unmet needs, using inappropriate or costly social care services, being poorly prepared at home and being likely to be readmitted to hospital. It also sets out how lengthy hospital stays can increase the risk of infection, depression or low mood and loss of independence or confidence. There is clearly a balance to strike in discharging patients at the right time.
75. The Trust had diagnosed Mrs J with dermatomyositis. It was actively treating this, and her condition had settled. The Trust had also addressed Mrs J’s other issues such as her reduced kidney function and low calcium. She was stable, no longer acutely unwell, and did not need to be in hospital any longer.
76. Mrs J had been in hospital for over two months by the time the Trust discharged her. It had diagnosed her with an illness that affects the muscles, and she had been mainly immobile for some time. This meant she had become severely deconditioned and needed to regain her fitness through physiotherapy. This does not need to be done in a hospital setting.
77. Looking at Mrs J’s records, there are several times she told staff she was keen to leave hospital and earlier in her admission they had to persuade her to stay. She also told staff she had a fear of hospitals and being in hospital was affecting her mental health. We can see the mental health team reviewed her on 23 August as she was low in mood.
78. Our rheumatology adviser explained Mrs J appeared to be suitable for discharge on 17 September. From what we have seen, she was stable and no longer acutely unwell. The Trust’s decision to discharge her on 17 September therefore looks to be in line with the GMC professional standards and the DH guidance.
First hospital admission: Mrs J’s discharge to the Centre
79. Mr J complains about the Trust’s decision to discharge his wife to the Centre. He says it was more like an ‘old people’s home’ than a rehabilitation centre. Looking at Mrs J’s clinical records, we can see he raised these concerns at the time.
80. Mr J says the Trust discussed the possibility of transferring his wife to a specialist facility in Sheffield. He told us he was initially against this as he did not understand the seriousness of her condition or that different hospitals specialise in different conditions. He says he agreed once doctors explained this to him at a meeting.
81. In its complaint response, the Trust said it could find no evidence of this meeting or anything to suggest it wanted to transfer Mrs J to a specialist centre in Sheffield. It said it looked to transfer her to a specialist neurological rehabilitation centre in Dewsbury, but they declined the referral due to Mrs J’s poor mobility.
82. Looking at Mrs J’s notes, we can see the first reference to her needing neurological rehabilitation was on 22 August. On 23 August, there is a note saying Mrs J did not want to go to a neurological rehabilitation placement in Sheffield or Barnsley, but she then agreed to it later the same day.
83. There is a note of a meeting between Mr and Mrs J and her doctors on 23 August where they listed the outcome as ‘agreed to go to neuro rehab’. We think this is the meeting Mr J refers to. The next day there is a note saying the Trust had referred Mrs J for neurological rehabilitation.
84. On 26 August, Mrs J’s notes say a neurological rehabilitation unit in Dewsbury declined the referral. They suggested the Trust refer Mrs J to Barnsley or a non-specialist unit instead. On 31 August, Mrs J’s notes say Dewsbury had said she was not suitable, and she was ‘not for Barnsley’ so the Trust would need to discharge her to an intermediate care centre.
85. On 9 September, the notes say an intermediate care centre had declined the Trust’s referral due to Mrs J’s poor mobility and the discharge team were trying to find an alternative placement. Mrs J was then accepted by the Centre on 14 September and on 16 September it said it could take her the following day.
86. Our rheumatology adviser explained dermatomyositis causes significant muscle weakness, and it can take a long time to recover. They said patients sometimes need rehabilitation and discharging Mrs J to an intermediate care centre was appropriate. She had become deconditioned due to being unwell for over three months and mostly immobile.
87. The DH guidance sets out 10 principles for effective discharge including starting discharge planning early, a person-centred approach, effective coordination with others, good communication with others, collaborative working and patient involvement.
88. From what we have seen, the Trust considered Mrs J’s needs and co-ordinated her care with others. It ensured she was fit for discharge, identified she needed ongoing care, spoke with her and her family about this and identified a suitable placement. The decision to discharge Mrs J to the Centre appears to be in line with the DH guidance.
89. However, the records show there was discussion of a speciality facility in Sheffield and a meeting with Mr and Mrs J about this. The Trust’s complaint response does not accurately reflect this and is therefore not in line with our Principes. We recognise this has caused Mr J confusion and unnecessary distress.
90. While the Trust’s complaint handling should have been better, we do not think it is so poor it would amount to a failing. We will therefore not be taking any further action. We recognise Mr J may be disappointed with this decision. We hope we have clearly explained our thinking here.
Second hospital admission: Mrs J’s clinical care and treatment
91. Mr J complains the Trust did not investigate, diagnose, or treat his wife’s symptoms appropriately. He also complains the Trust did not transfer his wife to a specialist centre during this admission.
What happened:
92. The Trust readmitted Mrs J from the Centre with an inflamed, weeping, and painful rash. She had pain all over her body, swelling in her lower legs, poor oral intake, incontinence and lethargy. Mrs J’s GP had prescribed oral antibiotics, but her rash was getting worse.
93. Doctors thought Mrs J had low sodium caused by dehydration and the medications she was on. They also started treatment for a bacterial skin infection and a flare up of dermatomyositis but carried out tests to rule out any other sources of infection. These included blood tests, blood cultures and a chest X-ray.
94. Blood tests showed Mrs J’s white cell count and C-reactive protein were high indicating a possible infection, and the Xray showed a possible chest infection. Doctors prescribed a broad-spectrum antibiotic designed to treat a wide range of bacteria. They also prescribed an antibiotic used to treat bacterial infections including respiratory infections.
95. Doctors later switched the broad-spectrum antibiotic to one used to treat skin infections following advice from microbiology. They then switched antibiotics again on 1 November as Mrs J’s C-reactive protein was not improving and blood cultures had identified a type of bacteria that can cause infections in those with weakened immune systems.
96. Dermatology reviewed Mrs J on 27 October. They advised doctors to continue with the current treatment and to get skin swabs and a skin biopsy. They planned to have a meeting with the ward nurses and tissue viability nurses (TVNs) to review Mrs J. TVNs specialise in the assessment and management of wounds.
97. A TVN tried to review Mrs J on 27 October as she was refusing care and interventions. Mrs J would not let them examine her and said she would let them review her on 31 October. However, from what the nurse could see Mrs J also had pressure sores. Mrs J was also reluctant to eat and drink so doctors started intravenous fluids.
98. On 28 October, Mrs J refused to allow dermatology to review her. Like with the TVN, she said she would let them examine her on 31 October. She also refused to allow rheumatology to review her. On 30 October, Mrs J again refused to allow a TVN to assess her. She also continued to refuse interventions by nursing staff.
99. On 31 October, following advice from rheumatology, doctors planned to start Mrs J on an immunosuppressant once she had finished her course of antibiotics. Dermatology reviewed Mrs J on 31 October. They felt she had dermatomyositis, a secondary skin infection and moisture-associated skin damage. They noted her rash was significantly better.
100. Mrs J had a skin biopsy on 31 October and a meeting took place between ward nurses, TVNs and dermatology. Mrs J allowed them to complete a full body assessment. She also agreed to let nurses reposition her every four hours and clean her skin and wounds going forward.
101. On 3 November Mrs J would again not allow a TVN to examine her. She said she felt fine, her back was improving, and she would agree to an exam on 7 November. She also refused to allow doctors to examine her back on 4 November and refused all care interventions by nurses on the morning of 5 November.
102. On 7 November, Mrs J had abdominal pain and vomiting in the morning and doctors prescribed medication that treats nausea and vomiting. A TVN saw her in the afternoon, and she consented to an exam. They noted she had scattered superficial wounds but much of the surrounding skin had improved, and her rash had settled. They also noted she was more accepting of care.
103. Sadly, nursing staff found Mrs J in cardiac arrest at around 10.05pm. This is where your heart suddenly stops pumping blood around your body. Staff tried to resuscitate her but were unsuccessful and very sadly pronounced her dead at 10:52pm.
What should have happened:
104. We can see Mrs J was readmitted with several problems. This included worsening skin inflammation (caused by dermatomyositis), an infection, pressure sores and moisture associated skin damage.
105. The Trust started her on antibiotics for the infection and increased corticosteroids for dermatomyositis. It also provided supportive care with pain relief and skin care. It carried out investigations and consulted with relevant specialists. Doctors also considered starting Mrs J on an immunosuppressant but decided to wait due to her infection.
106. In between Mrs J’s two hospital admissions, doctors considered starting her on antibodies used to treat autoimmune diseases after she developed a painful rash. They decided to check the levels of an enzyme found in the muscles first as elevated levels can indicate muscle damage. They increased corticosteroids in the meantime.
107. Our rheumatology adviser explained the Trust could have considered starting Mrs J on these antibodies during her second admission as by that time she had significant skin involvement. They said the Trust could have also considered a referral to a regional myositis specialist team.
108. However, our rheumatology adviser felt Mrs J’s problems were more likely to do with her infection, skin fragility and swelling due to her severe and prolonged multi-system ill health. They said Mrs J was very frail by the time she was re-admitted to hospital.
109. We can see Mrs J’s health problems were complex. The Trust appears to have investigated the causes and treated her presenting problems appropriately. We therefore consider the Trust’s actions were in line with the BSR guideline and the GMC professional standards.
110. We know Mr J has specific concerns around whether the Trust should have transferred Mrs J to a specialist centre for treatment. Our rheumatology adviser confirmed dermatomyositis is a condition a general rheumatologist should be able to manage without input from a specialist centre.
Second admission: Mrs J’s heart issues
111. Mr J has told us he is particularly concerned the Trust missed signs his wife had heart issues during her second admission.
112. Mrs J had an ECG on 26 and 27 October. The first ECG showed she had a fast heartbeat with frequent premature beats originating above the ventricles. This can be a sign of an underlying irregular heart rate. The second ECG showed a normal heartbeat with ectopics. These are early or extra heartbeats.
113. The first ECG also showed evidence of a septal myocardial infarction. This is a type of heart attack often associated with a buildup of plaque in the arteries that restricts blood flow. The notes say this had probably happened some time ago.
114. Both our clinical advisers said Mrs J’s history and the Trust’s findings did not point to a heart issue being the cause of her illness. We also know tests carried out during the first admission showed Mrs J’s heart was generally normal.
115. From what we have seen, the Trust considered a possible heart issue and carried out appropriate tests to investigate this. Both our clinical advisers said these investigations showed no obvious signs of heart involvement or heart failure. We therefore consider the Trust’s actions were in line with the BSR guideline and GMC professional standards.
116. We understand the worry Mr J has experienced and that he is concerned because Mrs J’s death certificate lists problems with her heart. We hope our explanation provides him with some reassurance.
Second hospital admission: Mrs J’s capacity
117. Mr J complains his wife did not have mental capacity during this admission, particularly in the days leading up to her death. He has told us about times she behaved oddly and seemed to see things that were not there.
118. We can see staff did consider whether Mrs J had capacity, though no formal capacity assessment took place. This was due to her refusal to let ward nurses, the medical team, doctors from dermatology or TVNs examine her. She also initially refused to allow nursing staff to provide any care.
119. A nurse in the emergency department noted Mrs J had capacity on 26 October. A doctor from dermatology did the same on 27 and 31 October, as did a TVN on 27 October. Mrs J usually allowed staff to examine her and nursing staff to care for her from 31 October onwards, so this became less of an issue.
120. The doctor made notes on Mrs J’s capacity on 27 October as she was refusing to be examined. Mrs J told them she understood they needed to examine her to get a full picture of her condition so they could see what treatment she needed. However, she wanted to give her skin time to heal first. The doctor noted she did not appear to be low in mood and there was no evidence to suggest she had any mental health issues.
121. A TVN similarly made notes on Mrs J’s capacity on 3 November as she refused to allow them to examine her. They noted she might benefit from a mental health review and capacity assessment once her infection markers had come down and she was more stable (infection can cause confusion). They felt this was needed to ensure she fully understood the impact of refusing care and treatment.
122. The GMC professional standards say all patients have the right to be involved in decisions about their care and treatment and be supported to make informed decisions if they can. They also say doctors must start from the presumption that all adult patients have capacity to make decisions about their care and treatment.
123. We have not seen anything within Mrs J’s notes to suggest she lacked capacity. We can see staff considered whether she had capacity and spoke to her several times to ensure she understood the impact of her actions. We note Mrs J had previously refused admission to hospital in June/July and to participate in therapy against medical advice.
Overall
124. We have seen no indications anything went wrong with Mrs J’s care and treatment at the Trust. We recognise this is a complicated case and our statement is lengthy and detailed. We hope Mr J can see how carefully we have considered what happened. We also hope we have provided him with some reassurance, and this allows him to grieve his wife’s loss.