16. We follow an open and fair process of reaching an independent and impartial decision in the work that we do. We are unbiased in reaching that view and to do so, when we look at a complaint, we first use relevant standards and guidance (where available) to inform us what should happen.
17. We then look at all accounts of events to establish what did happen. We do this by taking the complainants’ account and the organisation’s account into equal consideration.
18. Following this, we look at whether the care and treatment fell far enough below what we would expect to be considered a failing. To determine whether an error amounts to maladministration/service failure we need to make a judgement about how serious it was.
19. As not every error will be maladministration or service failure, it is very important that we make clear when something has fallen below the standard and when something has fallen so far below the standard to be maladministration or service failure. To differentiate between the two, we refer to errors which fall below the standard as ‘mistakes’, ‘shortcomings’, or referring to ‘what went wrong’. For those which fall so far below the standard, we can use the terms maladministration and service failure, along with ‘failings’ and ‘fault’.
20. When we identify a failing, we next go onto consider the claimed injustice experienced and if we can clearly link this to the failing and the impact stated. Where we identify an injustice and impact that we can link, we next consider what the organisation has done to put matters right. We often refer to this as the ‘remedy’.
21. We use our Principles for Remedy to determine our approach to securing remedy.
22. We do have regard to the outcome the complainant/aggrieved is seeking when determining the remedy. However, it is for the Ombudsman to decide on a remedy that is appropriate and proportionate to the injustice sustained and if we think more could be done by the organisation, we may make a range of recommendations.
Moving Mrs O onto a bed closer to the nurses’ station
23. Ms O complains that the Trust did not move her mother (Mrs O) onto a bed closer to the nurses' station in the ward. She complains that if the Trust had done this, it would have prevented her, and other family members from the shock of finding Mrs O unresponsive, as staff on the ward would have seen what was happening and realised this first.
24. We were extremely sorry to learn that Ms O’s family were the ones to find her unresponsive on the ward when visiting and acknowledge how distressing and traumatic this experience would have been for them.
25. The Trust explained that from Mrs O was admitted onto the ward at around 1.30am, and that it would have been unreasonable to wake and move other patients at this point in the early morning. However, it accepted it could have made a consideration to move Mrs O to a bed closer to the nursing station during the day on 25 August 2023 and apologised that this was not done.
26. We also understand from the Trust that each bay of seven patients on the ward has at least one dedicated nurse and support worker, meaning the ratio of staff to patients in each bay would be two to seven at the minimum. Although staff members may leave the bay for short periods of time, the Trust explained patients would not be in an unattended bay for any significant period of time.
27. We sought input from our physician adviser to help inform our decision on this part of the complaint.
28. We understand there is no clear guidance on prioritising patient’s proximity to nursing stations on a ward, and that this is a matter of clinical judgement. The decision can be based on a number of factors relating to the patient’s symptoms as well as the condition and consideration of other patients on the ward or bay.
29. We have also reviewed the records from Mrs O’s admission to the ward. From the records we can see the Trust left a meal with Mrs O between 5pm and 5.30pm. We can also see that Mrs O deteriorated quickly as at 5.55pm she was found unresponsive. The Trust explained this represented a sudden and unanticipated deterioration in her condition, which we also understand from our advice is the case.
30. In our work we must be able to say the claimed injustice is likely to have happened as a result of any indications of failing (our own policy on case working section 3.7) and (same policy 3.10) there are times where, even if we conducted a further detailed investigation, this would not be practical or provide us the opportunity for a response through investigation.
31. Having considered the available evidence alongside our advice, we consider we cannot say it is likely Mrs O’s family would not have found her in an unresponsive state if the Trust had moved her onto a different bed. This is because there is a lack of certainty around two key aspects of the consideration which limits our ability to make a decision on the balance of probabilities.
32. Firstly, although the Trust has accepted it could have considered moving Mrs O to a closer bed, we are still faced with a ‘what if’ hypothetical situation. We recognise the Trust did not wish to disturb other patients on the ward during night-time ward admission and accept it could have done this the day after. We also recognise a decision to move would be based on clinical judgement in the situation and would vary considerably on various health factors and other patients in the bay.
33. The second consideration which limits our ability to make a balance of probabilities decision on this issue relates to ascertaining whether if a move occurred would this have prevented family from finding Mrs O unresponsive. We consider we cannot say it is likely that the outcome would have been prevented if Mrs O has been moved.
34. As we have outlined, we understand Mrs O’s deterioration was sudden and unanticipated. We are unable to determine from the records, or accounts of the events, at what exact time this sudden deterioration in health occurred. We can be certain that it was somewhere within a 25-minute window between approximately 5.30pm and 5.55pm.
35. We appreciate this leaves Ms O and her family with a degree of uncertainty around the final hours of Mrs O’s care. However, we do not consider we can attribute this uncertainty to the Trust, rather it is the result of the circumstances of the case.
36. We consider we have no evidence with which to say with any robustness that moving Mrs O closer to the nursing station would have prevented her family finding MRs O unresponsive.
37. As the Trust have explained, staff may have been required to leave the bay for certain periods of time according to ward needs or may not have noticed the deterioration for other reasons such as dealing with other patients. We acknowledge that moving Mrs O may have reduced the chance of Mrs O’s family finding her, but we cannot say it is likely that this would have prevented this happening.
38. We consider the lack of certainty on these factors limits our ability to link the injustice claimed. We also do not consider there would be any additional evidence we could obtain which would allow us to reach a greater degree of certainty at a full detailed investigation.
39. In a situation where there is a lack of certainty or evidence, our usual approach would be to make a balance of probabilities decision. This allows us to say whether it is more likely than not that something would occur and to identify evidence which we place weight upon.
40. We have attempted to ascertain whether it is more likely than not that the family would not have found Mrs O if she had been moved. We have also considered whether staff would have been able to notice the deterioration sooner before the family attended if the Trust had moved her. We are unable to make that link.
41. It is also important to note that we are unable to guarantee that the Trust would have moved Mrs O if it had carried out the consideration to move her onto a closer bed.
42. Given both of these limitations, we consider we are unable to say it is more likely than not that if the Trust had considered moving Mrs O, this would have prevented her family finding her unresponsive. We recognise the upset this caused and do not wish to detract from that. Based on the reasons we have given, we are therefore not intending to look into this part of the complaint further.
Failure to carry out observations and document pain score
43. Ms O has also raised concerns that the Trust failed to carry out a set of Mrs O’s observations and did not record her pain scores during the admission. She is concerned that this meant Mrs O may have experienced unnecessary pain and a loss of dignity prior to her death.
44. In the response of 7 May 2024 and additional comments provided, the Trust accepted it should have recorded another set of observations at 3.08pm and that it had not recorded information about Mrs O’s pain score. It apologised for both of these issues and outlined service improvements it had made to improve education and training in this area.
45. We understand observations and pain scores should have been carried out according to the Nursing and Midwifery Council’s standards of proficiency for registered nurses. This guidance explains clinicians should observe and assess a number of factors such as comfort and pain levels, and nutrition and hydration status to determine the need for support and intervention.
46. As with the previous component, although we can see the Trust has acknowledged a failing here, we have focused our consideration on the potential impact of these concerns as the Trust has accepted that it should have acted differently. The potential impact Ms O has described relates to Mrs O possibly experiencing unnecessary pain and a loss of dignity, particularly in the hours before her death.
47. We have reviewed the relevant records from Mrs O’s admission and also sought input from our physician adviser to help inform our decision on this part of the complaint.
48. From the records, we can see the last documented observations carried out by the Trust were at 2.08pm. As the Trust accepted, a further set should have been carried out an hour later at 3.08pm but were not. We can see Mrs O was attended to and reviewed at several points in the hours between 2.08pm and her death.
49. This includes being assisted with hygiene needs at 4.01pm and 3.30pm. We consider this clearly demonstrates attempts by the Trust to support and maintain Mrs O’s dignity whilst on the ward.
50. We have also seen no indication that the Trust recorded Mrs O’s pain scores during her admission. The Trust accepted it should have done this, and from our advice we understand this should have been done.
51. Although the Trust did not document formal pain scores during Mrs O’s admission, we can see clear evidence from the records that her pain levels were kept under regular review. The notes from several reviews of her care including at 6.16am and more relevantly 16.32pm on 25 August document information about whether she was experiencing pain.
52. The notes indicate that the Trust took steps to attempt to reduce Mrs O’s pain following these reviews. This includes through interventions such as offering buscopan (a medication used to treat abdominal pain) and additional laxatives as well as further investigations to determine the cause for longer-term management. From our advice, we understand the management plan the Trust implemented to manage Mrs O’s symptoms was appropriate and in line with the RCEM guidance on Bowel Obstruction. Our adviser did not raise any concerns about the Trust failing to manage Mrs O’s pain appropriately.
53. The impact Ms O has described around this part of the complaint relates to her mother potentially experiencing unnecessary pain in the hours before her death. We acknowledge that the absence of formal recorded pain scores makes it impossible to determine the degree of pain Mrs O was experiencing with absolute certainty.
54. Although the pain scores have not been recorded, the Trust has documented clear information about Mrs O’s pain levels. Where it has documented concerns about increasing pain levels, particularly in the hours before her death, we can see it took action to manage this. Having sought advice, we consider these steps were appropriate.
55. Although Mrs O was experiencing pain, we consider the Trust were taking appropriate steps to manage it, and recording her pain scores would not have changed the management plan.
56. Based on the above, we do not consider we can link the Trust not recording Mrs O’s pain scores, or a set of observations to Mrs O experiencing a loss of dignity, or unnecessary pain. We are therefore not intending to carry out further consideration of this part of the complaint.