Bisoprolol
15. Mrs E believes bisoprolol had an adverse effect on her mental health and this contributed to her mobility problems. Her son raised concerns about bisoprolol following her admission to the Hospital in July 2023 on several occasions. A doctor eventually agreed to stop bisoprolol on 4 September. Her son wanted to know why they did not stop bisoprolol sooner.
16. The Medical Adviser told us doctors prescribed bisoprolol for Mrs E to reduce the fast heart rhythms that were detected. These were potentially life-threatening. The Medical Adviser said the dosage was in line with the BNF. This recommends that clinicians can prescribe beta blockers such as bisoprolol for people who have an abnormal heart rhythm.
17. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed. They must be satisfied that any medication they prescribe serves the patient’s needs.
18. The records show doctors at a different hospital first prescribed bisoprolol for Mrs E following the fitting of a pacemaker on 21 June 2023. The reason for her transfer to the Hospital was to provide ongoing medical input relating to her delirium. Bisoprolol continued when Mrs E arrived at the Hospital on 2 July.
19. On 6 July 2023 nurses were concerned that Mrs E had some small episodes of ventricular tachycardia (where the heart beats too quickly and not enough blood is being pumped around the body). A doctor prescribed an increased dose of bisoprolol. Following this Mrs E had a settled night and slept well. The regular prescription was then increased.
20. Mr E raised concerns with one of the doctors about bisoprolol on 24 July 2023. The doctor noted how they explained why Mrs E needed bisoprolol and why the dosage had increased. Mr E felt his mother had been ‘drugged.’ The doctor’s view was that the delirium was likely due to her surgery and could fluctuate. The doctor said it can sometimes take months for the delirium to resolve.
21. The records show that on 22 August 2023 a doctor reviewed Mrs E and noted she was stable, looked well and had no symptoms. They decided to stop some of her medication, including bisoprolol. The exact times when bisoprolol was administered are not clear from the clinical records. We can see evidence it restarted when Mrs E was readmitted on 2 September.
22. Mr E again referred to bisoprolol when he had a discussion with a doctor following the incident on 3 September 2023. The doctor said this would not usually cause someone to be sleepy. Mr E met with a consultant the next day to discuss his mother’s care. The consultant agreed to stop bisoprolol which he felt may have been the cause of some of her episodes of confusion. It seems bisoprolol was administered for the final time in the early hours of 4 September. Doctors asked Mrs E’s GP to review bisoprolol after her discharge from the Hospital.
23. In its complaint responses the Trust explained that doctors did not find a clear cause for Mrs E’s hallucinations and confusion. It accepted that these symptoms can be side effects of bisoprolol. The evidence indicates that doctors decided to stop the medication on 4 September 2023 following discussions with Mr E and his concerns about possible side effects.
24. The Medical Adviser said it was clear that Mrs E had signs of delirium before 3 July 2023 when doctors at the Hospital increased her dosage of bisoprolol. The Medical Adviser said there were several possible causes of Mrs E’s delirium. These include the fact she had undergone a major surgery, low levels of sodium in her blood and a urinary tract infection, which doctors evaluated and treated appropriately. Doctors were correct to explore the possible causes of her delirium.
25. The Medical Adviser explained that while the BNF says symptoms of delirium can be due to bisoprolol he had never known that to be the case. He said many people take bisoprolol to the end of their lives and it is not usual for it to have a sedative effect. It also needs to be noted that Mrs E was taking a very low dosage of the medication. There was no requirement to stop bisoprolol at an earlier stage.
26. The Medical Adviser said the care doctors provided was exemplary with no evidence of any failings in evaluation or care. Doctors also completed records to a high standard. But medications administration records were incomplete. The Medical Adviser said, unfortunately, complications often occur when older people have prolonged hospital stays after complex invasive procedures. The alternative would have been a rapid deterioration in Mrs E’s health.
27. We find that doctors prescribed bisoprolol appropriately for Mrs E in line with the BNF. They provided medication that served her needs as required in Good Medical Practice. We recognise Mrs E and her son dispute this. We hope they are reassured that we have seen no indication of any failings in this respect.
Mobility
28. Mrs E believes clinicians did not do enough to help maintain her mobility while she was in the Hospital. Mr E suggests documentation relating to his mother’s mobility was inadequate.
29. The Physiotherapy Adviser told us there was no single guideline in 2023 specifically covering mobility management for older adults in hospital. But physiotherapists should have provided care for Mrs E based on the Delirium Guideline and the CSP Standards.
30. The Delirium Guideline explains how healthcare professionals should diagnose and treat delirium for adults in hospital. It recommends encouraging all people to mobilise following surgery and also for patients at risk of developing delirium. It notes that intermittent confusion is a feature of delirium. Clinicians should promote mobility and self-care by encouraging people to walk, with or without help.
31. The CSP Standards highlight the physiotherapist’s responsibility to assess, promote and support mobility as a core element of care. This includes clinical judgment in patients with fluctuating presentation such as intermittent confusion or disorientation. The CSP Standards say all physiotherapists must assess and support mobility as a fundamental part of restoring function and dignity, particularly in older people.
32. The clinical records show physiotherapists regularly reviewed Mrs E’s mobility throughout her admission. We can see details of such reviews on eleven occasions in July 2023 and four occasions in August. Meaningful engagement was often limited for different reasons. For example, on 4 July Mrs E was too confused and on 7 July she was too drowsy. These findings were repeated at other assessments. Mrs E’s mobility was clearly limited by episodes of confusion, drowsiness and disorientation.
33. The Physiotherapy Adviser said, despite the challenges, physiotherapists maintained a constant approach. They reassessed Mrs E regularly and adapted care as appropriate. This was in line with the Delirium Guideline and the CSP Standards. Physiotherapy was restricted by Mrs E’s medical condition rather than by any failure of clinicians to meet standards of care. The evidence suggests physiotherapists provided patient-centred care.
34. We have seen nothing to suggest that records were incomplete relating to the assessments of Mrs E’s mobility. We find physiotherapists followed the relevant standards in providing care for Mrs E.
Complaint handling
35. Mr E said the Trust had not answered some of his specific questions and its replies contained errors. He is also concerned that the consultant mentioned in his mother’s complaint was allowed to respond without any independent input from someone not involved in his mother’s care.
36. Our Principles of Good Complaint Handling say public organisations should be ‘customer focused.’ They should listen to the complainant’s views and ensure they understand what the complaint is about and the outcome the complainant wants. They should also ensure they are ‘open and accountable,’ which includes investigating complaints thoroughly and fairly based on the available facts and evidence. It also includes asking a member of staff who was not involved in the events leading to the complaint to review the case.
37. Mr E met with his mother’s consultant before she left the Hospital. It seems there are different recollections about what was supposed to happen following the meeting. The consultant understood he had agreed to provide a written summary of Mrs E’s care. Mr E understood the consultant was to ask one of his colleagues to provide a summary.
38. Mr E made a formal complaint to the Trust on 27 September 2023. The Trust’s complaints team acknowledged this on 3 October and said it would ask the consultant to contact him and record a formal complaint. In internal correspondence the complaints team asked the consultant to answer each point individually. There is no evidence the complaints team made any attempt to contact Mr E to discuss his concerns or understand the outcomes he was seeking.
39. Mr E’s initial complaint began with a summary of seven central issues about different aspects of his mother’s care. Mr E then went into more detail about each of the issues with lists that were a combination of his comments and detailed questions.
40. On 8 March 2024 Mr E emailed the Trust to point out he had yet to receive a response. The Trust apologised for the delay and said it had been liaising with the consultant. It then issued its first complaint response on 4 April 2024.
41. The Trust’s first response largely consisted of the consultant’s recollections and a chronology of events. Another member of staff provided a response to the general concerns about mobility. The complaints team amalgamated these statements to produce the first response. This response briefly addressed the seven central issues of the complaint. The Trust did not respond to any of Mr E’s supplementary comments and questions.
42. It is clear that the consultant did not carry out the complaint investigation himself or respond directly to the complaint. But it is understandable that this is Mr E’s impression given that his statement formed such a central part of the first complaint response.
43. Mr E was dissatisfied with the first response and emailed the Trust to this effect on 23 April 2024. He rightly pointed out that the Trust had not answered many of his original questions. He specifically asked that the consultant should provide additional clarification of what he had said in the Trust’s first complaint reply.
44. The Trust sent its second reply to Mr E on 7 August 2024. This response included further input from the consultant. It answered some, but not all, of the specific questions Mr E had about the first response, again with input from the consultant. The Trust did not explain why it had chosen not to address all Mr E’s detailed questions and comments. This was despite Mr E specifically asking for these points to be considered and for an explanation about why they had not been answered.
45. The Trust has not answered many of the questions Mr E asked in his complaints. This includes almost all of the supplementary questions and comments he made in his first complaint and some of the questions he asked in his second complaint. It offered Mr E the opportunity of a meeting with a consultant to address his concerns. Mr E has explained how he lives too far away for a meeting to be practical. In these circumstances the Trust should have ensured it responded to his concerns or, if that was not possible, should have explained why.
46. Where the Trust has responded to the issues we can see that it has done so based on evidence in the clinical records. We can see no evidence to suggest there were significant errors in the complaint responses. The omissions were significant, and this has left Mrs E and her son without some of the explanations they were seeking.
47. Clearly, the consultant was best placed to answer many of Mr E’s questions. But his statement and further response did not cover all the issues. The complaints team failed to recognise this despite Mr E’s second complaint.
48. We find the Trust did not follow our Principles of Good Complaint Handling. It was not ‘open and accountable’ or ‘customer focused.’ It did not demonstrate that it listened to Mr E or that it understood the outcome he wanted. It did not investigate his complaints thoroughly and fairly. There is evidence of maladministration in the Trust’s complaints handling.
49. Mrs E and her son have been left with unanswered questions because of poor complaint handling. We can see how this has been a source of distress and frustration for them.