Fall on 28 January
20. Mrs B complains that when she visited her father on the afternoon of Saturday 28 January, she learned he had suffered a fall earlier in the day but no doctor had yet come to review him. She stayed with her father until around 8pm and a doctor had still not come, and a review did not take place until the Monday. She considers this delayed care contributed towards her father’s deterioration.
21. The Trust’s Falls Prevention and Management policy says it expects, ‘staff must attend immediately to patient falls’. It says, ‘patients who are haemodynamically stable (stable blood pressure and heart rate) with or without injury must be reviewed by their own medical team within 24 hours after the fall’.
22. The Trust has since further explained this approach to us. It said that all patients are under a ‘parental team’ led by a consultant. This team may not be available 24 hours a day, but there is a medical team available all the time and they look after patients out of hours. If a patient has a fall, the medical team should attend ‘as soon as possible’. The parental team will then follow-up later to make any necessary decisions about the management of the patient’s condition.
23. The Royal College of Physicians, National Audit of Inpatient Falls best practice guidance says the aim of an initial assessment of a patient following a fall is to exclude any serious injuries. It says patients without a suspected injury or deterioration in their health should have a ‘medical assessment within 12 hours of the fall’.
24. The guidance further explains falls can be a sign of a medical deterioration and so it is important to review a patient’s condition afterwards ‘to ensure no new medical problems are missed’.
25. A nursing note from 2.35pm on 28 January says Mr C had fallen and another patient’s relatives had witnessed this. They told the nurse Mr C was trying to walk to the toilet and he fell from his bed to the floor. They helped him get back into bed.
26. The nurse took Mr C’s observations and noted he was confused. There were ‘no signs of injury’, and he was awaiting a doctor’s review.
27. The Trust’s Falls Prevention and Management policy says a ‘post fall checklist/sticker must be completed within 2-4 hours of the fall’. This sticker has been added to Mr C’s records, but staff did not complete this on 28 January (there is only one note made on the sticker by a rehabilitation practitioner on 30 January).
28. Nursing notes from 5.50pm say Mr C had fallen from the bed at 2.25pm and had landed on his bottom and had ‘no injuries’. He ‘remains confused’ and was still waiting for a doctor to review him. The nurse documented they spoke with the family about what had happened.
29. There is a further entry at 8.20pm when Mrs B spoke to the nurse in charge. Mrs B raised several concerns about her father’s care, including that he was still waiting for a doctor’s review. The nurse confirmed the doctors were aware her father needed a review. The nurse told the family there was no regular medical team over the weekend and so it would be best for her to come in on Monday to speak to a doctor.
30. The following day, the records show the nursing team continued to care for Mr C. A note from 5.20am on 30 January says that when the nurse was assisting Mr C with his personal care, they saw a bruise on his back and on his buttocks. This was ‘probably the result of the fall’. Mr C remained confused and ‘would benefit from CT examination’.
31. A consultant reviewed Mr C at 11.51am on Monday 30 January. Mr C was sitting in a chair and reported feeling ‘well’ with no pain. The consultant noted he had new and increasing confusion. They requested blood tests, a confusion screen and a CT head scan to rule out a head injury as the cause of his confusion.
32. Our physician adviser has confirmed there was a delay in a doctor reviewing Mr C. This took place around 46 hours after he had fallen. This does not meet with the Trust’s own policy, or with the Royal College of Physician guidance of a 12-hour timescale.
33. In consideration of this advice and the guidance we have reviewed, we find failing in how long it took for the medical team to review Mr C.
34. Mrs B has told us she considers the delay in the medical team seeing her father delayed them making decisions about his treatment, and this contributed towards his declining condition. We recognise this was very upsetting for Mrs B and can see from the notes at the time that she was very worried for her father.
35. We have considered if we can link a clinical impact to what happened. Our physician adviser has reviewed the actions taken by the medical team, and the outcome of the tests.
36. The CT scan did not show Mr C had suffered a bleed on his brain. He had also not suffered any significant physical injuries due to the fall. No action was therefore taken in response to the scan.
37. Mr C’s blood tests on 30 January showed his C-reactive protein (CRP) level was raised. A higher-than-normal CRP level indicates inflammation or infection in the body. He also had a higher-than-normal white blood cell count. This can also indicate infection, inflammation or stress to the body.
38. A doctor who reviewed Mr C later that day, prescribed him antibiotics based on the results of these tests. They did not document the reason for this prescription, but it appears to be on suspicion Mr C had an infection.
39. A doctor reviewed Mr C the following morning. They noted his blood test results, and urine dipstick test results from 19 January. This earlier test showed the sample grew Klebsiella in the laboratory, this is a type of bacteria that can cause infection if it enters the urinary tract. The urine test result from a sample taken on 29 January showed ‘heavy mixed bacterial growth’.
40. The doctor spoke with the microbiology team to discuss the antibiotic treatment for Mr C. The team recommended intravenous antibiotics used to treat a UTI and suggested an alternative should he become more unwell.
41. We understand it is a key concern for Mrs B that earlier treatment for a UTI could have made a difference to the outcome for her father because his cause of death was recorded as being in part due to urosepsis.
42. Our physician adviser has explained that for older people, urine dipstick tests should not be used to diagnose a UTI because they give unreliable results. We have referred to guidance from Public Health England on diagnosing people over the age of 65, or those with a catheter, with a UTI. While this guidance is aimed at primary care, it provides relevant guidance and a helpful explanation: ‘Dipsticks become more unreliable with increasing age over 65 years. By 80 years half of older adults in care, and most with a urinary catheter, will have bacteria present in the bladder/ urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm’.
43. Our physician adviser has commented that while Mr C’s urine sample taken on 19 January grew bacteria, it is common to find these bacteria present in older people. In-line with the Public Health England guidance, this does not require antibiotic treatment.
44. In terms of the finding of heavy mixed bacterial growth from Mr C’s urine sample on 29 January, our physician adviser has commented this suggests contamination of the sample. This is because typically, with a UTI, only one type of bacteria will grow. This means the result was not a relevant finding.
45. Our physician adviser has said instead, clinicians should diagnose older people based on whether they are showing the signs and symptoms of a UTI. The Public Health England guidance says signs of a UTI include a high temperature, a new frequency or urgency to urinate, pain in the lower abdomen and new confusion.
46. On 30 and 31 January, the notes from examinations of Mr C say he had no abdominal pain. He also did not have a temperature. Mr C had confusion and our physician adviser has explained that while this can be a common sign of a UTI, confusion/ delirium is also not an uncommon symptom for an older, unwell person in hospital. Factors such as medication side effects, nutrition and hydration issues and urinary retention can contribute to this.
47. In terms of Mr C’s blood test results, our physician adviser has commented several things could account for a slightly higher CRP level and higher white blood cell level. For example, the fall Mr C suffered on 28 January could have caused inflammation in his body, or simply being unwell could account for these results. Taken alone, our adviser has commented the blood test results did not necessarily indicate a UTI.
48. Overall, our physician adviser has said the evidence is not convincing to support Mr C had the signs and symptoms of a UTI. It appears the medical team was being cautious in proceeding with antibiotic treatment. Our adviser has also said there was no evidence Mr C was developing sepsis as a result of an infection at this time and we consider this point in more detail further on in our report.
49. In terms of the impact we can therefore link to the delay in a medical review, while an earlier review would likely have led to Mr C having earlier tests, we cannot say this would have made an overall clinical difference to him. This is because he did not suffer a physical injury that required treatment. We also do not consider the evidence is convincing that he needed antibiotic treatment for a UTI, and so we cannot say the timing of this treatment had a bearing on the outcome for Mr C.
50. We do however recognise the delay caused Mrs B considerable concern and distress at the time of events when she felt the team was not providing the level of care her father needed. She has since questioned the difference this could have made. We hope the information we have been able to provide about this offers some reassurance to her.
51. We consider the distress and upset Mrs B suffered because of this failing is an injustice to her. While the Trust has apologised for what happened, it has not taken further steps to explain what it will do to prevent this happening again. We have therefore set out our recommendations at the end of this report.
Catheterisation
52. Mrs B complains hospital staff did not catheterise her father, despite him previously attending the Trust for prostate cancer treatment. She says this led to her father wetting his bed and having to sit in soaked pyjamas and bed sheets. We are very sorry to hear how upsetting it was for her to feel staff were not maintaining her father’s dignity as he deserved.
53. Our physician adviser has explained prostate cancer can often make it more difficult for a patient to pass urine and this can lead to urinary retention. They also commented incontinence is common in older people in hospital, but it would not usually be managed with intermittent self-catheterisation.
54. On review of the records, an emergency nurse practitioner reviewed Mr C on his admission on 18 January. There is no reference to him having any issues with passing urine or needing catheterisation. It says he had been to the toilet earlier that day.
55. Mrs B has however told us that on his admission, she told the team her father self-catheterised twice a day at home. She says the staff told her to bring his catheters into the hospital, and they provided incontinence pants. This discussion is not documented in the records, but we acknowledge Mrs B’s account of what happened.
56. Once admitted to a ward, a nursing care plan shows the nursing team assessed Mr C as being continent and he was using urine bottles. There is no reference to Mr C self-catheterising at home.
57. The nursing records up to 28 January document Mr C was independent with his personal needs and he was using urine bottles to pass urine in the night. There are references to him going to the toilet independently during the day with use of a walking frame and some support from staff. The nursing charts indicate the team checked him every two hours to make sure his skin was ‘dry and clean’, although we do not have charts that cover every day of his admission and so we cannot say if these checks occurred consistently.
58. Our physician adviser has commented that as Mr C appeared able to pass urine independently, this suggests he was not completely incontinent and did not have absolute urinary retention.
59. The records document a discussion Mrs B had with the nurse in charge on 28 January. She told the nurse about how her father relied on catheterisation at home, and he kept wetting himself in hospital because this was not being managed correctly. The nurse said incontinence would not necessarily indicate the need for a catheter, but they would arrange a scan of his bladder to check if he was retaining any urine, and if so, they would catheterise him.
60. The scan the following day showed Mr C was retaining over 500ml of fluid and he was only able to pass 50mls when asked to try and use a urine bottle. Our physician adviser has said this implies he had urinary retention, and this warrants a catheter. A nurse catheterised Mr C shortly after the scan.
61. We are sorry to hear of Mrs B’s concerns, and we do not dispute her account of what she told staff on her father’s admission. The Trust commented in its complaint response the the staff caring for Mr C on the ward were unaware of his usual practice of self-catheterising, but they acted on this information when Mrs B raised her concerns on 28 January.
62. Our physician and nurse advisers have both said the teams caring for Mr C would have relied on him or his family telling them how he managed his toileting needs at home. From the evidence we have reviewed, while Mrs B had an initial conversation with staff about this on her father’s admission, it does not appear the ward nursing team were aware of this information.
63. We are very sorry to hear Mrs B’s account of finding her father in soaked nightclothes. We also recognise her point that her father had previously attended the Trust for treatment for prostate cancer and she feels there should have been joined-up communication between the departments. The Trust has apologised this did not happen.
64. The NMC’s The Code says nurses must ‘deliver the fundamentals of care effectively’. This includes, ‘bladder and bowel care’, and ‘making sure that those receiving care are kept in clean and hygienic conditions’.
65. On review of the records and the advice we have received, we can see the nursing team assessed Mr C as being able to use urine bottles and go to the toilet to manage his needs. Our nursing adviser has commented they have not seen indication in the records Mr C was suffering with urinary retention leading up to 28 January, and so there is no evidence he would have benefitted from earlier catheterisation.
66. Following careful consideration of the available evidence and the advice we have received, we do not consider the nursing team acted outside of the NMC guidelines we have referred to above and have therefore not found failings in this part of the complaint. We recognise how strongly Mrs B feels about what happened and we have been sorry to hear of the concern she had for her father during this time.
Management of care from 28 January
67. Mrs B complains the clinical team did not act promptly enough when her father’s condition started to worsen. She questions if there was sufficient input from the cardiology doctors, and if the teams responded with sufficient urgency to signs he was developing sepsis. Mrs B says she was realistic about her father’s condition but considers the poor level of care quickened his deterioration.
68. The NHS website describes the main symptoms of heart failure as breathlessness, fatigue, swollen ankles and legs. Fluid builds-up in the legs because the heart is unable to pump blood around the body as well as it should. Less common symptoms of heart failure are a cough, a bloated tummy, confusion and an irregular heart rate.
69. On his admission on 18 January, Mr C was lethargic and had increased swelling in his face and legs. He had shortness of breath after minimal exertion, a cough and crackles in his lungs. He had a swollen abdomen which was reported to be normal for him. He was also mildly disorientated.
70. The medical team referred him to the heart failure team for review. A heart failure specialist nurse reviewed Mr C on 24 January. They considered his medical history, his symptoms and noted he was well-known to the community heart failure team that was supporting him outside of hospital, and he had a recent admission for similar issues.
71. The nurse noted Mr C did not want any cardiac procedures, such as surgery, and there was ‘limited scope’ to start heart failure medications due to his poor kidney function. The nurse made several recommendations for managing his care, including continuing to administer the diuretic furosemide and to transfer him to the cardiology ward.
72. Our physician adviser has commented that on review of the records, Mr C’s symptoms were primarily due to heart failure. The involvement of the community team in his care at home suggests Mr C’s heart failure was already severe. This is because people can usually manage heart failure at home without the need for specialist care.
73. Our physician adviser has further explained that Mr C had both heart failure and kidney failure, and these conditions often make the other worse. He not only had chronic kidney disease (a long-term condition), but also recent worsening kidney function – acute kidney injury. Treatment for heart failure often worsens kidney function. This means it can be challenging for a medical team to get the balance right between treating heart failure while accepting the medications will worsen kidney function.
74. We have set out our consideration of Mr C’s condition following his fall on 28 January above, and that we do not consider there is convincing evidence he had a UTI. The consultant review on 30 January noted the team was treating Mr C for decompensated CCF. This is a sudden and severe worsening of the symptoms of heart failure.
75. NICE guidance on acute heart failure says for patients already taking a diuretic (as Mr C was on admission), clinicians should ‘consider a higher dose of diuretic than that on which the person was admitted’. It says clinicians should review the need to restrict a person’s salt or fluid intake, and they should closely monitor the patient, including their renal function.
76. The medical team administered intravenous diuretics, they were restricting Mr C’s fluids and were reviewing his renal function. Our physician adviser has also commented the team tested Mr C’s B-type natriuretic peptide (BNP) levels, this is a hormone produced by the heart. Higher levels indicate a problem, including heart failure. This test helps guide management of the condition.
77. Our adviser has commented Mr C was suffering with fluid overload, but the medical team was managing this appropriately. The medical reviews show that while Mr C was unwell, his condition remained relatively stable until 2 February.
78. In consideration of the advice we have received, we find the medical team was managing Mr C’s heart failure in-line with the NICE guidelines referred to above.
79. A medical review on the morning of 2 February says Mr C was more breathless with a high breathing rate, indicating his condition was worsening. The doctor requested further tests, and gave instructions for his medications including continued diuretics, and a nebuliser to help with his breathing.
80. A further review that day refers to Mr C having increased pressure in the jugular veins in his neck. Our physician adviser has said this often means there is too much fluid in the body. The doctor planned for Mr C to have a further review from a heart failure nurse, however, later that day a bed became available on the cardiology ward. He was transferred there at around 4pm.
81. Our physician adviser has commented that despite aggressive treatment for heart failure, Mr C’s condition continued to deteriorate. They have said it was appropriate to refer him for a further heart failure review. We consider this action meets with GMC guidance that says doctors must ‘refer to another practitioner when this services the patient’s needs’.
82. The Trust said it did not move Mr C earlier to the cardiology ward because of an outbreak of COVID-19. The team thought it preferable for him to be under the guidance of the cardiology team, but not to move him there until it was safe.
83. A cardiology consultant reviewed Mr C soon after his transfer and noted he was very unwell and was likely going to further deteriorate. They spoke with his family to explain the focus should now be on keeping him comfortable. The team continued to administer furosemide but did not offer any new treatments. Mr C sadly died the following morning.
84. We understand Mrs B questions the difference it could have made if her father had been on the cardiology ward earlier. Our physician adviser has commented general physicians routinely treat heart failure. The heart failure specialist nurse had input in giving recommendations to manage his condition. They commented there was little scope for offering him anything further due to his poor kidney function. This suggests Mr C’s treatment would not have been different, even with an earlier transfer.
85. By the time Mr C was moved to the cardiology ward, he was sadly no longer responding to heart failure treatment and the cardiology team did not consider they could administer anything further.
86. We recognise Mrs B’s concern the medical teams did not treat her father for sepsis. Our physician adviser has explained Mr C’s deterioration was due to heart failure, not an infection or sepsis. Mr C did not have a high temperature which is typical if a person has an infection that has spread into their kidneys and into the blood stream, and he did not have the signs or symptoms of a UTI.
87. While the Trust initially listed urosepsis as a cause of death, in its complaint response to Mrs B, it provided a reconsideration of this. It said there was no strong evidence her father had urosepsis because he had no temperature and his blood tests did not support this diagnosis. It considered this was an error.
88. The GMC’s Good Medical Practice says doctors should work collaboratively with colleagues and make clear and accurate records. We do not consider the Trust met this standard when recording Mr C’s cause of death, and this is a failing.
89. We understand this error in reporting the cause of death has led to Mrs B having on-going concerns about what happened, and distress wondering if her father received the care he needed.
90. To address this concern, the Trust apologised the medical team did not discuss the cause of death at the time before completing the certificate. It also gave feedback to the team, and shared this more widely, emphasising the importance of accurately confirming the cause of death. We acknowledge this action means its staff will learn from this case.
91. While we hope the information we have been able to share goes in some way to bringing some answers for Mrs B’s concerns, we will also ask the Trust to apologise to Mrs B for how this error has impacted her.
92. In consideration of the advice we have received, and the guidance we have referred to, we consider the medical teams managed Mr C’s care appropriately from 28 January to 3 February, in-line with the NICE guidance for heart failure. Sadly, Mr C deteriorated due to worsening heart failure and there were no further options for treatment the teams could offer.
93. We are very sorry for how distressing this time was for Mrs B and her family. We recognise she has continued concerns, and this exacerbated her distress and upset during a very difficult time. We hope we have been able to clearly explain how we have reached our decision for what happened.