4. Mrs F complains the Trust has not implemented promised actions in relation to failings it identified in the care and treatment it provided to her mother, Mrs G, in 2023.
5. Mrs F says she and her whole family has lost faith in the Trust and are terrified of ever being admitted to the Trust. Mrs F is seeking financial remedy.
6. Mrs G had multiple admissions to the Trust in 2023, initially with COVID-19 symptoms, and subsequently with shortness of breath. Sadly, Mrs G died during her last admission in April 2023.
7. Mrs F complained to the Trust about how it had treated Mrs G. Mrs F specifically complained about the following:
• staff failed to feed Mrs G properly even though the family had discussed this with the Trust on many occasions • staff provided no assistance to Mrs G when she needed to go to the toilet, she was left to soil herself as staff presumed she was incontinent due to her age • staff were negligent in nursing care around repositioning, not having cream to apply to sacral lesions and no available pillows • staff were negligent in its care of Mrs G’s leg wound • there was a lack of communication from the Trust when Mrs G’s condition deteriorated.
8. The Trust acknowledged failings in its care of Mrs G that Mrs F had raised. It informed Mrs F it would make service improvements, and it detailed the actions it was planning to take (details of these actions can be found in our decision below).
9. Mrs F and other family members visited the Trust later in 2023 and could not see that the promised service improvements had been made. Mrs F complained to us that the Trust had not taken the actions it had said it would, as she is concerned similar failings are still occurring.
13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indication that something has gone wrong.
14. We have set out below the actions the Trust has taken in response to each of the issues it identified. We asked our adviser whether the actions taken by the Trust would be likely to prevent a similar failing from reoccurring. We also asked whether there was evidence to show the action had been taken, and whether there was sufficient monitoring to ensure the improvement is maintained. We have included their observations below.
Nutrition
15. The Trust acknowledged it failed to calculate Mrs G’s MUST score (a nutritional assessment) which meant it delayed referring her to a dietician. It recognised staff were also unclear about Mrs G’s nutritional status, delayed following up dietician referrals, and delayed prescribing nutritional supplements.
16. The Trust’s action plan states staff on older persons wards have completed MUST training. It also said patients’ nutritional status will be audited monthly by a senior nurse to ensure compliance. Our adviser explained audits provide the opportunity for the Trust to identify and address any lapses in nutritional care in a timely manner.
17. The Trust also explained there is now a protected mealtime group which focuses on meal provision and hydration. This is a group of senior nurses, dieticians, and the catering manager, who conduct ward audits twice a week to ensure patients are prepped for protected mealtimes. Our adviser explained the twice weekly visual audits at mealtimes can identify any concerns at the time of the events.
18. Our advisor told us these interventions are reasonable to prevent a similar situation occurring in the future. Staff training and auditing compliance with nutritional documentation is appropriate to ensure improvements have been made.
19. The lifetime auditing outlined by the Trust ensures improvements are maintained and staff are continuously learning and improving. Our adviser said these interventions should improve nutritional care on the wards.
Toileting and handling
20. The Trust acknowledged staff did not provide Mrs G with assistance following an episode of incontinence.
21. The Trust explained each patient and their care is allocated to a registered nurse who is responsible for their care needs. Care and assistance are provided on an ‘as needed’ basis and care is documented after each occasion. Nursing staff also complete additional rounds to routinely and regularly check patients who require more assistance with their care needs, such as continence care. Continence care is also embedded in patient leaflets to increase awareness.
22. The Trust has also implemented an auditing process to ensure improvements are made and monitored.
23. The Trust also acknowledged it failed to provide the required level of assistance for moving and handling Mrs G.
24. The Trust set a target of 90% staff compliance for moving and handling and for patients to be moved by appropriately trained staff. It said all staff receive regular mandatory moving and handling training and it is conducting ongoing audits to ensure staff are compliant.
25. Providing a timely response to episodes of incontinence helps maintain skin integrity and reduce the incidence of moisture associated skin damage. Staff, patient, and carer awareness is important to ensure timely assistance is provided.
26. Our advisor told us these interventions are reasonable to prevent a similar situation occurring in the future. The action taken by the Trust ensures timely continence care is embedded within daily nursing care. This includes providing patient and carer information and auditing to ensure staff compliance is increased and maintained.
27. In relation to moving and handling, our advisor told us these actions should ensure similar events do not happen again. They explained moving and handling training is mandatory for all staff, and auditing should ensure improvements are maintained and monitored. Our advisor did say it is not possible to fully prevent individual errors.
28. We can see the Trust is using a care bundle model, which ensures all fundamental aspects of pressure ulcer prevention are included in patient care. This includes incontinence care, nutrition, and keeping the patient moving safely. Compliance with the care bundle is included in a Pressure Ulcer Monthly Report, and it is reviewed at the Patient Safety Group.
Leg wound
29. The Trust acknowledged failings in how it cared for a wound on Mrs G’s leg.
30. The Trust explained that all wounds should be noted on a body map and should have a wound care plan. It planned to audit five patients a week for a period of one month, to ensure these are present.
31. The Trust has implemented an updated risk assessment tool which includes assessing for the presence of moisture due to perspiration, urine, faeces or exudate (this is oozing from a wound). If moisture is a risk factor, nurses can follow the moisture lesion treatment pathway to ensure the most appropriate barrier product is used. A stock of barrier cream is available in each ward. This means staff do not have to wait for it to be prescribed, and they do not have to wait for it from the pharmacy.
32. The Trust has also reviewed its training against the NHS curriculum and delivered staff training in pressure ulcers, wounds, and leg ulcers. Our adviser said this should ensure staff are working to best practice.
33. Our advisor told us these actions show the Trust has taken sufficient systemic action to prevent a similar failing from occurring. The Trust has also implemented an auditing process, which we have set out in paragraph 28 above.
Communication
34. The Trust acknowledged staff failed to inform Mrs F of changes to her mother’s condition.
35. The Trust explained there is signage on the wards to inform patients of the matron and provide contact details for the matron and head nurse. The Trust has implemented red uniforms for matrons so they are more easily identifiable. This was also discussed in the department’s Mortality and Morbidity meeting and in the care group governance huddle, to highlight the importance of good communication with relatives.
36. The Trust has shared with us the presentation that was given to staff at the Mortality and Morbidity meeting. Our advisor explained family and patients seek differing levels of communication. They said the action taken by the Trust is reasonable and changes, such as new matron uniforms, should ensure the improvement is maintained.
Consideration of the Trust’s actions
37. Our NHS Complaints Standards say as part of providing fair and accountable responses organisations should identify suitable ways to put things right for people. Our Principles for Remedy say putting things right may include changes to procedures or staff training to ensure the poor service is not repeated.
38. We have not seen any indication to suggest the Trust has not implemented the actions it promised to. The information we have seen shows the Trust identified failings in the care it had provided to Mrs G, and it acknowledged and apologised for these. This appears to be in line with our NHS Complaint Standards.
39. The Trust has also implemented suitable improvements for each failing identified following Mrs F’s complaint. This appears to be in line with our NHS Complaint Standards and our Principles for Remedy, as it has put in place service improvements to ensure the poor service is not repeated.
40. We understand witnessing concerning events so soon after her complaint to the Trust was upsetting for Mrs F and has caused her real concern. Systemic changes cannot always be made immediately. It is possible the Trust was still implementing and embedding improvements when Mrs F and family attended.
41. We think the remedy provided by the Trust, via the acknowledgement and apology, and the service improvements, are suitable actions to put things right here. We have seen no indication the Trust has failed to act in line with the NHS Complaints Standards here.
42. We thank Mrs F for bringing her concerns to us. We hope our statement reassures her that the Trust has made improvements since she complained about the care her mother received from the Trust, and that these improvements should be maintained.
1. We have carefully considered Mrs F’s Complaint about Medway NHS Foundation Trust (the Trust). We acknowledge how distressing the original events, and Mrs G’s death, and the Trust’s subsequent actions have been for Mrs F.
2. Based on the information we have considered we have decided not to consider Mrs F’s complaint further. This is because we have not seen any indication of failings on the Trust’s actions.
3. We thank Mrs F for bringing her complaint to us. We understand it was distressing for her to see things which suggested the Trust had not made promised improvements following her complaint about how it cared for her mother. We hope our explanation fully explains our decision and reassures her about action the Trust took as a result of her complaint.