32. Before we decide if we should conduct a detailed investigation of a complaint, we look at if there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
Emergency department 33. Mrs L said staff in ED left her mother for 24 hours with no one-to-one care and they did not assess the impact of her fall which was the reason for her mother’s admission. She says it recommended one-to-one care but did not action this.
34. The Trust disagreed and said it put one-to-one care in place. It said it brought her to the hyper acute stroke unit (HASU) which is situated in ED, because she had left-sided weakness and the stroke team were to assess her. It said the stroke team undertook various assessments.
35. The records show Mrs N arrived at HASU at 8.32pm on 30 December. At 8.35pm a HASU senior doctor assessed her, and clinical observations began at 8.36pm.
36. We have seen indications staff assessed Mrs N and the impact of her fall. For example, they undertook a blood test at 8.47pm, and an electrocardiogram (ECG, a test that records the electrical activity of the heart to check its rhythm and rate) at 8.54pm. It also performed a Computerised Tomography (CT, a medical imaging test that uses X-rays and a computer to create detailed, cross-sectional images of inside the body) head scan at 9.02pm.
37. Our ED adviser explained, the CT head scan was done to assess Mrs N for any significant head injury following her fall at home. The results of the scan were reported at 9.49pm and the conclusion was ‘no acute intracranial event appreciated’. An acute intracranial event is a sudden, life-threatening medical emergency caused by bleeding inside the skull. This means the CT scan did not reveal any concerning findings, like bleeding.
38. A stroke assessment nurse carried out a pain assessment at 8.36pm, and a junior doctor carried out another at 9.21pm. Both were reported as ‘no pain’.
39. At 10.36pm a health care assistant was allocated to care for Mrs N on HASU. At 11.26pm they noted she was ‘very wondersome and agitated…requiring one-to-one observation, high falls risk and insisting on trying to mobilise’.
40. On 31 December at 1.11am it noted she ‘continued to be agitated and wandersome, has bitten a Health Care Assistant (HCA), currently requiring two HCA’s to observe her’.
41. Later, at 12.59pm, observations were done, and the medical team reviewed her at 4.24pm. The Trust transferred Mrs N to a ward at 5.57pm.
42. From our review, we think the Trust implemented one-to-one care whilst Mrs N was in ED, and two health care assistants were observing her from approximately 1am.
43. We consider the Trust assessed the impact of her fall whilst Mrs N was in ED as it carried out investigations such as a CT head scan.
44. RCP guidance says on chart 4 if a National Early Warning score (NEWS) is 0, monitoring should be minimum 12 hourly (NEWS is a tool used to improve the detection and response to clinical deterioration in adult patients).
45. The records say Mrs N’s NEWS score was 0. We think the observations were done in line with this, as we can see staff did were observations less than 12-hourly.
46. We consider the Trust implemented one-to-one care and closely monitored Mrs N whilst she was in ED. It performed scans to assess the impact of her fall, and her NEWS score was also monitored.
47. We have seen no indications of failings here. We will take no further action on this and hope it provides some reassurance to Mrs L.
Falls risk assessments 48. NICE guidance on falls in older people says at 1.1.2.1 ‘older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention’.
49. At 1.1.2.2. it says multifactorial assessments may include the following:
• identification of falls history • assessment of gait, balance and mobility, and muscle weakness • assessment of osteoporosis risk • assessment of the older person’s perceived functional ability and fear relating to falling • assessment of visual impairment • assessment of cognitive impairment and neurological examination • assessment of urinary incontinence • assessment of home hazards • cardiovascular examination and medication review.’
50. Mrs L says staff did not assess the impact or injury from Mrs N’s fall. She says this did not happen either in ED or during her hospital stay. She raises concerns staff did not do a falls risk assessment or appropriately manage her risk of falls. She says it used guard rails and equipment, which were not fit for purpose.
51. The Trust did not acknowledge anything went wrong and said a falls risk assessment was done.
52. As outlined above, we think the Trust adequately assessed the impact of Mrs N’s fall during her stay in ED. We have next considered if the Trust appropriately managed her risk of falls in the hospital ward.
53. When the Trust transferred Mrs N to a ward, it carried out a falls risk assessment the same day, at 7pm. This was approximately one hour after her transfer to the ward.
54. We consider the falls risks assessment was in line with NICE guidance because it carried out a multifactorial falls risk assessment. We can see it identified factors such as she had a falls history, with falls in the last 12 months.
55. Further, it assessed her mobility. It considered she did not have a clinical condition which impacted her mobility and did not consider her unsteady or unsafe or dizzy when walking or transferring. Staff noted no walking aids required, however they noted Mrs N required supervision.
56. Our nursing adviser’s view, which we agree with, is the Trust appropriately assessed Mrs N’s impact and injury from her fall. We think this because it carried out a multifactorial falls risk assessment in line with NICE guidance. This, in turn, assessed and managed her risk of falls appropriately as it noted what should be done to manage Mrs N’s risk of falls (for example supervision when mobilising).
57. Regarding Mrs L’s concerns the Trust used equipment not fit for purpose, we have not found anything to show there was equipment used whilst in ED so cannot comment on this.
58. Bed rails were used during Mrs N’s stay on a hospital ward. For example, the moving and handling assessment and management plan completed on 7 January says, ‘are bed rails required?’ and the box is ticked ‘yes’. The notes show they were used on 31 December, 7 January and 14 January and 21 January.
59. MHRA guidance on bed rails says ‘bed rails, also known as side rails or cot sides, are widely used to reduce the risk of falls. Although not suitable for everyone, they can be very effective when used with the right bed, in the right way, for the right person’.
60. It also says ‘use of bed rails can increase the risk of falling. In some cases, the patient may attempt to climb over the bed rail, leading to the potential to fall from a height’.
61. We have assessed if the Trust should have used bed rails. MHRA guidance explains they can be effective. Mrs N was at high risk of falls and was noted as confused. We consider bed rails may have not be suitable for Mrs N due to these reasons and could have increased her risk of falling.
62. We think bed rails may have presented with some risks and potentially the Trust should not have used them.
63. Our nursing adviser helped us understand; bed rails are not appropriate for confused and mobile patients. They explained that the Trust did not complete the bed rail assessments weekly as recommended, and the assessment does not indicate it informed the family about its use of bed rails.
64. We have carefully balanced the accounts, our adviser’s view and the records available to us. We think that there are indications the Trust should not have used bedrails, as it could have increased her risk of falling and staff should have informed Mrs N’s family about this. We think, as MHRA guidance explains, this could have increased Mrs N’s risk of falling.
65. We have next considered the possible impact this had on Mrs N. We asked Mrs L about her view on the impact of this. She explained to us, due to inappropriate equipment, Mrs N fell in hospital again and when she was admitted to a care home they found bruises all over her body.
66. We have found no indication in the records Mrs N fell over during her hospital stay. For example, there is no fall recorded in her records, or note of any injuries sustained. We are therefore unable to say the use of bed rails led to the impact Mrs L told us about.
67. The records say that staff supervised Mrs N whilst bed rails were in use, which we think would have mitigated the chance of her falling.
68. We consider the evidence does not indicate the bed rails caused Mrs N to fall (or sustain bruises) during her stay in hospital. This means, if we investigated further, it is unlikely we would find the impact Mrs L told us about. Because of this, we have decided not to take any further action.
Treatment for UTI and delirium 69. The NMC Code states at points:
• 1.2 ‘make sure you deliver the fundamentals of care effectively’ • 3.1 ‘pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages’ • 10.2 ‘identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who used the records have all the information they need’.
70. NICE guidance on delirium prevention, diagnosis and management says at 1.4.5 ‘address dehydration by: ensuring adequate fluid intake to prevent dehydration by encouraging the person to drink, consider offering subcutaneous or intravenous fluids if necessary’.
71. Mrs L says staff did not properly care for her mother when she developed a UTI and delirium. Specifically, she explained staff delayed treatment, nurses did not encourage her to drink enough fluids, the appropriate documents were not completed to record her fluid balance, and the jug of water was often out of her reach.
72. The Trust in its response said hydration assessments were undertaken daily, and the required level of monitoring was in place. It said this consisted of either fluid balance chart or hydration chart monitoring. It felt the assessments were completed to a high standard. It did not consider anything went wrong.
Delayed treatment 73. Mrs L says staff delayed treatment for Mrs N’s UTI, which caused her to develop an Acute Kidney Injury (AKI) and she required urgent rehydration.
74. The records show that Mrs N’s GP prescribed a course of pivmecillinam (a type of antibiotic used to treat UTIs) for a suspected UTI on 28 December. They prescribed two tablets as a single dose followed by one tablet for three days (meaning the course would finish on 31 December). Therefore, we can presume that Mrs N had doses of pivmecillinam before her admission to hospital.
75. NICE guidance on treatment for an uncomplicated UTI says adults are treated for three days with antibiotics.
76. We have seen no indication the Trust gave Mrs N pivmecillinam on 30 or 31 December. The Trust gave her a single dose of pivmecillinam on 1 January, and there is an entry on the same date asking for an urgent review because the pharmacist said the Trust will not use pivmecillinam anymore.
77. Our ED adviser explained to us, it would be important for the Trust to give Mrs N her prescribed course of pivmecillinam, particularly because she had already had some of the doses.
78. Our physician adviser also said the incomplete course of pivmecillinam is not in line with the NICE guidance above. This is because the prescribed course of antibiotics was not completed. We have found indications something went wrong here, as the Trust should not have missed Mrs N’s dose of pivmecillinam.
79. We asked the Trust about this. It said at the time, due to Mrs N’s confused and agitated state, she was refusing all medications. It explained Mrs N was able to communicate her needs and despite staff giving her reassurance, she strongly refused.
80. We also discussed this with Mrs L. She expressed concerns such as the nursing assessment on 31 December documented that Mrs N did not have mental capacity. She said the Trust should have taken the appropriate steps to administer the medication, taking into consideration she had dementia.
81. We have balanced both accounts and carefully reviewed what we think the impact of the missed dose was. Our physician adviser helped us understand, guidelines do not tend to mention the risks of incomplete courses of antibiotics.
82. They further explained, for a UTI to cause an AKI, this typically happens when a patient with a UTI gets sepsis or sepsis shock. National Library of Medicine guidance says ‘sepsis is one of the most common triggers of AKI and about 60% patients with sepsis shock developed AKI’.
83. Our physician adviser told us, Mrs N’s clinical features, and particularly her observations, do not fit with sepsis. From our review of the records, we found no indication Mrs N had sepsis. Therefore, our view is the missed dose of antibiotics did not likely cause Mrs N to develop an AKI.
84. We think there is a possibility Mrs N did not recover from her UTI as soon as she would have, if it was not for the Trust missing a dose of pivmecillinam. We have balanced all accounts, our adviser’s view, and the records. We do not think an investigation into this part of the complaint would achieve a satisfactory conclusion.
85. As our Service model guidance states at section 3.10: ‘there will be occasions when we decide that there are other reasons why we should not investigate a complaint made to us.’ This includes that ‘an investigation would not be practical, would not reach a satisfactory conclusion and there would be no value in providing that response through an investigation.’
86. In line with this, we will not take any further action on this part of the complaint. This is because of the difficulty in reaching a view on the impact of the missed dose. As our physician adviser explained, guidelines do not mention risks of incomplete doses.
87. There is a possibility Mrs N may have not recovered any sooner if it was not for the missed dose. We consider this is something it would be difficult to reach a view on. Further, the indication of a failure due to the missed dose, likely did not lead to the impact Mrs L told us about (an AKI).
88. We do not think an investigation into this issue would achieve a satisfactory outcome due to the reasons as outlined above. Further, as we will go on to explain, we think the Trust treated Mrs N’s UTI appropriately for the duration of her hospital stay following this.
89. On 2 January the Trust gave Mrs N nitrofurantoin modified release to treat her UTI. On 3 January it changed it to cephalexin. Our physician adviser helped us understand are both appropriate medications to treat a UTI, recognised in NICE guidance.
90. The notes document cephalexin was then continued for seven days. We have found no indication there were any missed doses of these medications and consider it gave Mrs N the medications in line with what it had prescribed.
91. Our physician adviser explained to us that the choice and duration of the antibiotics the Trust prescribed are in line with the NICE guidance as noted above.
92. We have found no indication that the treatment the Trust gave Mrs N was inappropriate. We consider it prescribed different medications to help ease and treat her UTI. We will therefore take no further action on this.
93. We recognise our decision to not investigate the missed dose of pivmecillinam may be disappointing for Mrs L. We hope she can understand our reasoning.
Fluid intake and hydration chart monitoring 94. There are entries in the records to suggest staff encouraged Mrs N to drink. For example, on 3 January it noted due to Mrs N’s delirium they should ‘encourage oral intake’.
95. Examples of staff encouraging her to drink were on 5 January ‘put water close to [Mrs N] and encouraged oral intake, drank half a glass’.
96. On 8 January ‘encouraged oral fluid intake’ and on 9 January ‘encouragement and assistance given for eating and drinking’ and on 10 January ‘encouraged oral intake’. We consider this is in line with NICE guidance to ensure adequate fluid intake as there is evidence to suggest staff encouraged Mrs N to drink.
97. The notes also said on 3 January part of the plan was to complete fluid charts. The records show daily hydration assessments. Further, there are fluid balance records showing 24-hour input and output of her fluids. Our adviser explained this was appropriate, that in the nursing documentation it noted she needed to be encouraged to drink fluids.
98. On 12 January ‘fluid balance not recorded for last couple of days has been in the balance previously and has been encouraging oral intake daily with renal function improving’. Whilst the fluid balance was not recorded for a couple of days, the nursing notes show they were encouraging Mrs N to drink (for example on 10 January ‘encouraged oral intake’).
99. We think this was in line with NMC Code point 10.2 to ‘identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who used the records have all the information they need’. There are no other issues we have found with documenting fluid balance and have not found indications this had any effect on Mrs N’s fluid intake.
100. There are also intentional rounding assessments for hydration, and checks were done approximately every two hours. Our nursing adviser’s view, which we agree with, is the nursing documentation for fluid balance and hydration and ongoing care delivery for delirium, are in line with the NMC Code. Specifically, point 10 to ‘keep clear and accurate records relevant to your practice’.
101. On 4 January, Mrs N’s blood test results came back and showed an Acute Kidney Injury (where your kidneys suddenly stop working properly). The doctor asked the nursing team to continue to encourage oral intake and prescribed IV fluids for overnight.
102. Later the same day, a nurse cannulated Mrs N and started IV fluids. Mrs N began to get agitated and pulled out the cannula. It was noted they will re-cannulate and continue IV fluids once Mrs N was settled. An entry the following day at 6.20pm said ‘cannulated, IV fluids commenced and in progress’.
103. We consider this to be in line with NICE guidance as the Trust offered intravenous fluids once it became necessary.
104. On 6 January, it was noted following another blood test that the ‘AKI was resolving not back to baseline renal function yet but progressively improving’. Later the same day, a doctor noted she no longer required IV fluids as Mrs N was now tolerating oral fluids well. It said ‘regular prompting for fluids please’. IV fluids were recommenced on 8 January as they considered they were required again.
105. We think this is in line with NICE guidance as the Trust restarted IV fluids whenever Mrs N required them, which suggests the Trust ensured adequate fluid intake. We consider this also suggests the Trust treated Mrs N for delirium appropriately.
106. For the reasons outlined above, we have not seen indications of failings here. We will not take any further action on this. This is not to underestimate how difficult this must have been for Mrs N and her family.
Dementia 107. The NMC Code says at point 3.1 ‘pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages’.
108. Mrs L says staff did not appropriately care for her mother as an Alzheimer’s patient, not recognising the need to take her to the toilet, the need for her to walk, overall limited engagement with her mother’s wellbeing and lack of dignity and privacy.
109. She also raised concerns nurses discriminated against her mother because of her age. She says they advised her to urinate in the bed if she needed to use the toilet.
110. The Trust said staff frequently assisted Mrs N to the toilet, and the nursing team strive to ensure a patient’s privacy is maintained during their hospital stay. It said staff undertake dementia training, and the nursing and medical team frequently care for patients living with dementia on the ward. Overall, it considered it cared for Mrs N appropriately as a dementia patient.
111. We have carefully balanced both accounts, obtained input from our nursing adviser, and reviewed the records to assess if there are indications the Trust cared for Mrs N, as a dementia patient, appropriately.
112. We have seen staff regularly assisted Mrs N to the toilet. For example, on 2 January ‘nurse reports that patient has been going to the toilet frequently. Last three did not actually pass urine’.
113. On 5 January ‘always wanting to get out of bed and walk around. Transferred her to the commode once to help her pass urine’. On 8 January ‘walked to the toilet with two assistance’ and on 12 January ‘continent of urine via toilet’ and on 16 January ‘mobile to toilet with frame assisted’.
114. Staff observed her whilst mobilising ‘health care assistant present as walking and standing frequently’. Also, on 12 January ‘observed Mrs N mobile up and down several times’ and ‘[Mrs N] managing well and maintaining mobility on the ward’.
115. There is a hospital dementia care plan, completed on 31 December. The care plan was then reviewed on 7, 8 and 9 January, to ensure nurses were appropriately managing Mrs N’s confusion.
116. There is further evidence to suggest staff were caring for her appropriately in line with the NMC Code. There are falls risk assessments completed, pressure ulceration risk assessments, reposition and skin assessment charts as well as moving and handling assessments. Our adviser explained such records are relevant and in support of patients with Alzheimer’s.
117. The pressure ulcer prevention care and management plan says staff repositioned Mrs N every two hours and carried out a skin inspection every two hours.
118. There is also record of a ‘this is me’ passport for people living with dementia completed. It states the passport ‘helps us give individualised and patient centred care and build a better relationship by understanding you as a person’, and the passport then includes details about Mrs N. For example, it says, ‘my mobility – increasingly poor’ and ‘how I take my medication – as instructed – very well’.
119. Overall, we think there are multiple entries within the medical notes to suggest staff frequently assisted Mrs N when mobilising and going to the toilet and ultimately caring for her as a patient with Alzheimer’s. We consider this is in line with the NMC Code as it suggests staff tried to promote her wellbeing and prevent ill health.
120. We have not found anything in the records to suggest staff did not uphold Mrs N’s dignity or privacy, or anything to suggest nurses advised her to wet the bed. We recognise Mrs L’s view and have balanced her account, with the Trust’s account and reviewed the evidence available to us when reaching a decision. We cannot conclude nurses encouraged Mrs N to do this.
121. We understand why Mrs L brought her concerns to us and can see why this would be distressing for her and her family.
122. We think staff acted in line with the NMC Code and appropriately cared for Mrs N as a patient with Alzheimer’s and will take no further action on this.
Discharge 123. NICE guidance on transition between inpatient hospital settings and care home settings says at 1.5.13 ‘from admission, or earlier, if possible, the hospital and community-based multidisciplinary teams should work together to identify and address factors that could prevent a safe, timely transfer of care from hospital’.
124. Mrs L says her mother was declared medically fit on 13 January, but it took a further five days for staff to discharge her and staff did not discharge her with the appropriate equipment (a Zimmer frame) in transport.
125. The Trust in its response said as soon as her mother had been assessed by the care home and their acceptance of her mother had been confirmed, it arranged for her to be discharged to the care home on the same day.
126. The records document Mrs N’s husband informed the Trust on 13 January they will be funding Mrs N’s care at the care home.
127. On 17 January the care home confirmed it would accept Mrs N on 18 January before lunch time, so the Trust records arranged transport and informed her family about the transfer.
128. Our adviser explained the availability to transfer her to the care home would depend on when the care home was ready to accept Mrs N.
129. As the care home informed the Trust that it was ready to accept her on 17 January, the Trust discharged and arranged for Mrs N to be transferred to the care home on 18 January. We do not consider there were any unnecessary delays in discharging Mrs N.
130. We think the Trust acted in line with NICE guidance because it discharged Mrs N as soon as it could. We will therefore take no further action on this.
Appropriate equipment not sent 131. Mrs L also complained that when the Trust discharged her, the appropriate equipment was not sent with her in the transport.
132. The Trust said in its response ‘[a Sister] is truly sorry for the oversight of not sending the Zimmer frame, that your mother had been using on the ward, with her to the home. It is unclear whether staff were of the impression that your mother already had one or there would be one available for her in the home. However, [a Sister] would expect the staff to check this with the therapists, discharge team and the home. [a Sister] has shared this issue in the ward safety huddle to ensure that the team clarify equipment needs on discharge’.
133. As the Trust has acknowledged this, we will assess whether it has done enough to put this right.
134. Our Complaint Standards say ‘give colleagues the confidence and freedom to offer fair remedies to put things right. Take action to make sure learning is identified and used to improve services’.
135. Level one on our severity of injustice scale explains a case will generally be level one if the impact includes ‘annoyance, frustration, worry or inconvenience. This would typically arise from a single (one-off) incidence’. We usually consider an apology to be appropriate for these cases.
136. We consider this part of the complaint sits on level one of our scale because it was a one-off incident which led to annoyance, frustration and inconvenience. We do not consider it would have had long term impact and instead was of short duration.
137. We do not recommend financial remedy for complaints which sit on level one on our scale. We think the Trust has done to put this right, is enough. We consider it is in line with our Complaint Standards as it said it will share the issue at the ward safety huddle to prevent similar incident happening again and has apologised.
138. We recognise this must have been frustrating for Mrs L and her family at an already difficult time.
Medical records 139. The NMC Code says at point 10 ‘keep clear and accurate records relevant to your practice’. To achieve this, you must:
‘10.1 complete records at the time or as soon as possible after an event, recording if the notes are written sometime after the event
10.2 identify any risks or problems that have arisen, and all the steps taken to deal with them, so that colleagues who use the records have all the information they need
10.3 complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to this requirement’.
140. Mrs L says nurses falsified the notes and they are not a true reflection of what happened. She says the notes say nurses did not recognise her mother had Alzheimer’s which is not true.
141. The Trust has not acknowledged any issues with records and said it considers the assessments were documented to a high standard.
142. We have not found anything in the records to suggest the records were falsified or documented a lack of recognition Mrs N had Alzheimer’s. For example, the nursing assessment upon her admission to the ward on 31 December documented Mrs N has a pre-existing diagnosis of dementia. Also, on 2 January the notes say ‘progression of dementia’. There is also a ‘hospital dementia care plan’ form completed on 31 December.
143. Our adviser’s view, which we share, is the Trust assessed and documented Mrs N’s personal needs for her Alzheimer’s and clinical condition appropriately.
144. We have balanced both accounts and reviewed the evidence available to us and consider there is more evidence than not the notes were not falsified. For example, we have not found anything contradictory or backdated.
145. The records also suggest there was recognition Mrs N had dementia. We consider this in line with the NMC Code, to keep clear and accurate records.
146. We recognise Mrs L says the notes are falsified and are sorry to hear of her concerns. We hope this can provide some reassurance the records do not suggest there was not a lack of recognition her mother had dementia.
Complaint handling 147. NHS Complaint Standards says organisations should ‘see complaints as an opportunity to develop and improve its services and people’. It also says they should be ‘thorough and fair when looking into complaints and give an open and honest answer as quickly as possible, considering the complexity of the issues’.
148. Mrs L raised concerns about the complaint handling of the Trust. She says there is lack of assurance the same thing will not happen again and no apology or engagement with the executive team responsible.
149. She says the complaints process took a significant period to resolve. In addition, there was no medical or multi-disciplinary team input into the complaint despite this request and therefore the complaint has not been fully reviewed.
150. We have reviewed the timeline of complaint responses which is as follows:
• 26 January 2023 Trust acknowledgement letter following receiving consent form. It said it will respond by 30 March • 28 March 2023 response from Trust • 4 May 2023 Mrs L responded to the Trust • 18 October 2023 a local resolution meeting took place • 19 October 2023 the Trust sent a letter to Mrs L following the local resolution meeting.
151. Upon review we have not found any indications the Trust did not respond within the timeframe it said. We think the responses also responded to each issue raised. We acknowledge Mrs L does not agree with what it said, and have taken her view into account.
152. We are satisfied the Trust handled Mrs L’s complaint, in line with our Complaint Standards above. We consider it involved the relevant staff members and considered the relevant available evidence. It then reflected its findings openly and honestly in its complaint response.
153. The Trust responded to each issue and explained why it felt there were no failings in the care provided. It also said:
‘as a result of our investigation into your complaint, the following actions will be undertaken: • [a Sister] has discussed your concerns with the team on [the ward] for shared learning • [a nurse] has reflected on your concern and will use this example as part of her reflective documents, which she will complete as part of the Nursing and Midwifery Council revalidation process, to improve future practice • [a nurse] has reflected on your experience and the impact that this has had • Your concerns will be discussed at the next Department of Medicine for Older People and General Medicine clinical group meeting for shared learning.’
154. We consider the complaint handling was in line with our Complaint Standards to ‘see complaints as an opportunity to develop and improve its services and people’ and will not take any further action on this as we have seen no indications anything went wrong or fell below what is expected in its complaint handling.
The ward 155. Mrs L raises concern the ward Mrs N was on, is not appropriately set up for patients with dementia. She says the Trust confirmed the ward is not set up for dementia patients during the local resolution meeting, yet there is no evidence this has changed and it continues to treat patients with dementia on the ward.
156. She explained the ward is not suitable because of the layout, environment, and staff. She says the positioning of the nurses’ desks mean they often have their backs to patients, so are unable to see when a patient is climbing over rail guards.
157. The Trust in its response said the desks are situated in a way to ensure wires are not trailing from the computers and causing a trip hazard. It said it has observed nurses at the desks within the bay and held discussions with them. It said the concerns will be shared with the nursing team.
158. Mrs N was admitted to an acute hospital. We have reviewed the records to assess if there’s any indication Mrs N should not have been cared for on this ward as a patient with dementia.
159. The records show that when bedrails were used, staff monitored Mrs N. As explained earlier in our report, we have found no impact from this, such as Mrs N falling out of bed. There is no record of Mrs N falling during her stay in hospital.
160. We have not found anything to suggest Mrs N should not have been on this ward. Our adviser’s view, which we share, is adequate care was put in place to support and address Mrs N’s safety.
161. We consider the Trust acted in line with our Complaint Standards that say organisations should ‘see complaints as an opportunity to develop and improve’, as it has fed Mrs L’s concerns back to the nursing team and held discussions with the nurses at the desks within the bay.
162. We have not found any indication Mrs N should not have been cared for on this ward and will not take any further action on this.
Duty of candour 163. Public Health England’s information on duty of candour says ‘the intention of the duty of candour legislation is to ensure that providers are open and transparent with people who use services. It sets out some specific requirements providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong’.
164. Mrs L raises concern the Trust did not follow duty of candour processes. A duty of candour is where health and care professionals must tell the person when something has gone wrong and apologise to the person or offer an appropriate remedy or support to put matters right.
165. She has concerns because upon her mother’s admission to the care home, they discovered bruises on her body, and the Trust did not inform her about her mother’s falls during her stay in hospital.
166. The Trust in its response said it would like to reassure her that there is no evidence that her mother had a fall whilst in hospital. It said she had her bloods taken and peripheral cannulas (small, flexible tube inserted into a vein to allow for intravenous administration of fluids, medications and blood products) inserted on several occasions, which is the likely cause for the bruising.
167. It added that her mother was taking enoxaparin (anticoagulant medication, used to prevent blood clots in the leg in patients who are on bedrest), which can make patients more susceptible for bruising.
168. We have reviewed the records and have not found anything to suggest Mrs N fell during her stay, and there is no reported incident of a fall. For example, on 7 January a falls risk assessment was done, and the form asks, ‘fall during this episode of care?’ and the answer was ‘no’. Further, on 9 January the nursing notes state ‘no falls’.
169. We have carefully balanced both accounts and the medical notes. After a careful review, we consider there is more evidence than not, the Trust did not fail in fulfilling its duty of candour in line with Public Health England information as set out above. We have therefore found no indications of failings here.
170. We were sorry to hear about the issues raised about the care and treatment Mrs N received during her hospital stay, and Mrs N’s sad deterioration. We recognise this was a difficult and distressing time, and hope the above explanation provides some reassurance to Mrs L.