Nutrition 17. Miss P complains the Trust did not provide or support her mother with adequate nutrition or hydration during her admission between June and July 2023. She says her mother needed additional support to eat as she had problems feeding herself, and she raised this with the Trust. However, she says it did not listen to her, and this meant her mother did not get the nutrition she needed. She feels if the staff had helped her mother to get the nutrition she needed, her mental state, physical health, and overall outcome would have been improved.
18. We were sorry to hear Miss P’s concerns about how the Trust managed her mother’s nutrition and hydration during her admission. From what she told us, it is clear that she feels this impacted her mother’s sad death and this thought continues to cause her significant ongoing distress.
19. BAPEN guidelines say nutritional screening is the first step in identifying people who may be at nutritional risk or potentially at risk, and who may benefit from appropriate nutritional intervention. It gives guidance on how to use the Malnutrition Universal Screening Tool (MUST) to calculate a patient’s overall risk of nutrition by checking and scoring a patient’s BMI, weight loss, and acute disease effect (for example if the patient is acutely ill and there has been or is likely to be no nutritional intake). The score for each is merged to achieve an overall score.
20. A total score of: • zero, means a patient is low risk and they should receive routine clinical care • one, is medium risk and the patient should be observed • two or more, is classed as high risk and this indicates the need to treat. This includes referring the patient to a dietician, implementing local policy, and improving and increasing the patients overall nutritional intake.
21. The Trust’s policy on Nutrition and Hydration says: • all adult inpatients must be screened using MUST within 24 hours of admission to identify patients who are malnourished or at risk of being malnourished • nutritional screening must be repeated weekly as a minimum for all inpatients • all patients with a MUST score of three or more should be referred to the dietitian immediately who will advise on the most appropriate nutritional intervention • patients who have a MUST score of one or more will have a Nutrition Care Plan completed and if no improvement is made within three days of interventions, patients will be referred to the dietitian • where patients are identified as requiring assistance to eat at mealtimes the red tray system will be implemented to alert staff to the patient’s need for support • the nurse in charge is responsible for ensuring the patient receives the required level of assistance to enable them to eat their meal.
22. The Trust policy on when to refer a patient to a dietician differs from BAPEN guidance. BAPEN recommends this should be when a patient’s MUST score is two or more. The Trust’s policy says this should be when a patient’s MUST score is three or more. In this case, we will refer to the national guidance on when a patient should be referred to a dietician to ensure we fairly measure the Trust’s actions against what is expected from it on a national level.
23. Miss P’s mother’s medical records show the Trust initially admitted her in mid-June 2023 due to her feeling weak, tired, confused, and experiencing left flank (side) pain. On admission, she reported a loss of appetite over the last six months, acid reflux, and a substantial weight loss of nine kilograms (kg).
24. During this admission the Trust identified a lesion on her pancreas. The Trust discharged her five days later but readmitted her later the same day as she was experiencing shortness of breath with cyanosis (a bluish discoloration of the skin due to lack of oxygen in the blood) around her lips and eyes, and a new onset of confusion.
25. The Trust carried out a MUST assessment for Miss P’s mother on the same day, within 24 hours of her readmission which is in line with its policy on screening adult inpatients to assess their risk of malnutrition when admitted. The MUST score on this date was zero which means she was at low risk of malnutrition. When it repeated her MUST score two days later, this remained at zero.
26. Seven days after her readmission, the Trust recorded Miss P’s mother’s weight as 49.4kg. It started using the red tray system for her mother’s meals following day although it is not clear from the medical records what prompted this decision. Miss P told us that she started the process of using the red tray system for her mother when she selected it on the food menu. However, we cannot see any evidence in the medical records to support this or explain why the Trust implemented the red tray system. There are differing accounts about what happened here.
27. The red tray system signals to the nursing staff which patients may need more support with eating. The Trust told us the red tray system does not always indicate that a member of staff physically assists a patient with mealtimes, unless they have been assessed and this is recommended specifically, however close supervision and support should be provided. At this point, there is no evidence that physical assistance had been recommended for Miss P’s mother.
28. The Trust carried out another MUST screening at the beginning of July, one week after the previous screening, and her score was two. From the information in the medical records, she had lost around 7kg since her previous screening as the Trust recorded her weight as 42.5kg during this screening. In line with the BAPEN guidance, a score of two indicates Miss P’s mother was at high risk of malnutrition and this should prompt a referral to the dietetic team or the implementation of the Trust’s policy on nutrition.
29. Three days later, the Trust met with Miss P to discuss her concerns about her mother’s overall condition, including her eating and drinking. Miss P told the Trust that her mother needed more help with her nutrition and hydration, and she was concerned about the reduction in her fluid and food intake.
30. Following this meeting, the Trust referred Miss P’s mother to a dietitian on the same day. Due to record keeping, we cannot see what prompted the Trust to refer her to the dietetic team. It is not clear if this was due to her increased MUST score from the beginning of July or the concerns Miss P raised, but given the timing, on the balance of probabilities, it is likely this was due to Miss P raising her concerns.
31. The dietetic team reviewed Miss P’s mother one day later. It recommended that she should have nutritional supplements, be on the red tray system for her meals, and be encouraged and assisted with both eating and drinking (such as cutting foods up into smaller pieces). The team also said she needed to be weighed weekly and calculated her fluid requirements as 1290mls per day. One week later, the dietetic team reviewed Miss P’s mother again and recommended that staff should monitor her food charts.
32. From what we have seen, the Trust completed food charts on most days between Miss P’s mother admission and when she saw the dietician at the beginning of July. It documented that she declined some meals and ate small portions of others. We can see the Trust consistently documented her food intake every day following the dietician review at the beginning of July which is in line with the later recommendation from the dieticians during the review the following week. We can see that Miss P’s mother continued to eat small amounts and refused some meals.
33. The medical records show that the Trust followed the nutritional plan put in place by the dietetic team. It provided her with the nutritional supplements prescribed by the dietician, continued to monitor her weight weekly, and as above, it completed food charts in line with the dietetic team recommendations.
34. Although the Trust followed the recommendations from the dietetic team, we have seen that something went wrong with Miss P’s mother’s nutritional support before the team saw her. This is because the Trust’s initial nutritional screening of her when she was first admitted looks to be incorrect.
35. Our dietician adviser explained that the Trust did not consider Miss P’s mother’s reports of recent loss of appetite or weight loss when it calculated her MUST score as zero when she was admitted. This is because if it had taken these factors into account, it is likely that this would have formed a poor nutritional picture and increased Miss P’s mother’s MUST score. Therefore, this could have led to an earlier referral to the dietetic team. However, she was not referred to the dietitian until early July, 11 days later.
36. Based on this and the information we have seen in the medical records, we consider the Trust did not follow BAPEN guidance when it initially calculated Miss P’s mothers MUST score when she was admitted. It did not consider increasing her mother’s weight loss and acute disease score which may have put her at an overall higher risk of malnutrition and prompted support or an earlier referral to the dietetic team. This is a failing.
37. It then missed a further opportunity to consider Miss P’s mother’s overall nutritional picture when it scored her MUST as zero two days later. Our nursing adviser explained that based on the food charts that the Trust did complete, Miss P’s mother was not eating enough to maintain a MUST score of zero and therefore the Trust’s calculation that she was low risk from the beginning of her admission does not appear accurate.
38. We consider the Trust missed an earlier opportunity to implement its nutrition policy or refer Miss P’s mother to the dietitian team and the eventual referral at the beginning of July, could have been actioned 11 days earlier. We will consider the impact of this later in our report.
39. Miss P is concerned that the Trust did not physically support her mother to eat and drink, and this meant she was not getting the nutrition she needed as she could not feed herself. As above, we have seen evidence that the Trust was using the red tray system for her mother from the end of June, however, the Trust’s Nutrition and Hydration policy does not specify how much support patient’s using this system should get.
40. The dietician’s nutritional plan does not say to what extent the Trust should have supported Miss P’s mother physically during mealtimes. We also cannot see any evidence to suggest the Trust was concerned Miss P’s mother could not feed herself. Therefore, it is difficult for us to say whether the Trust should have physically supported her mother to eat.
41. The entries in the medical records conflict with Miss P’s account of what happened. For example, the medical records document that her mother was able to eat a piece of toast on her own and that nursing staff were prepared to offer her assistance if needed. However, Miss P told us her mother was not able to eat unsupported and did not get the help she needed.
42. Based on this information, there are differing views about what happened and what Miss P’s mother’s needs were. Even on the balance of probabilities, we cannot draw a conclusion as to which is the more accurate version of events. We are sorry that this may disappointing for Miss P.
43. As we have seen that something went wrong with Miss P’s mother’s nutritional screening, we have gone on to consider the impact of this. From what we have seen, the Trust missed an opportunity to accurately screen Miss P’s mother nutritional status and refer her to the dietetic team 11 days earlier than it did.
44. Miss P told us the lack of nutritional support impacted her mother’s condition and contributed to her poor mental state. She feels her mother may have lived longer had she received the right nutrition care from the Trust. She told us she does not feel the Trust listened to her when she raised her concerns about her mother’s care.
45. From what she told us, it is clear that Miss P’s concerns about how the Trust managed her mother’s nutritional care continues to cause her distress. We imagine it was a very difficult time for her as her mother was very unwell, and we were sorry to hear that she feels the Trust did not listen to her concerns at the time.
46. Our physician adviser explained that Miss P’s mother’s rapid decline in health was due to untreatable pancreatic cancer and the complications of this. Therefore, her mother’s nutrition and hydration would not have impacted the progression of the cancer. This means that the Trust’s actions regarding the MUST screening, did not impact Miss P’s mother’s sad outcome.
47. It is understandable that this information may be upsetting to Miss P. We hope the information from our advisers helps to reassure her that her mother’s nutritional intake does not appear to have impacted her condition.
48. Our dietician adviser explained that although the delay in the Trust referring Miss P’s mother to the dietetic team did not impact her overall condition or sad outcome, it could have caused Miss P some of the distress she told us about.
49. They explained that earlier involvement from the dietetic team may have relieved some of the distress Miss P experienced. This is because an earlier referral could have provided her with reassurance that the Trust was listening to her concerns.
50. It is clear from the medical records that Miss P’s mother was very unwell, and her condition was terminal. Therefore, her appetite is likely to have dropped, and we can see that this was distressing for the family to witness her loss of appetite. This rapid decline in her health may have also impacted her mental well-being.
51. We can see evidence in the medical records to show the Trust followed the nutritional plan put in place by the dietician at the beginning of July. For example, it provided her with the prescribed supplements and continued to use the red tray system to monitor her nutritional intake. The dietetic team continued to be involved with Miss P’s mother’s care and considered her nutritional care as part of her palliative care. However, the effectiveness of this plan was limited due to Miss P’s mother’s clinical situation and disease progression.
52. We imagine this was an incredibly stressful and upsetting time for Miss P given her mother’s diagnosis and rapid disease progression. Her concerns about her mother’s nutritional state may have caused her further distress at an already upsetting time.
53. It is difficult for us to say if Miss P’s mother’s nutritional intake could have improved if the dietetic team had reviewed her 11 days earlier. This because the medical records document that she continued to refuse meals and eat small portions following the team’s input at the beginning of July. It is also difficult for us to say how her poor nutritional status may have impacted her mental well-being as it is clear from the medical records that her diagnosis and clinical condition was upsetting and significantly distressing for both Miss P and her mother.
54. However, we consider if the Trust had referred Miss P’s mother to the dietetic team earlier, this may have relieved some of the distress Miss P experienced due to her concerns about her mother’s nutritional intake, as it may have provided her with some reassurance.
55. Our Principles of Remedy say that to put things right, organisations should provide an apology, explanation, and an acknowledgement of responsibility.
56. In its response to the complaint, the Trust explained that although it had documented information about Miss P’s mother’s nutritional intake in her medical records, it acknowledged that it did not fully complete food charts for her and the entries about her nutritional intake was inconsistent. It shared the importance of completing accurate and consistent food charts with staff for wider learning.
57. It explained it referred her mother to the dietetics team as the nursing team recognised she had a reduced nutritional intake. It apologised that it did not escalate Miss P’s concerns about her mother’s nutritional status or reflect this in the medical records. It acknowledged the medical records contradict Miss P’s experience as it had a different account of events. It discussed the importance of listening to and escalating concerns of patients and their families to ward staff.
58. The Trust has acknowledged and apologised for the way it handled Miss P’s concerns about her mother’s care, which is in line with our Principles. However, it does not acknowledge it missed an earlier opportunity to recognise her mother’s poor nutritional picture and refer her to the dietetic team sooner.
59. Although the Trust’s actions did not have any clinical impact on Miss P’s mother’s condition or sad outcome, we can see how her concerns about her mother’s nutritional intake may have caused her some of the distress and upset she told us about. We imagine it made an already distressing situation more stressful.
60. Miss P wants service improvements and a financial remedy. Based on the information we have seen, the Trust has partially recognised issues with Miss P’s mother’s nutritional care and discussed this with staff. However, we cannot see that it has considered service improvements to prevent the same thing from happening again.
61. We considered our Severity of Injustice scale as Miss P requested a financial remedy to resolve her complaint. The impact of the failings we found, falls into the lower levels of our Severity of Injustice scale and we would expect an apology and service improvements to remedy the impact that flowed from the failings, which in this case is distress and upset.
62. Based on this, the Trust has not fully acknowledged or remedied what happened. We consider the Trust could do some further work to resolve this complaint and should implement service improvements regarding nutritional screening to prevent the same thing from happening again. Therefore, we will make recommendations at the end of our report.
63. From what Miss P told us, it is clear that her mother’s sad death was extremely distressing for her, and this continues to significantly impact her emotional well-being. We hope that our findings regarding her mother’s nutrition during her admission, gives her some reassurance that her nutritional status does not appear to have impacted her clinical condition or her sad outcome, and clarifies any information she was unsure about.
Hydration 64. Miss P is concerned the Trust did not support her mother with her hydration needs during her admission between June and July. From what she told us, it is clear that her concerns about how the Trust managed her mother’s hydrations need, continue to cause her ongoing distress which we were sorry to hear.
65. The Trust’s policy on Nutrition and Hydration says a patients fluid intake will be monitored using the fluid intake charts as required.
66. From what we have seen, the Trust recorded Miss P’s mother’s oral fluid intake for one day at the beginning of her admission in June. We cannot see any further documentation regarding her fluid intake until the beginning of July, the day after the dietetic team reviewed her. This means we do not know what her fluid intake was during the first 12 days of her admission, so we cannot say whether or not she received enough fluids during this time period.
67. However, we recognise that before the beginning of July, Miss P’s mother had not been referred to or assessed by the dietetic team, who requested at that point, that the Trust should record her fluid intake for three days. Therefore, this information was not a requirement until this point, and we cannot say the Trust got anything wrong when it did not record her fluid intake before this date. Based on this information, the Trust followed its own guidance on hydration here, which says fluid intake will be recorded as required and it started to do this when the dietetic required it to do so.
68. When the dietetic team assessed Miss P’s mother in early July, it recommended that she should have Ensure Plus juce, which is a fruit juice style supplement drink for people with or at risk of developing malnutrition. The team also recommended that staff should encourage Miss P’s mother to drink fluids.
69. Following the dietetic review, the Trust consistently completed the fluid intake charts for Miss P’s mother to include the supplement drinks for the rest of her admission. We have seen further evidence on the food charts to suggest she also received some form of hydration in other ways such as fruit juice and tea with her meals. We have also seen evidence that suggests staff encouraged Miss P’s mother to drink fluids as per the dietician’s recommendation in early July.
70. From what we have seen, the Trust followed its own guidance on hydration as it recorded Miss P’s mother’s fluid intake as required (when the dietetic team asked it to do so). It also encouraged Miss P’s mother to increase her fluid intake in line with the dietetic team’s recommendations. Based on this, the Trust did not get anything wrong when it managed Miss P’s mother’s hydration care and recorded her fluid and nutritional supplement intake after the dietetic team reviewed her.
71. Although the information in the fluid balance and food charts suggest Miss P’s mother received some hydration during her admission, our nursing adviser explained that she did not appear to meet the fluid requirement of 1290mls per day, set out by the dietitian during the assessment in early July. We have considered if this may have impacted her overall condition.
72. Our dietician adviser explained that Miss P’s mother did not appear to complain of being hungry or thirsty during her admission despite not meeting the fluid requirements set out by the dietetics team.
73. Our physician adviser explained that Miss P’s mother was diagnosed with pancreatic cancer during her admission which sadly, could not be cured. They explained that a loss of hunger and thirst is part of the end stages of life and in Miss P’s mother’s case, a result of her rapidly progressing cancer. They went on to explain that her hydration status did not appear to impact the progression of her cancer or her clinical condition.
74. Based on the evidence we have seen and the clinical advice, Miss P’s mother’s hydration status did not impact her clinical condition, or her sad outcome and we have seen no indication that anything went wrong. The Trust followed its own policy on hydration when it monitored and documented her fluid intake following the dietetic assessment in early July.
75. We hope the information from our advisers goes some way to reassure Miss P that the Trust followed relevant guidelines when it managed her mother’s hydration care during her admission and clarifies any information about this that she was unsure about.
Side room 76. Miss P complains the Trust isolated her mother in a side room at the beginning of July with no means to alert the staff she needed assistance. She says the Trust did not take account of her mother’s personal needs as it did not consider that she could not hear or see well, struggled to use the call bell, found it difficult to communicate, and could not alert the staff that she needed help She told us this isolation broke her mother’s spirit and feels this contributed to her deterioration.
77. We were sorry to hear Miss P’s concerns that the Trust isolated her mother in a side room during her admission, and how the distress of this impacted her mother’s deterioration. It is clear from what she told us that this action by the Trust caused Miss P a great deal of concern about her mother’s care.
78. The medical records show the Trust moved Miss P’s mother to a side room at the end of June following advice from its Infection Prevention and Control Team. When the Trust took a urine sample from her six days earlier, this contained an Extended Spectrum Beta-lactamases (ESBLs) infection. ESBLs are chemicals produced by bacteria in infections, that are more resistant to antibiotics and makes infections harder to treat.
79. Public Health England gives guidance on how to manage ESBLs and says robust infection control measures are important to prevent the spread of infection. This includes hand washing and patient isolation. NMC the code says nurses should deliver the fundamentals of care effectively.
80. Based on what we have seen, the Trust followed the guidance from Public Health England when it moved Miss P’s mother to a side at the end of June as she had been diagnosed with an ESBLs infection, and this requires patient isolation to prevent the spread of infection. We cannot say the Trust’s decision to isolate Miss P’s mother in a side room was wrong, as it followed relevant guidance.
81. We have seen evidence in the medical records that the Trust provided personal care to Miss P’s mother and reviewed her during her period of isolation for four days between the end of June and beginning of July. For example, we can see it provided her with hygiene care and left her comfortable with the call bell within reach at the end of June. This action is in line with NMC guidelines which say nursing staff should provide the fundamentals of care effectively.
82. We cannot see that Miss P, or her mother raised concerns about her ability to alert staff if she needed assistance or that she was not able to use the call bell until early July when Miss P discussed her mother’s care with the Trust and explained her main issues of concern. This included that she felt her mother was forgotten in the side room and she had difficulty pressing the call bell to alert staff she needed help. She felt her mother should be in the open ward to increase her ability to get attention from the nursing staff if needed.
83. At this point, the Trust moved Miss P’s mother back into the main ward area after it took further advice from its Infection Prevention and Control Team about the risk of doing so. It seems the Trust was unaware of Miss P’s concerns about her mother’s ability to alert the staff she needed assistance before this meeting in early July. We cannot see any evidence in the medical records to suggest the Trust had its own concerns that her mother was unable to use the call bell or needed additional help to call for assistance.
84. Based on what we have seen, the Trust followed guidance from the NMC and Public Health England when it nursed Miss P’s mother in a side room due to an infection and provided nursing care to her as it delivered the fundamentals of care effectively.
85. We can see evidence that the Trust reviewed Miss P’s mother during her period of isolation, so we are satisfied it did not forget to care for her as Miss P suspects. Therefore, there are no indications the Trust got anything wrong here.
Conclusion 86. Based on the evidence we have seen and the clinical advice, we consider the Trust followed NMC and Public Health England guidance when it nursed Miss P’s mother in a side room between the end of June and beginning of July. It followed its own policy on hydration when it managed her hydration needs. Therefore, we will take no further action of this aspect of the complaint.
87. However, the Trust did not follow BAPEN guidance when it initially carried out nutritional screening for Miss P’s mother when she was admitted towards the end of June. Based on our Principles, we consider it reasonable the Trust does some further work to remedy this complaint as it has not recognised or acknowledged a missed opportunity for earlier dietetic input for Miss P’s mother. We will recommend an acknowledgement of what went wrong and service improvements to prevent the same thing from happening again.