Frequent ward moves
22. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We realise the negative impact of frequent move for patients in hospital, particularly when experiencing delirium. We have seen the Trust has already done enough to address this issue.
23. Mr C complains about the number of times the hospital transferred Mr O. Whilst he understands the reason for some of the moves, he says on other occasions staff moved Mr O without informing his next of kin and despite his fluctuating mental and physical capacity.
24. Mr C says this caused confusion and distress for Mr O. Additionally the lack of communication by staff caused uncertainty for the family about what was happening.
25. The Trust has apologised for the uncommunicated moves. Additionally, it says it has implemented a scheme called ‘keep me here’ to prevent inappropriate transfers of patient care.
26. NICE guidelines 103 say, ‘avoid moving people within and between wards or rooms unless absolutely necessary’
27. We asked our adviser about the impact of frequent moves and whether the Trust has done enough to improve this issue.
28. Our adviser said frequent moves are a common problem within hospitals. Literature indicates the negative impact of multiple moves and a frequent change of hospital environment for a person experiencing delirium or confusion. There are no national guidelines that outline a minimum or maximum amount of times a patient should move during admission.
29. Our adviser reviewed the ‘keep me here’ initiative implemented by the Trust. They considered it was a good idea on face-value and a proactive piece of work by the Trust. They were not aware of any other such schemes. They acknowledged the scheme is in its infancy and it will need to be assessed via an audit to understand whether it has any meaningful impact.
30. Our adviser also noted Mr O’s fall did not happen the day he changed wards, rather a couple of days later. They said had he fallen within the first 24 hours of moving wards, the fall could have been linked to the ward change.
31. We do not underestimate the recognised impact of frequent ward changes, and understand this contributed to Mr O’s confusion. We also realise the frustrating impact on the family, particularly when moves were not communicated appropriately. We consider the Trust has done what we would ask it to do by apologising and implementing a scheme to make service improvements. We will not be looking at this part of Mr C’s complaint further.
Falls
32. Before we decide if we should conduct a detailed investigation of a complaint, we also look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We appreciate the devastating impact of Mr O’s falls. We cannot link the events complained about with the negative impact Mr C has claimed
33. Mr C has raised his concerns about two falls Mr O experienced whilst in hospital. He says these were not witnessed by staff. He says Mr O was not escorted to the bathroom on the day of his fall in October. He says staff were not present for the second fall because it was handover time.
34. Mr C said the first fall resulted in an SAH and SDH which have impacted on his deterioration and have caused long-term health implications.
35. The Trust said staff assessed Mr O on admission to ascertain the level of risk in relation to falls. It says Mr O was assessed as requiring observation and supervision to mobilise so was allocated a bay with additional staffing support.
36. It said Mr O was encouraged to ask staff for assistance when mobilising.
37. NICE guidelines 161, says ‘older people who present for medical attention because of a fall… should be offered a multifactorial fall risk assessment’.
38. NICE guidance 161 says, ‘multifactorial assessment 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 and neurological examination, assessment of urinary incontinence, assessment of home hazards, cardiovascular examination and medication review’.
39. NICE guidelines 161 identify a falls assessment should include medication review alongside encouraging and supporting physical activity and exercise addressing the person’s risks of falls such as balance, coordination, strength and power.
40. The guidelines go on to say staff should discuss with the patient how to move around safely and how to seek help, how to use unfamiliar equipment for example the call bell and to be aware a person’s risk factors may change when they are in a hospital.
41. We can see on admission staff completed a comprehensive assessment of Mr O. They reviewed Mr O’s medication and took his standing and lying blood pressure. We can see the physiotherapist assessed his mobilisation and there is evidence of a multi-disciplinary meeting.
42. We can see several entries where the medical surgical therapy team have assessed and supported Mr O’s mobility, including standing and sitting, walking to the bathroom, using stairs and the toilet. We can see they identified he was steadier with a Zimmer frame and encouraged independent mobility.
43. We can see a nursing note that indicates staff supervised Mr O to the bathroom on the day he fell. It says he fell inside the cubicle and hit his head.
44. We asked our adviser whether appropriate measures were in place to minimise the possibility of Mr O having a fall.
45. They identify clinical records indicate Mr O had had several falls preceding his admission. This meant he was more at risk of a fall. They say staff took appropriate action with regards to assessing his mobility on admission.
46. They note records indicate Mr O’s confusion was relatively mild on admission and he presented as alert. The physiotherapy assessment indicated he was able to walk unsupervised. This would have impacted on the risk assessment.
47. The falls assessment tool within the records indicate Mr O was under ‘routine supervision’ at this point. Our adviser considered this was appropriate given the outcome of the assessment.
48. We can see from records, Mr O was reviewed regularly after admission and there is nothing in the notes to suggest his presentation had changed or deteriorated, He remained on ‘routine supervision’.
49. Unfortunately, Mr O fell in the hospital setting at the end of October.
50. We can see this prompted medical intervention. He went for a CT (computer tomography, a computer guided X-ray) scan promptly. There is evidence of neurological observation and a referral for a neurological review, alongside a medication review.
51. Within the records, is included the Trust’s ‘enhanced levels of care assessment and care plan’. This outlines appropriate levels of supervision from ‘routine ward supervision’ through to ‘eyeline supervision’ to ‘arm’s length supervision’.
52. This documents states, ‘eye supervision should be in place if a patient has been ‘identified at being at risk of falls with one or more of the following – an inpatient fall has occurred, impulsive reactions, requires supervision or assistance to mobilise but non complaint in using call bell, experiencing dizziness’.
53. Eyeline supervision involves, ‘relocation of patient to high visibility area, cohorting high risk patients if above achievable – 1 staff member allocated to the bay using current staff levels. Member of staff to stay in the bay / observe the side room at all times’.
54. According to the Trust’s assessment tool. Mr O remained on routine supervision up until his second fall in December.
55. Our adviser said routine supervision was a clinically sound decision when Mr O was admitted to hospital according to the assessment. However, following this first fall, it would have been appropriate and in line with the Trust’s own assessment tool to escalate Mr O’s level of supervision.
56. We know Mr O received significant injury as a result of the first fall. We realise how distressing this must have been for the family. We consider the level of supervision was appropriate at this time and in line with NICE guidance 161. Therefore, we cannot link the Trust’s actions with the injuries related to the first fall.
57. Records do not indicate Mr O experienced significant harm from the second fall. However, he was high risk of falls at this time, and we cannot see the Trust raised his supervision level. We consider the Trust missed an opportunity to minimise the risk of this fall happening, and further potential damage, by increasing its supervision levels.
58. Whilst we consider the level of supervision was appropriate prior to Mr O’s first fall, we asked our adviser whether it is possible to attribute Mr O’s subsequent care and health needs to the fall in October and the fall in December.
59. They said Mr O attended hospital with a history of some falls and confusion. His acute presentation was with delirium. He had not been assessed with dementia, but records allude to him being in the pre-diagnosis stage of dementia.
60. We can see the Trust completed a MoCHA assessment after the fall in October. This is an assessment designed to detect cognitive impairment. This showed significant deficits in Mr O’s mental state. They say it is likely the head injury obtained when Mr O fell in October caused some lasting damage, on top of Mr O’s pre-existing health conditions. This must have been a very worrying time for both Mr O and Mr C.
61. We realise how distressing it was for Mr O and the family when he fell again in December. We consider the Trust should have increased supervision levels prior to this to minimise the possibility of a further fall. We cannot say this fall contributed to his deterioration.
62. We do not think it is possible to attribute the deterioration reported in Mr O’s health, including the need for 24 hour care, solely to the head injury sustained in October 2023, or the impact of the fall in December. Mr O’s health was sadly deteriorating prior to his falls under the care of the Trust.
63. We are in no way saying the injuries sustained from the October fall did not impact significantly on Mr O’s health or make his care more difficult. We consider the Trust had supervision in place in October, in line guidance, and this should have increased after the fall. We also know Mr O was unwell prior to be admitted to the Trust. We cannot attribute the need for 24 hour care solely on the injuries sustained in October and December 2023.
Communication
64. Mr C complains about the lack of communication by staff to the family about Mr O’s clinical situation. He said they were often told incorrection information about Mr O’s condition.
65. Mr C also said there was poor communication with the hospital between wards leading to confusion by staff.
66. In its response, the Trust said as a direct action of the concerns Mr C raised, it identified measures it would put in place to ensure that staff coming onto shifts are uninterrupted during the handover period and allows them to have the full information for all patients.
67. GMC’s Good medical practice says, ‘you must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. This means you must a) share all relevant information with colleagues involved in your patient’s care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers’.
68. We cannot see from the records and written handover notes or evidence of verbal handovers when the Trust transferred Mr O to different wards.
69. We can see some evidence of nursing handovers notes when shifts changed.
70. We can see there is evidence of the risk assessments and care plans continuing throughout Mr O’s admission.
71. We asked our adviser about his view of the communication between staff. They told us there is no national guidance in place to say how handovers should be conducted. They said if they are done verbally it is normal practice that these are not recorded.
72. Our adviser felt there was no evidence of a disconnect within nursing notes. They considered the logical flow of notes, the continued care plans and risks assessments suggested a continuity of care for Mr O whilst he was an inpatient.
73. With regards to Mr C’s complaint about the communication with the family, we can see a number of nursing notes within the records indicating a reasonable amount of communication between staff and the family.
74. GMC guidance 32 says, ‘you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
75. The Trust acknowledged a shortfall in the level of communication and apologised. It said it has introduced a communication care plan to allow it to ensure all relevant communications are documented and discussed with the next of kin. The Trust said it will be auditing this regularly to ensure that this tool to aid communication is being used and is effective.
76. We appreciate the concerns Mr C and the family had about Mr O. We realise the importance of good communication and the impact a lack of this will have. We can see the Trust has acknowledge this shortfall, apologised and has made some service improvements as a consequence. It has done what we would expect it to do.
77. We were sorry to hear about Mr O’s experiences in hospital and the deterioration in health he has experienced. Our decision does not take away the importance of Mr C’s complaint and our awareness of the concern and distress Mr O’s health decline has caused for the family.