Visiting during COVID-19
21. Ms C complains the Trust should have let a family member visit her mother during her admission so they could assist with her care. She feels had they been able to help with her mother’s eating and drinking they could have prevented a decline in her health.
22. Ms C explained it was not until they received the Trust’s complaint response that they were told a family member could have visited their mother. Ms C says staff did not offer this to the family.
23. Ms C says her sister asked about visitation several times; when the Trust first admitted their mother and when it transferred her. Each time the Trust told Ms C’s sister visitation was not allowed. She says ‘as a family, we regret not pushing hard on this, but we accepted the staff decision given the unprecedented situation with COVID. My sister did try to visit in person but was turned away.’ Ms C also has explained to us how difficult it is for them to ‘still have to answer these questions after so long after the Trust had made it perfectly clear they no longer want to engage with us.’
24. It must have been difficult for Ms C to later find out her mother’s health had deteriorated. We appreciate it would have been very upsetting to the family that they were not able to see her during this admission. We are sorry to hear of the significant distress this caused.
25. Within its initial complaint response dated 21 February 2022, the Trust said that it recognises how upsetting it was for family members not being able to support loved ones during the pandemic and it acknowledges the of the communication difficulties that arose due to COVID-19 and he imposed restrictions on visiting.
26. The Trust explained that there was an increased risk of contracting COVID-19 when attending the hospital. It said that the Trust was very aware of this issue and followed Public Health England guidance in terms of infection control and processes. It said that at the time of admission, the prevalence in the Stockport area was very high and the consideration of risks versus benefits had to be assessed.
27. The Trust said that the Matron for Dementia Care explained that at the time of admission, the Trust had visiting restrictions in place. It said that within the visiting policy, it indicated that patients with cognitive impairment may be able to have visitors, but that this decision should be made on an individual basis by Senior Management who have had a full overview to enable them to make a full and informed decision whilst weighing up the risks.
28. The Trust apologised that this was not an option that was discussed and for the upset that this must have caused at an already difficult time.
29. Within its second complaint response dated 9 August 2022, the Trust apologised again for the distress that has been caused. It acknowledges how upsetting it must have been for Ms C to not have been able to see her mother. It explained that the Trust was operating under unprecedented times. At the time, the visiting was very restricted and in order to try and keep families updated, the Trust created a family liaison team to keep families updated. It said that the liaison team had regular contact with Mrs K’s family. It said that the staff were aware of the policy, and it was under review in relation to the spread of COVID-19.
30. Within the Trust’s final complaint response dated 21 February 2023, it said that the risk assessments in relation to visiting during the pandemic was a virtual clinical judgement assessment that was taken on individual patients on a day-to-day basis by each ward and dependant on the acuity of the patient and associated risks on the ward.
31. As part of our investigation, we have reviewed the hospital records. An entry in the medical records on 20 April 2021 shows Mrs K’s daughter called the ward to ask about visiting. The registered nurse told the daughter the ward had a no visiting policy.
32. We refer to the NHS ‘visiting healthcare inpatient settings whilst COVID-19 is in general circulation’ guidelines (March 2021). This says that ‘one close family member could visit during the patient’s hospital admission’. These guidelines gave NHS Trusts the discretion to ‘stop all patient visits depending on its capacity’.
33. The Trust’s decision to stop visitors due to the high level of COVID-19 in the area was in line with the above NHS guidelines. This said, the right for a family to request an exemption to this rule was still in place.
34. The records show Mrs K had a pre-existing diagnosis of dementia with confusion. Therefore, she met the criteria in the NHS policy to potentially have one named family member visit and support her during her hospital admission.
35. Unfortunately, whilst we appreciate the policy did not require documentation, it does not change the fact its absence means the Trust cannot evidence this was done. Additionally, it cannot assure Mrs K was part of this risk assessment every day.
36. Instead of telling the daughter they could ask for exemption to this rule, the nurse told Mrs K’s daughter she was only allowed to drop off some clothing.
37. We cannot determine what would have happened had staff correctly told the family of their right to apply for exemption to the no visiting rule. This is a missed opportunity has caused Mrs K’s family distress and we are likely to find this to be a failure.
38. It is important to note that COVID-19 was an unprecedented time, and the NHS was under a great deal of pressure knowing how to navigate the impact of the pandemic. This does not detract from the impact and upset that not being able to visit Mrs K has had on her family.
39. Ms C told us she feels ‘guilty’ for not being with her mother and providing her support during her inpatient stay. This guilt has caused her significant upset and distress at what was already a difficult time following her mother’s death.
40. We have found that the Trust staff did not correctly follow its visitation guidelines. Specifically, its senior staff missed an opportunity to carry out daily risk assessments to determine whether Mrs K needed support from a family member during her inpatient stay.
41. As an outcome of her complaint, Ms C seeks an explanation, apology, and service improvements. From viewing the final complaint responses from the Trust, it has already acknowledged that it failed on this occasion and has provided an in-depth explanation as to why this happened.
42. We do not feel that the Trust could implement any service improvements for this complaint point due to the COVID-19 pandemic now being over. This is no way detracts from the impact that this has had on Mrs K’s family.
43. We think that the Trust has done enough to remedy this complaint point, and that there is nothing further that we could ask it to do.
Nutrition
44. Ms C feels the Trust did not take appropriate action regarding her mother’s nutritional intake. She feels her mother’s health deteriorated when she was in hospital as the Trust did not make sure she was consuming enough food or water. Ms C feels the Trust could have prevented this by letting a family member visit her mother to help.
45. We recognise it would have been very distressing for Ms C to find out her mother had lost weight during her hospital admission, and her health had rapidly declined. We are sorry to hear this has caused her ongoing worry that her mother’s care fell below the standard expected.
46. Within its complaint response letter dated 12 February 2022, the Trust said that Mrs K had daily food charts completed whilst she was a patient on Bluebell Ward which reflects her poor oral intake. It said that as Bluebell is not a strict inpatient facility, strict in/out fluid balance charts were not required, but that it was documented that Mrs Ks fluid intake was poor, and the GPs were aware of this.
47. Within its final complaint response dated 21 February 2023, the Trust set that when Mrs K was admitted to the AMU on 11 April 2021, her must score was zero. It said that Mrs K was transferred to ward B4 on 12 April 2021 and a MUST assessment should have taken place on 18 April 2021 but that there was nothing in the medical notes to indicate that one took place. The Trust sincerely apologised for this.
48. The 'MUST' calculator is a five- step nationally recognised and validated screening tool for adults and can be used to establish nutritional risk. The MUST tool is the most common form of nutritional screening used in the UK across hospitals as well as in the community. An overall MUST score will determine if any action is needed to modify a person's nutrition. A zero score is low risk; one is medium risk (monitor) and two or more is high risk when action is to be taken.
49. The Trust say that Mrs K had a MUST assessment on 20 April 2021. Her MUST score was recorded as 0 meaning that she was at low risk of malnutrition. The Trust that that the MUST score should have been completed every seven days, and the Trust apologised for this.
50. The Trust say that the Trust’s electronic system was being updated to include a prompt for staff to complete a MUST assessment if one has not been completed when required. It says that it hopes the change will reassure Mrs K that in future, such assessments will not be missed.
51. As part of our investigation, we have viewed the relevant medical records. The Trust admitted Mrs K on 11 April 2021, and staff completed a MUST assessment. This is a screening tool used to identify adults who are at risk of malnutrition or obesity. It also includes management guidelines which can be used to develop a care plan.
52. The MUST assessment shows Mrs K had a normal dietary intake and she had not had any unintended weight loss. Staff did not weigh Mrs K, instead they measured her mid upper arm circumference (MUAC) which was in a normal range at 24 cm. Based on this information Mrs K’s MUST score was zero, indicating she was at low risk of malnutrition.
53. MUAC is a recognised and widely used alternative to weighing a patient. If staff are unable to measure a patient’s height or weight, they can calculate a likely body mass index (BMI) range using the patient’s mid upper arm circumference.
54. On 12 April 2021 a senior nurse noted, on 12 April 2021 Mrs K was tolerating diet and fluids with encouragement. The Trust then transferred Mrs K to another ward (B4) with a note saying she would need assistance and prompting for eating and drinking.
55. On 13 April 2021, the nursing notes show Mrs K’s MUST assessment was overdue. The following day the Trust transferred Mrs K to another ward (B2) where it was noted she was taking diet and fluids ‘fairly well.’ As part of the ward admittance process staff weighed Mrs K and noted she was 60 kg. Records show Mrs K had only eaten porridge and some ice cream that day.
56. On 15 April 2021, Mrs K’s nutrition and hydration care plan showed she had a normal diet with fluids. This statement is not supported by the food and fluid intake chart which says she ate only one quarter of her porridge throughout the day. At this point the medical records show Mrs K had not lost weight and her MUST score was still zero.
57. The food and fluid charts show Mrs K was only having a couple of spoonfuls of food such as porridge, ice cream and yoghurt from 15 to 19 April 2021. She was declining any solid foods. Staff again weighed Mrs K on 18 April 2021. She weighed 57.8 kg which is a decrease of 2.2 kg in four days.
58. On 20 April 2021, the Trust transferred Mrs K to the complex discharge planning ward for rehabilitation. The admission assessment form noted Mrs K was on a normal diet and fluids. It also said she needed minimal assistance with feeding. In her first night on the new ward Mrs K’s medical records show she refused to eat supper, and she had ‘not had much fluids’.
59. The senior nurse scored step 1 for Mrs K’s body mass index as zero. For Steps 2 and 3, they wrote ‘new to ward’ with no score documented.
60. At 2.30am of 21 April 2021, a senior nurse completed a new MUST assessment with Mrs K’s score remaining at zero. It also showed Mrs K’s MUAC was 21cm, a reduction of 3 cm since she was admitted 10 days previously.
61. At 10am, an occupational therapist arrived to assess Mrs K. The medical records show they found Mrs K laid in bed with food and tablets stuck in her mouth. The therapist then helped Mrs K to drink.
62. Later that day it is noted Mrs K refused her liquid medication and breakfast. Staff also noted Mrs K had only eaten a small amount of her supper and had a drink.
63. On 22 April 2021, the medical notes show Mrs K was ‘quite agitated’ and refused to eat her breakfast. It also noted she only had a few sips of fluids. The next day staff noted Mrs K was tolerating fluids and had two tubs of ice cream at lunchtime. By 3pm, a physiotherapist noted Mrs K was not responding and was declining. A staff member noted at 11.45pm Mrs K had managed to take a small drink.
64. A staff member then requested a speech and language therapy (SALT) referral. The Trust asked a GP for guidance as Mrs K was becoming more non-compliant and the decline in her food intake.
65. The SALT assessed Mrs K on 22 April 2021. They identified that Mrs K had:
• a moderate impairment in her swallowing (oropharyngeal dysphagia) • decreased awareness and control of the food being swallowed • was at risk of potential aspiration (inhalation of food or fluids into the lungs).
66. The SALT recommendations for Mrs K were:
• mildly thick fluids in an open cup • a puree diet via a teaspoon • be upright and alert • to slow rate • minimise distractions • check oral cavity clear post intake.
67. The National Institute for Health and Care Excellence (NICE) guidelines for ‘Nutrition support in adults’ (2012) recommends using a MUST tool to monitor a patient’s nutrition and detect those at risk from malnutrition.
68. NICE guidelines explain a MUST screening must be carried out if ‘there is clinical concern’ for the patient’s nutritional intake. An example of ‘clinical concern’ includes poor appetite. This is because, a patient’s nutritional status ‘is affected by a number of different factors and can therefore change rapidly. Regular review of the nutrition support care plan by a care professional enables the plan to be adapted to best meet the current needs of the person’.
69. The MUST explanatory booklet says:
• if MUAC is less than 23.5 cm, BMI is likely to be less than 20 kg/m i.e. subject is likely to be underweight.
• if MUAC changes by at least 10% then it is likely that the weight and BMI have changed by approximately 10% or more.
70. The NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’ (2021) says:
• all hospital in-patients should be screened on admission and screening should be repeated weekly or when there is cause for clinical concern • nutrition support should be considered for people who have eaten little or nothing for more than 5 days and /or are likely to eat little or nothing for the next five days or longer.
71. Dementia UK says patients in the later stage of dementia often have difficulties with eating, drinking and swallowing. They give guidance on what can be done to help a dementia patient at risk of malnutrition. Some of the common interventions used are:
• finding out their favourite foods • offering snacks • offering supplements • using a familiar face at mealtimes • asking family to bring food in.
72. Mrs K was an inpatient at the Trust from 11 to 30 April 2021. This is a total of 19 days. The food and fluid intake charts evidence Mrs K’s poor dietary intake from 13 April onwards. According to the NMC code, Mrs K’s intake was sufficient for staff to consider she needed nutritional support by 18 April 2021.
73. On admission to each ward, staff should have completed a MUST assessment within six hours. This means, at a minimum, there should have been four MUST assessments in Mrs K’s records. One for her initial admission and one for each of the further three wards she was moved to. We have only been able to find two MUST forms from 11 and 20 April.
74. Our adviser says the documentation of the 20 April assessment was inaccurate and poorly completed. Our adviser says the 20 April MUST score of 0 was wrong. The MUST score is a three-step process, where you total three independent scores relating to BMI, weight loss and the effects of acute disease. Writing ‘new to ward’ with no score documented for not sufficient.
75. Our adviser says, based on the MUAC reading taken on 20 April, staff should have given Mrs K a score of two or more due to her unintended weight loss. This indicating she was at high risk of malnutrition. The NICE ‘nutritional support in adults’ guidelines class this as a clinical concern as she had lost more than 10% of her admission weight.
76. This is three days before the Trust’s complaint response said it recognised there was a clinical concern with Mrs K.
77. According to the MUST explanatory booklet, at this point staff should have:
• referred to dietitian, nutritional support team or implement local policy • set goals, improve and increase overall nutritional intake • monitor and review care plan weekly.
78. Unfortunately, in Mrs K’s case, this did not happen for another three days.
79. Our review of the medical records evidence issues with Mrs K’s nutritional intake from her admission onwards. Staff recognised that Mrs K needed assistance and prompting for eating and drinking on 12 April 2021.
80. Our adviser agrees appetite can decline when a patient has dementia and is unwell. They also say the appetite can be improved and we cannot say that nutritional intake would not have increased had interventions been in place.
81. Sadly, we will not know if staff could have improved Mrs K’s intake because they did not consider these interventions. We appreciate the difficult and stressful time for staff during the pandemic. However, this has resulted in a lost opportunity to address Mrs K’s nutrition needs sooner and has again left the family with unanswered questions.
82. Overall, it appears her care fell below the standard expected and this amounts to a failing.
83. We have seen evidence of the service improvement that the Trust has made because of Mrs K’s complaint. Within the Trust’s electronic system, a prompt has been added for staff to complete a MUST assessment if one hasn’t been completed, when required.
84. Overall, we consider the Trust has provided a response which is in line with the NHS Complaint Standards as it is fair, accountable, and promotes a learning culture by acknowledging what went wrong and using this complaint as an opportunity to implement a service improvement. We consider this is proportionate to what went wrong.
Discharge supplies
85. Ms C says the Trust did not discharge her mother with the appropriate medical supplies over a bank holiday weekend. She says the Trust said it would send some over in a taxi. Ms C says this did not happen and the Trust has never shown her proof it organised this.
86. The Trust apologised in its response. It said the failure to send a supply of thickener, and medication was due to human error. Once the Trust identified the error, they sent supplies to Mrs K’s home via taxi. The Trust have spoken to the staff member involved to address this as part of their personal learning. It also amended its Stroke Inpatient Operating Procedures (SOP) to standardise and streamline its process, to prevent similar mistakes from happening again.
87. Our ‘NHS Complaints Standards’ says when things go wrong, we expect organisations to ‘give meaningful and sincere apologises’. We also expect organisations to ‘be honest when things go wrong’ and ‘identify suitable ways to put things right for people’.
88. We accept the confusion and delay in sending medical supplies for Mrs K when she was discharged would have caused added frustration and inconvenience for Ms C. We recognise this was a particularly sensitive and difficult time, as Mrs K remained very unwell on discharge from hospital.
89. Our current thinking is the Trust has taken sufficient action to address this issue. We are pleased to see it was open and honest in its response and acknowledged the medical supplies had not been ordered and sent correctly. We are pleased to see it also took prompt action to send the supplies to ‘put things right’ when it became aware of the error.
90. Finally, we can see it has taken steps to improve its service, to prevent similar human errors in future by way of discussing the event with the staff member involved for their reflection and learning. We consider these steps are appropriate to put things right.
Catheter
91. Ms C says the Trust did not tell her it had fitted a catheter for her mother. She says it was not until she got home the family realised one was in place. She says the Trust’s failure to provide supplies with the catheter, and a completed catheter passport, made this shock worse. The passport is a document that records the reason, type and maintenance of the catheter.
92. The Trust confirms a ward GP did not update the discharge documentation to show Mrs K had a catheter. It apologised for this omission and raised the issue of poor record keeping directly with the GP so they could learn from this mistake. The Trust have apologised for any upset this must have caused.
93. The NICE guidelines for ‘Patient experience in adult NHS services’ says, ‘if the patient cannot indicate their agreement to share information, ensure that family members and/or carers are kept involved and appropriately informed.’
94. As Mrs K had dementia, it was the Trust responsibility to tell her family that Mrs K had a catheter before it discharged her. The urinary catheter risk assessment form shows staff discussed the catheter with Mrs K. The entry about speaking with her carer (daughter) is blank. The absence of documentation means it is not possible for the Trust to evidence they spoke to Mrs K’s daughter about the catheter.
95. The only mention we can find where a nurse spoke to the family about Mrs K’s catheter was on 1 May 2021, after the Trust discharged her home.
96. A review of the discharge checklist identifies some potential concerns. The section asking if Mrs K has a catheter is not filled in. This includes questions around whether she needed a continence assessment and if the continence team were aware of the catheter.
97. The section asking if catheter equipment has been supplied only shows the word ‘catheter.’ There is a note saying, on 30 April 2021, ‘contacted daughter’ in the verbal handover section. There is nothing else written in this section and nothing to show this contact included telling Mrs K’s daughter about the catheter.
98. There are indications someone wrote in the word ‘catheter’ after this form was initially done. In the ‘day of discharge – action section: Clexane/NR/Catheter equipment/Dressings’ someone has written ‘N/A.’ At some point someone has then placed a tick on top of that entry, and the word ‘catheter’ appears to have been added.
99. Due to the lack of detail, we cannot rule out the potential that the tick and word ‘catheter’ may have been added after contact was made with Mrs K’s family. There were also no details about whether any catheter equipment was to go home with Mrs K.
100. Records show staff documented the insertion of the catheter on the district nurse referral form. Staff did not tick the option to show they were including a catheter passport when they were sending Mrs K home. This appears to support Ms C statement that the Trust did not send them one.
101. The Trust’s discharge process fell short of the standards we would expect in Mrs K’s case. On the balance of probability, it appears the Trust did not tell Mrs K’s family she had a catheter before discharge. There was no evidence to show Mrs K was sent home with catheter supplies or catheter passport.
102. There was a failure in the Trust’s discharge documentation to Mrs K’s GP. This meant the GP was not aware of Mrs K’s catheter and they did not have a clear clinical picture of her needs.
103. We are sorry to hear of the shock and distress Ms C experienced when she found her mother had a catheter in place. Our NHS complaints standards say we expect organisations to ‘give meaningful apologises’ when things go wrong. It also says we expect staff to ‘recognise the need to be accountable for their actions and to ‘identify what learning can be taken from a complaint’.
104. In this case, we are pleased to see the Trust apologised for its poor communication in the complaint response. We can also see it has directly addressed this issue with the staff member concerned and ‘held them accountable’ for this poor service. The Trust has correctly asked the GP to learn from this complaint to prevent similar issues in the future. We currently consider these actions are appropriate to put this part of the complaint right.
End of Life care
105. Ms Mc Kendry says the Trust did not tell them her mother would need end of life care when she came home. This meant they were not physically and mentally prepared for this. She says the Trust have not clarified in its responses if it classed Mrs K as end of life when they discharged her.
106. On 24 April 2021, the Trust arranged a Zoom (video call) meeting as Mrs K’s family worried about her reluctance to engage. The family requested an access visit be arranged as soon as possible as they wanted to discharge Mrs K home.
107. On 26 April 2021 the nursing records indicate staff asked the GP to assess Mrs K’s decreased oral intake and to determine if she was approaching a palliative (end of life) stage. There is no evidence of the ward GP’s assessment. It is not possible for us to determine if the ward GP assessed Mrs K or what the outcome of the assessment was.
108. From viewing the available records, we can see that Mrs K was discharged on 30 April 2021.The discharge summary and letter to the GP does not mention that Mrs K was end of life. Whilst there is a ‘Symptom Control in Palliative Care And/Or Last Days of Life’ medication chart completed, this is dated 4 May 2021, post discharge.
109. We have also reviewed the district nurse referral from Mrs K, which does not say that she was end of life at this stage.
110. On the balance of probabilities, we cannot say that Mrs K was end of life when she was discharged. As patients can become end of life very quickly, whilst Mrs K may have been extremely unwell, this does not necessarily mean that she was deemed to be at the end of her life upon discharge. This may have been the case a few days after, as recorded within the available evidence. As such, we cannot reach a view on this complaint point.
Weekend support
111. Ms C says her mother did not get appropriate support from the district nurses, or her own GP, on discharge. Ms C feels this was due to the Trust not telling the district nurse or the GP that her mother needed end of life care.
112. The same as above, we are unable to comment on whether Mrs K was at the end of her life when she was discharged. As such, we are unable to hold the Trust accountable for the care she received once she was discharged, or for not advising any external staff within the Trust that Mrs K was at the end of her life.
113. We have found that the Trust has already remedied the complaints points where we have found failings. The Trust was facing unprecedented times because of the global Covid pandemic. We are pleased to see that it has apologised and acknowledged that its service had fallen short and implemented service improvements.
114. We are unable to reach a decision on the balance of probabilities for two of the complaint points.
115. We would like to reiterate that our findings do not detract from the upset and impact that the complaint has caused. We would like to thank Ms C for sharing her complaint with us.