Mobilisation
29. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and found no indications anything went seriously wrong regarding this point of complaint.
30. Mr U says Mrs U was not adequately mobilised during in her admission to the NCA in December 2022. Mr U says as a result, Mrs U developed a DVT in her leg.
31. The Nursing and Midwifery Council’s (NMC) ‘Standards of proficiency for registered nurses’ 2018 is the standard nurses must demonstrate when caring for people across all care settings. Section 7 of the standards sets out guidance on mobility.
32. It says nurses should use best practice approaches for meeting needs for care and support with mobility and safety, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions.
33. It says nurses should observe and use risk assessment tools to determine need for support and intervention to optimise mobility and safety, and to identify and manage risk of falls using best practice risk assessment approaches, use a range of contemporary moving and handling techniques and mobility aids, use appropriate moving and handling equipment to support people with impaired mobility and use appropriate safety techniques and devices.
34. From Mrs U’s medical records, we can see she had a mobility assessment upon admission. We can see it was noted her mobility needs had changed she needed support from one person when walking. It was also noted, Mrs U needed support from one member of staff when mobilising from bed or chair.
35. From Mrs U’s medical records, we can see she also had moving and handling assessments. A moving and handling assessment is used to identify needs of a patient who requires assistance with mobility.
36. Our nursing adviser said Mrs U’s moving and handling assessments found she had no problems with her comprehension, communication, or behaviour.
37. From Mrs U’s medical records, we can see shortness of breath was identified as a barrier to increased mobility and she was given breathing techniques and exercises by therapists.
38. We can also see Mrs U was assisted by a walking frame to help with mobility and reduce risk of falls.
39. Our nursing adviser reviewed Mrs U’s nursing records and said she was stood up and mobilised daily for the duration of her admission.
40. Our nursing adviser also said Mrs U had regular reviews and mobility practice with therapists which helped to increase the distance she was able to mobilise prior to her discharge.
41. Having reviewed all the available evidence, we consider the NCA followed NMC guidelines around mobilisation and consider Mrs U was adequately mobilised during her admission.
Medication on discharge
42. Mr U says the NCA prescribed morphine and codeine without adequate instructions on dosages or when to administer them. Mr U says he was not aware to only administer morphine and codeine when Mrs U was in pain.
43. The General Medical Council’s (GMC) ‘Good practice in prescribing and managing medicines and devices’ is guidance clinicians must follow when prescribing medication.
44. Section 40 when prescribing medication, clinicians should explain the likely benefits, risks and impact, including serious and common side effects what to do in the event of a side effect or recurrence of the condition how and when to take the medicine and how to adjust the dose if necessary.
45. From Mrs U’s records we can see she was discharged in late December 2024 with morphine and codeine medication. We cannot see any evidence Mr or Mrs U were specifically informed about dosages or when to administer medication, as we would expect in line with ‘Good practice in prescribing and managing medicines and devices’.
46. In its final response, the NCA said when Mrs U was discharged there were no pharmacy staff on site, who would usually explain medications on discharge. It said this should have been done by the discharging nurse, but there is no evidence of this.
47. This indicates the NCA has not followed the GMC’s guidance around prescribing medications.
48. We will consider the impact this may have had on Mrs U. Mr U says the lack of verbal instructions with Mrs U’s medication led to her receiving overdosages, which resulted in delirium. He says while delirious, Mrs U banged her shin which caused a large hematoma on her left leg.
49. We understand this accident would have been very traumatic and distressing for both Mr and Mrs U.
50. Our physician adviser said Mrs U could have become drowsy as a result of her taking the medication incorrectly but could not determine that this led to her injury and resulting hematoma.
51. Our physician adviser said Mrs U was of advanced age, with reduced mobility, and would have been prone to falls. We note there could be many reasons which led to Mrs U’s injury and could not possibly say it resulted directly from overdosages of medication.
52. It would therefore not be possible for us to link the lack of medication instructions to Mrs U’s accident and resulting hematoma.
53. That said, we have considered what action the NCA has taken to address concerns about medication instructions on discharge. In its final response, the NCA apologised to Mr U for shortcomings around communication in relation Mrs U’s medication.
54. It said it has discussed this with the discharging nurse and learning from Mr U’s case has been implemented. It also said this has been shared with the wider team and has been discussed at staff handovers.
55. While we cannot link Mrs U’s accident to the lack of medication instructions, we hope the action taken by the NCA can reassure Mr U learning has been taken from his case and this should help to prevent similar incidents in future.
Psychiatric treatment
56. Mr U says Mrs U should have received psychiatric treatment prior to her discharge from MU in January 2023.
57. In its final response, MU said prior to discharge Mrs U was alert, orientated and her observations were within normal limits. It said there is no evidence of any psychiatric diagnosis or treatment in her medical records.
58. The GMC’s ‘Good Medical Practice’ provides guidance on what medical records should contain.
59. Section 69 says medical records should contain relevant clinical findings, drugs, investigations, treatments, information shared with patients, concerns or preferences expressed by the patient, reasonable adjustments and communication preferences, and decisions made.
60. In line with section 69 of ‘Good Medical Practice’ it should be recorded in Mrs U’s medical records, if she required any psychiatric intervention, however there is no mention or evidence of any psychiatric illness or condition.
61. Our physician adviser said while Mrs U appeared to be confused at times, there was no suggestion or indication she was suffering from any psychiatric illness, or she had a diagnosis of any psychiatric condition.
62. It therefore would not have been necessary to provide any psychiatric treatment or intervention. We hope this can provide reassurance to Mr U.
63. Having reviewed all the available evidence, we have not seen any evidence to suggest Mrs U should have received psychiatric treatment prior to discharge in January 2023.
Supervision of food and drink
64. Mr U says while Mrs U was in MU in January and February 2023, there was a lack of supervision of food and drink intake and that Mrs U was not encouraged to eat and drink more frequently.
65. Mr U says Mrs U was malnourished and lost weight.
66. The NICE guidelines CG92 ‘Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition’ provides guidance on nutrition.
67. It recommends completing a malnourishment universal screening tool (MUST assessment) for patients at risk of malnutrition. A MUST assessment is tool used to identify if a patient is at low, medium, or high, risk of malnutrition.
68. From Mrs U’s records, we can see on admission, a MUST assessment was completed which identified her at high risk of malnutrition.
69. Mrs U was referred to the dietetic team and it was recommended her food intake to be monitored on food charts and Ensure Compact (nutrition supplement) be offered. It also recommended Mrs U be given a red tray which indicates increased supervision is needed at mealtimes.
70. In its final response, MU said in Mrs U’s medical records there is no evidence Ensure Compact supplements were prescribed during Mrs U’s admission. It said food charts had gaps and there was no evidence to suggest Mrs U was given a red tray at mealtimes. It also said there was delay in the reinsertion of Mrs U’s nasogastric feeding tube following surgery.
71. We understand and appreciate this would have been very concerning for Mr U.
72. Our adviser said there was little information in Mrs U’s records around nutrition. Due to the gaps in Mrs U’s medical records and food charts our adviser was unable to come to a view around Mrs U’s nutrition or hydration intake.
73. We have considered whether we can reach a view based on the evidence that is available to us.
74. Having done this, we are not persuaded that we could ever reach a view as to whether Mrs U was malnourished, nor is there any further evidence we could get to help us to do this. It would therefore be unlikely that further investigation would come to any satisfactory conclusion regarding whether the shortfalls here resulted in Mrs U becoming malnourished.
75. We appreciate this will be frustrating for the family, and we are very sorry we have not been able to give them the answers they had hoped for.
76. That said while we have not been able to reach an independent view here, we can see that MU has already acknowledged some gaps in its recording of Mrs U’s food diaries and fluid charts whilst she was on one of the wards.
77. In its final response MU apologised to Mr U and said it has completed a quality improvement project to improve standards and management of patient weight and nutritional status.
78. We hope this can provide reassurance to Mr U, that whilst we can are not investigating this point further, that MU has already taken learning from his case and put improvements in place.
Anticoagulants
79. Mr U says Mrs U’s anticoagulants were incorrectly suspended in January 2023. Mr U says this led to Mrs U developing thrombosis and needing emergency surgery.
80. From Mrs U’s medical records, we can see had been prescribed Apixaban (anticoagulant) since her DVT.
81. The NHS webpage on Apixaban describes it as an anticoagulant medication which makes it easier for blood to flow through the veins and less likely to form blood clots.
82. From Mrs U’s medical records, we can see she presented to ED in late January 2023 with a large bleeding hematoma on her shin. We can see MU staff subsequently suspended Mrs U’s Apixaban medication.
83. We understand it would have been very concerning for Mr U to learn Mrs U’s anticoagulant medication had been suspended.
84. MU said this was necessary as active bleeding is a strong contraindication to anticoagulants and said the benefit of stopping anticoagulants outweighed the risks.
85. The British National Formulary (BNF) webpage ‘Apixaban’ provides guidance on the prescription of Apixaban. The BNF webpage lists active bleeding as a contraindication of Apixaban. This meant it would have been potentially harmful for Mrs U to remain on Apixaban.
86. Our vascular surgeon adviser said patients on Apixaban are at risk of increased bleeding which carries a direct risk to life. Our vascular surgeon adviser said the priority was to control Mrs U’s bleeding and the benefit of stopping Apixaban outweighed the risks.
87. We therefore consider it was a reasonable decision in line with ‘Good Medical Practice’ and BNF guidelines to suspend Mrs U’s anticoagulant medication in January 2023.
88. From Mrs U’s medical records, we can see she developed a mesenteric thrombosis and had emergency surgery in early February 2023. A mesenteric thrombosis is a blood clot which forms in the mesenteric veins in the gut.
89. We appreciate Mr U has raised concerns that the suspension of Mrs U’s anticoagulants could have caused this development of mesenteric thrombosis.
90. Our vascular surgeon adviser said Apixaban is used to stop the development of DVT which is a different type of blood clot to mesenteric thrombosis. Therefore, stopping Apixaban would have had no impact on the development of mesenteric thrombosis.
91. We hope this can reassure Mr U that stopping Apixaban did not lead to Mrs U developing mesenteric thrombosis.
92. Having reviewed all the evidence, we consider it was a reasonable decision in line with ‘Good Medical Practice’ to suspend Mrs U’s anticoagulant medication in January 2023.
Conclusion
93. We hope we have clearly explained the reasons for our decision regarding the concerns Mr U has raised and where possible reassure her with our explanation of the care and treatment provided by the Trusts.
94. We would again like to express our heartfelt condolences to Mr U and the rest of his family. We cannot imagine how difficult it has been for him to raise his concerns with us, and we would like to thank him for giving us the opportunity to consider him complaint.