Emergency Department
Pain relief
18. Mrs Y said ED staff did not provide her mother with pain relief for up to six hours when she attended in late May, which left her in pain.
19. The Trust said Mrs D was brought into the ED at 7.40am. It said a senior nurse had assessed her and recorded that Mrs Y had given her 7.5mg of oral morphine.
20. The Trust said an ED doctor assessed Mrs D at 11am and requested an X-ray which showed a fracture of the right hip. The Trust said whilst Mrs D was awaiting the results, she was prescribed IV paracetamol (1g) and 7.5mg of oral morphine which was administered at 1.15pm.
21. The Trust said once the X-ray results were received, staff gave Mrs D a Fascia Iliaca Block (FIB) at 2.15pm, which was the most suitable analgesia for her pain at the time.
22. A FIB is a regional anaesthetic technique where local anaesthetic is injected into the fascia iliaca compartment (a layer of connective tissue in the hip and thigh region) to provide pain relief for the hip and thigh.
23. National guidelines from the Royal College of Emergency Medicine on managing pain in the ED say patients in moderate pain should be offered oral analgesia at the initial assessment or should have the effectiveness of any analgesia they have taken evaluated within 30 minutes of the first dose.
24. ED staff noted Mrs Y had administered the oral morphine before Mrs D had arrived in the ED. The records do not state exactly when this was, however, Mrs D arrived at 7.40am, so we know it was before this. Mrs Y has also clarified it was her sister who had administered the oral morphine.
25. Mrs D was triaged and this was shortly followed by a rapid assessment and triage (RAT – a process that uses a quick, initial assessment to immediately determine a patient’s level of urgency and needs, prioritising care for the most critical cases first).
26. A clinician then assessed Mrs D at 11.19am, ordered scans and prescribed the FIB, which staff administered once the results of the X-ray came through, at 2.15pm.
27. NICE guidance on hip fracture management (1.3.6) says staff should consider adding nerve blocks if paracetamol and opioids do not provide sufficient pre-operative pain relief.
28. Our ED adviser felt staff in the ED assessed Mrs D and prescribed the appropriate pain relief in line with Royal College of Emergency Medicine guidelines.
29. However, our adviser said the problem in this situation was there was a significant delay in staff administering the pain relief once it had been prescribed.
30. The British National Formulary (BNF) recommends 5-10mg of morphine can be administered every four hours for acute pain in elderly patients.
31. Mrs D was in severe pain from her injury and there was at least six hours between her taking doses of oral morphine. Our ED adviser also said there was no reason Mrs D could not have had top up pain relief even after she had taken the first dose of oral morphine.
32. We consider this to be a failing in line with Royal College of Emergency Medicine guidelines which exacerbated the pain Mrs D was already experiencing.
Fluids
33. Mrs Y also said ED staff did not provide her mother with sufficient fluids, which left her feeling dehydrated.
34. The Trust said whilst Mrs D was awaiting the results, she was prescribed a litre of IV fluids which was administered at 1.15pm.
35. The Trust said on the day of Mrs D’s attendance, there was a shortage of infusion pumps in the ED which are used to deliver IV fluids.
36. NICE guidelines on IV therapy in adults in hospital say staff should:
‘Assess and manage patients’ fluids and electrolyte needs as part of every ward review. Provide IV fluid therapy only for patients whose needs cannot be met by oral or enteral routes and stop as soon as possible’.
37. We have reviewed the records and have not seen any evidence of the Trust providing Mrs D with fluids prior to the IV at 1.15pm.
38. Our ED adviser noted Mrs D was not nil-by-mouth during her time in the ED and there was no reason she could not have had oral fluids to rehydrate, while waiting for the IV pump. Our adviser said it was especially important for Mrs D to be hydrated due to her significant comorbidities and chronic kidney disease.
39. Mrs Y has clarified that due to her mother’s intrathoracic stomach (when part or all of the stomach pushes up through the diaphragm into the chest cavity), she had difficulty swallowing and could only manage small sips. We consider this made it especially important for the Trust not to delay in arranging IV fluids.
40. We recognise there were staffing and resource issues in the ED on the day of Mrs D’s attendance. Despite this, we consider staff should have been more proactive in responding to Mrs D’s fluid needs.
41. We consider this to be a failing which caused Mrs D some additional distress. We recognise Mrs D would have been thirsty during this time in the ED, however, we have not seen sufficient evidence Mrs D was clinically dehydrated during this time.
Incontinence
42. Mrs Y also said during her mother’s time spent in the ED, she passed a large volume of diarrhoea. Mrs Y said she alerted nursing staff on several occasions that her mother needed cleaning and changing. Mrs Y said it was two hours before nursing staff changed her.
43. The Trust said that as Mrs D had suffered a fractured femur, she required two nurses to provide her with personal care. The Trust said a nurse and a Health Care Assistant (HCA) changed Mrs D’s pad several times. The Trust said Mrs D did not wait two hours to be changed, although the HCA was unable to immediately change her pad at the time Mrs D asked due to dealing with a dementia patient who was at risk of falling and wandering.
44. We have reviewed Mrs D’s ED records from the day of her admission. The records are not extensive and do not make any reference to Mrs D being incontinent.
45. However, Mrs Y has provided a detailed account of the events, and the Trust has acknowledged in its response and subsequent meeting with Mrs Y that staff did not make detailed enough records on the day Mrs D was admitted, that would support its version of events.
46. The Trust said it had spoken to staff and reiterated that any interaction with a patient or family member must be documented.
47. The Trust also acknowledged after speaking to the HCA that there were some inconsistencies in its original account of events.
48. The ED records clearly document that Mrs D was unable to bear weight following her injury and would therefore require assistance with her toileting needs.
49. NICE guidelines on patient experience in adult NHS services say staff should:
‘Ensure that the patient's personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. Regularly ask patients who are unable to manage their personal needs what help they need. Address their needs at the time of asking and ensure maximum privacy.
Observe, assess and optimise skin hygiene status and determine the need for support and intervention’.
50. The guidelines do not specify how frequent any monitoring should be. However, Mrs D was in the ED for a total of twelve hours following triage, and our nursing adviser said it would be expected she would be regularly reviewed and receive assistance with toileting over this timeframe.
51. There is no documented evidence Mrs D was checked at all during these twelve hours, which is not in line with national standards and guidelines.
52. We recognise staff must prioritise urgent care and the HCA was unable to immediately attend to Mrs Y due to the safety of another patient.
53. Our nursing adviser said in this situation, staff would be expected to inform Mrs D or Mrs Y of the delay, and that they would assist as soon as they were able to.
54. We cannot say with certainty how long Mrs D had to wait for her pad to be changed as there is no documentation of these events. This itself is not in line with nursing standards, which state staff should demonstrate the ability to keep complete, clear, accurate and timely records.
55. Mrs D was a vulnerable patient who had suffered a fall and required assistance with mobilising to use the toilet. Nursing staff should have regularly reviewed her and supported her toileting needs during her time on the ED. We have seen no evidence to say this took place. We consider this to be a failing that compromised Mrs D’s dignity.
56. Mrs Y said her mother then developed a painful moisture lesion because of the length of time she had to wait to be changed in the ED.
57. Moisture lesions, or Moisture-associated skin damage (MASD) is the general term for inflammation of the skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva or mucus.
58. The Trust identified the MASD in early June, once staff had transferred Mrs D from the ED.
59. The records show prior to her admission, Mrs D wore continence pads and sometimes struggled to make it to the toilet due to her laxatives. There is also a note which states Mrs Y had expressed concerns about her mother’s pressure areas as she had been bedbound since the week before her admission .
60. Our nursing adviser said as Mrs D had been suffering with incontinence and reduced mobility for at least four days before her admission, it is likely she had some moisture damage prior to her time in the ED.
61. We are therefore unable to say the time Mrs D had to wait for her pad to be changed in the ED directly caused her to suffer a moisture lesion. However, we consider it is may have made any existing moisture lesion that Mrs D had worse, which increased her pain.
Ward 23
General hygiene
62. Mrs Y also said that once her mother was on a ward following surgery, staff did not adhere to general hygiene and infection control practices when caring for her mother. Mrs Y said she witnessed staff not washing their hands, lack of paper towels, and gloves not being changed.
63. The Trust did not provide comments on its staff’s hygiene practices. It said it would monitor infection control measures closely on the ward, following Mrs Y’s feedback.
64. NICE quality standards on infection prevention and control in hospital say:
‘People receive healthcare from healthcare workers who decontaminate their hands immediately before and after every episode of care. There should be evidence of local arrangements to ensure
• the availability of facilities for hand decontamination • all healthcare workers receive training in hand decontamination • regular local hand hygiene observation audits and undertaken.’
65. It is difficult for us to reach a view based on the available evidence to say whether staff were following infection control procedures each time in Mrs D’s case. Our nursing adviser said routine infection prevention interventions such as hand hygiene adherence and glove use adherence are not documented within patient records.
66. We have reviewed the Trust’s handwashing observational audits for the time Mrs D was in hospital on Ward 23. These audits are an indicator of how thorough nursing staff were in observing general hygiene on the ward.
67. NHS England does not set a single, universal target for handwashing audit scores but requires audits to be performed at least monthly with the goal to achieve a high compliance rate.
68. The audits from the ward show staff scored consistently high (never below 80%) and when there were issues identified, for example staff not using the correct method to wash their hands, staff put actions in place to resolve these. There were no repeat issues in the audits.
69. We have also reviewed the most recent Care Quality Commission (CQC) report for the Trust. The CQC assesses the risk of infection in healthcare settings and shares any concerns with the appropriate organisations. The CQC graded the Trust as good and did not report any significant issues with staff observing hygiene procedures.
70. We recognise Mrs Y feels strongly that staff not following hygiene and infection control procedures caused her mother to contract a campylobacter infection during her admission.
71. Campylobacter is a common cause of food poisoning with symptoms including diarrhoea, stomach cramps and a fever. Our adviser said it is generally an infection that is spread through contaminated food, and it would be difficult to determine the cause unless there was a significant outbreak on the ward.
72. The Trust investigated and said there was no evidence to suggest that staff actions and daily routine played a part in the campylobacter infection. Once the infection was identified, the Trust placed Mrs Y in a side room and began a course of antibiotics to treat it. We consider this shows staff were taking the appropriate infection control measures.
73. We acknowledge the Trust’s observance with general hygiene did not meet Mrs Y’s expectations. We have not seen sufficient evidence to say this fell below the expected standards.
Falls
74. Mrs Y said nursing staff did not do enough to prevent her mother from falling and did not properly document her first fall, which put her at risk of further falls.
75. The Trust said there is no evidence from the records that Mrs D fell in early June 2023. The Trust acknowledged that Mrs D fell in early July , and then around a week later.
76. The Trust said it logged both these incidents but failed to inform the family after the first incident on in early July.
77. The Trust explained the nursing team was aware Mrs D was admitted after a fall at home which resulted in a fracture, increasing her risk of further falls. It said staff placed Mrs D in a bed close to the nurse’s station. Mrs D was also wearing red slipper socks to reduce the risk of falls, and a falls wrist band which helps identify patients who are at risk of falls to other healthcare professionals.
78. NICE guidelines on assessing the risk of falls in elderly patients say:
• ‘older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past years and asked about the frequency, context and characteristics of the fall/s • 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.’
79. Mrs D’s records show staff carried out a falls assessment when she was admitted to the ward and the physiotherapy and occupational therapy team assessed her to improve, treat and manage her reduced mobility. Our nursing adviser said this was comprehensive and in line with NICE guidelines.
80. The multidisciplinary assessment put in place a care plan with interventions including red non-slip socks, an appropriate walking aid (Zimmer frame), a falls risk band and a call bell and drinks within Mrs D’s reach.
81. Our adviser said despite these interventions, Mrs D’s dementia presented a challenge as she would forget her Zimmer frame and overestimate her ability to mobilise safely.
82. The NICE guidelines say falls interventions should take into account whether the patient’s individual risk factors can be treated, improved or managed during the patient’s expected stay.
83. Mrs D’s dementia was an important risk factor that could not be improved during her admission, so staff had to manage this risk.
84. Our adviser said Mrs D required more than the general level of observation due to her dementia and staff should have conducted enhanced observations.
85. The Trust’s Falls Prevention policy that was in place at the time says all patients at risk of falls should be closely monitored and for some patients it may be appropriate to provide one to one observation or an enhanced observer (EO).
86. Additionally, the Trust’s internal procedure for Enhanced Observation has a risk assessment tool to identify patients who may be exhibiting behaviour which may endanger themselves or others and therefore may need an EO.
87. Once staff moved Mrs D to a side room for infection control reasons, they noted that she was at high risk of falls due to her dementia but there was no EO available. The notes state that supervision was provided, and a behavioural chart was in place, however it is unclear from the available evidence the level or frequency of this supervision.
88. Our adviser said the level of observation required for a patient at high risk of falling would result from a completed risk assessment tool, but the Trust do not appear to have done this once Mrs D moved to a side room.
89. The Trust has also not addressed in its response the reason why enhanced observations were unavailable. It explained that one-to-one care would be initiated if there was evidence of behaviours that are challenging or if patients are at significant risk of harm to themselves or others.
90. The Trust said on reviewing Mrs D’s notes, the nursing documentation does not indicate that one-to-one care would have been advised but recognised that nursing staff would have benefited in completing a risk assessment tool to identify the level of care recommended.
91. In early July, Mrs D suffered her first fall after getting up to use the toilet independently and without using the call bell. The Trust completed an incident report which documented the time of the events and the circumstances of the fall but did not inform Mrs Y.
92. Six days later, Mrs D had a second fall. This was a similar scenario to the first fall, where Mrs D had tried to use the toilet without assistance. The Trust again documented the fall in line with relevant standards and informed Mrs Y.
93. Our nursing adviser said as both these falls occurred in the exact same way as Mrs D’s presenting fall at home, an enhanced observation could have reduced the risk of her falling.
94. A national audit from the Royal College of Physicians says:
‘There are no single or easily defined interventions which, when done on their own, are shown to reduce falls. However, research has shown that multiple interventions performed by the multidisciplinary team and tailored to the individual patient can reduce falls by 20–30%. These interventions are particularly important for patients with dementia or delirium, who are at high risk of falls in hospitals’.
95. If the Trust had assessed the level of care and observation Mrs D needed, taking into account the risk factors caused by her dementia, this could have reduced the risk of her falling twice in early July.
96. We acknowledge Mrs Y said there was another fall, in early June. Mrs Y said a patient in the bed next to her mother told her about this and staff did not mention it when she visited the following day.
97. Mrs Y said if staff had properly documented this at the time, it may have reduced the risk of Mrs D falling in July.
98. The Trust said it had reviewed Mrs D’s records and there was no evidence to indicate she fell on the ward in June. We have also reviewed the records and we have not seen any clear evidence of this.
99. We have carefully considered this and find we do not have sufficient evidence to reach a view. This does not affect our overall view that the Trust did not do enough to reduce the risk of Mrs D falling.
Pain relief after surgery
100. Mrs Y said staff did not do enough to manage her mother's pain in the days and weeks following her surgery, which caused her severe pain.
101. The Trust said Mrs D’s medical notes indicate that her pain scores were monitored regularly, and she was provided with regular pain relief. The Trust acknowledged there may have been a lack of appropriate evidence to support that there was timely action and monitoring was undertaken when there was a high pain score to ensure Mrs D’s pain was adequately controlled.
102. Mrs Y said in mid-June, the Trust changed her mother's pain medication plan without speaking to her or the family, and this left her mother without sufficient pain relief over a weekend.
103. The Trust said it discontinued Mrs D’s slow-release morphine as Mrs Y had said that her mother had been feeling sleepy. It said it prescribed Oramorph 5mg four times a day, but this was prescribed on an as required basis. It said it then amended this a few days later.
104. Guidance from the Royal College of Anaesthetists (RCoA) on pain management following surgery says:
‘The treatment of acute pain is essential to facilitate recovery from surgery or trauma by enabling early mobilisation and avoiding complications, including the bed-bound risks of venous thromboembolism, pulmonary embolus, pressure sores and pneumonia. Severe untreated acute pain may also predispose to the development of chronic pain.
Opioids are very effective in treating acute pain and are best used as part of a multimodal analgesic approach in combination with paracetamol, non-steroidal anti-inflammatory drugs and local anaesthetics where appropriate. Initiating opioids in the acute setting requires a prescriber to ensure that the opioids are not continued beyond the expected period of tissue healing.’
105. Additionally, NICE guidelines specifically regarding pain management after a hip fracture say staff should offer paracetamol every six hours postoperatively unless contraindicated (when a particular treatment or medication should be avoided because it could be harmful to a person due to a specific condition, symptom or factor).
106. The guidelines also say staff should offer additional opioids if paracetamol alone does not provide sufficient postoperative pain relief.
107. Mrs D’s records show following her surgery, staff prescribed her regular paracetamol and daily doses of opiates between one and four times a day when the paracetamol was ineffective.
108. The Trust prescribed opiates in a variety of forms, which included short acting morphine, both regularly and as required, short acting oxycodone and a trial of controlled release morphine. The records also show Mrs D had regular reviews of her analgesia.
109. By mid-June, there had been occasions when Mrs D had declined further pain medication, and her physiotherapy assessments show she was no longer experiencing pain problems which were affecting her mobilisation.
110. Our geriatrician adviser said at this stage, as it had been two weeks since the surgery had taken place, the Trust was correct to begin reducing the slow-release morphine. This was in line with the RCoA guidelines on not continuing opioids longer than necessary and continuing to review this on a regular basis.
111. Over the weekend when the Trust made the changes to Mrs D’s pain relief, staff continued to record Mrs D’s pain scores and provided analgesia when she reported pain. During this time, Mrs D also received regular paracetamol in line with the NICE guidelines. The records show there was no period where Mrs D was without pain relief over these days and staff continued to assess her pain regularly.
112. We recognise Mrs Y was concerned that staff changed her mother’s pain treatment plan without discussing this with her first. We appreciate as Mrs D was a vulnerable patient with dementia, Mrs Y wanted her or her sister to be involved in any decisions about her treatment.
113. GMC Good medical practice says staff must give priority to the investigation and treatment of patients on the basis of clinical need.
114. Our adviser said it would have been appropriate, given Mrs D’s circumstances, to discuss any changes to her treatment plan with Mrs Y. However, the above guidance encourages clinicians to make patients their first priority, and there was no risk to the treatment plan being changed as Mrs D was continuing to receive pain relief when she needed it.
115. We understand Mrs Y’s concerns about staff regularly updating her. Based on the evidence we have seen, we consider the Trust managed Mrs D’s pain correctly following her surgery.
Rough handling
116. Mrs Y said nursing staff handled her mother roughly when moving her, which caused her mother pain.
117. The Trust assured Mrs Y that all staff have undergone statutory moving and handling training. It said it has shared Mrs D’s experience with staff on Ward 23 and will ensure close monitoring of inappropriate moving and handling techniques that put patients at risk.
118. We recognise it is difficult to say from Mrs D’s medical records that staff handled her roughly. We have carefully considered the available evidence to understand if nursing staff took the necessary actions to reduce the likelihood of Mrs D experiencing any pain while being moved.
119. The NMC Code says nursing staff should ask for help from a suitably qualified and experienced professional to carry out action or procedure that is beyond the limits of their competence.
120. Our nursing adviser said it is not always possible to avoid pain when moving a patient during periods of rehabilitation, but there are interventions staff can perform that can reduce pain levels.
121. In line with the NMC Code, the adviser said staff would be expected to escalate to relevant specialities in such circumstances.
122. Mrs D’s records show she had reported some pain while mobilising during physiotherapy sessions in the days following her surgery, even when staff had given her pain relief prior to the sessions.
123. Nursing staff had asked for additional advice from the physiotherapist due to the issues Mrs D was experiencing. The physiotherapist advised nursing staff to transfer Mrs D with two additional staff members to try and reduce this pain as much as the situation would allow.
124. The records clearly document staff were aware of Mrs D’s continuing pain which was worse when mobilising. Nursing staff made plans to limit this pain as much as possible when moving Mrs D and showed sensitivity to her circumstances.
125. We recognise Mrs Y had concerns about her mother’s vulnerability in the days following her surgery and found it difficult to witness her mother in pain when being moved. The evidence we have seen suggests staff took the correct actions to address this.
Conclusion
126. We appreciate this was a very difficult experience for Mrs D. She had sustained a serious injury that had required a significant surgery. Mrs D was also a vulnerable patient due to her comorbidities and her dementia.
127. This was also very challenging for Mrs Y as she witnessed her mother in pain and distress.
128. During Mrs D’s time in the ED, we consider the Trust failed to manage her pain and delayed arranging IV fluids. This exacerbated Mrs D’s pain and caused her and Mrs Y distress.
129. We also find the Trust failed to clean Mrs D in a timely manner after she had been incontinent. This again caused her and her daughter distress and compromised her dignity. Although we cannot say this caused Mrs D’s moisture lesion to develop, we consider it may have made any pre-existing lesion worse in the time before the Trust detected it.
130. Once Mrs D had undergone surgery and was recovering on the ward, we find the Trust failed to put measures in place to reduce the risk of her falling. We cannot say this caused Mrs D to fall twice in early July. However the Trust did not do enough to avoid the potential for this happening. We also recognise this in itself caused Mrs Y some distress.