Issue one- concerns relating to the falls
27. Miss X raises complains that due a negligence in care her mother received from the Trust, she suffered falls on the 4 and 7 March 2023.
Fall on 4 March 2023
28. We understand from the records, Mrs Y was admitted to the Trust’s emergency assessment unit (EAU) at 11.53pm on the 3 March 2023. Following this, she was found by a member of staff sat on the floor of the bathroom bay. We can understand how upsetting this must have been for Miss X to learn about.
29. The Trust say in its response dated 21 June 2023 that the fall was unwitnessed. This was because the nurse allocated to that bay was with another patient at the time. It says following the fall, Mrs Y was assisted off the floor. The Trust says Mrs Y confirmed she was not dizzy and did not have a black out. She was reviewed by a doctor and the falls specialist nurse.
30. We have carefully considered the evidence and have obtained clinical advice in relation to this.
31. NICE guidelines, ‘Falls: assessment and prevention in older people and in people 50 and over at a higher risk’ says in section 1.1.7 that professionals should: ‘Offer a comprehensive falls assessment and comprehensive falls management to people in hospital inpatient settings and residential care settings.’
32. The guidance further explains how a comprehensive falls assessment should be completed. In section 1.2.3 it says professions should:
‘Ensure that person’s individual risk factors identified in the comprehensive falls assessment are promptly addressed with appropriate interventions to reduce their risk of falls’.
33. From the records, specifically the ‘nursing admission and assessment’ document we can see at the time of admission on the 3 March 2023 it is documented that Mrs Y was at a high risk of falls. The records document that she was unable to stand and required assistance from 1-2 staff.
34. The records document that at the time of the fall she was found sitting on the floor. It is reasonable that if she was assisted by 1-2 staff, she would not have suffered a fall. There is evidence to suggest that the interventions advised were not followed. This is not in line with NICE guidelines detailed above.
35. We therefore consider there to be evidence to suggest that the fall on the 4 March 2023 occurred due to poor care. We find failings here.
Fall on 7 March 2023
36. Mrs Y suffered another fall on the 7 March 2023, which we understand was also unwitnessed. The Trust has acknowledged failings in its response dated 21 June 2023.
37. It says Mrs Y was able to confirm the version of events at the time. She stated that she was sat on the edge of the bed, and as the bed was too high, she was unable to put her feet firmly on the bed. As a result, she unfortunately fell.
38. The Trust says ‘we are sorry that the bed was too high, this should have been noticed during the assessment carried out at the admission stage. Please accept our sincerest apologies for this’.
Impact
39. Miss X says because of the falls her mother suffered bruising on her legs and stomach. She has provided pictures of Mrs Y which we agree shows considerable bruising on these areas. We appreciate how upsetting this must have been for both Mrs Y and Miss X.
40. The Trust says the bruising was not because of the falls, but because of the blood thinning medication Mrs Y was taking. It says following both falls, Mrs Y was assessed, and no injuries were noted. A computerised tomography (CT) scan was also performed which came back clear. Our adviser also tells us that in practice, older people generally can bruise more spontaneously.
41. We have obtained clinical advice in relation to this.
42. We can see from the records Mrs Y was taking blood thinning medication called Fondaparinux. This is from the anticoagulation group of medications.
43. Anticoagulants are medicines that help prevent blood clots. They are given to people who are at a high risk of getting blood clots to reduce their chances of developing serious conditions such as strokes and heart attacks.
44. NHS England guidance ‘Overview-Anticoagulant medicines’ detail likely side effects of taking such drugs which include ‘severe bruising’.
45. We can understand why Miss X has concerns that the bruising was caused by the falls given that this occurred shortly after these were suffered.
46. Based on the evidence we have seen and based on the balance of probabilities it is reasonable that the bruising was because of the medication rather than the falls. The records document no injuries following the falls and the CT scan was also clear.
47. We do not consider a link between the falls and the bruising Mrs Y suffered. We find it reasonable that because of the negligence in care causing the falls, this caused Miss X distress.
48. We have discussed our thinking on recommendations further in the report.
Issue two- concerns relating to the DOLS assessment
49. Miss X says that during the admission, Mrs Y was placed under a DOLS order. She complains there was no clinical need for this. It is important for us to highlight that our remit only extends to the clinical aspect of the DOLS assessment. We cannot reach a decision if it was correct for the DOLS order to be made as this is a legal decision.
50. Our decision has considered if the decisions that commenced prior to this were robust as these relate to a clinical assessment and are based on clinical judgment.
51. The Trust says an application for a DOLS order was made following Mrs Y showing signs of ‘temporary delirium’. This refers to an episode of sudden confusion.
52. We have obtained clinical advice in relation to this.
53. From the records we can see mental capacity assessments were completed. The first was completed on the 8 March 2023 which concluded that Mrs Y lacked capacity. Following this a DOLS application was made on the 9 March which was authorised until the 15 March 2023.
54. We can see another mental capacity assessment was completed on the 13 and 21 March both of which also concluded that Mrs Y lacked capacity.
55. We can see the initial DOLS order completed on the 9 March 2023 was active for seven days, an extension was then approved for a further 18 days. From the records we can see a further request was put in on the 21 March 2023, however this was cancelled by the safeguarding team as it was a duplication.
56. We can see the records detail Mrs Y did regain capacity for some time on the 12 March 2023, however the above applications covered the period up from the 9 March 2023 until Mrs Y’s death on the 25 March 2023.
57. Both the Trust’s ‘Deprivation of Liberty Safeguards’ policy and the Social Care Institute for Excellence guidance ‘Deprivation of Liberty Safeguards (DOLS) at a glance’, say that an application can be made where conditions are met which includes:
‘the person is suffering from a mental disorder and lacks capacity to decide for themselves about the restrictions which are proposed so they can receive the necessary care and treatment’.
58. The Trust’s policy states in section ‘assessment of capacity’ that:
‘The assessment of the person’s capacity to consent to care and treatment by the Northern Care Alliance must be assessed by someone from the healthcare team caring for the patient. This may be a doctor or a nurse. The assessment should be documented on the patient’s medical record’.
59. The Trust’s policy also states in section 5.1.8 that a mental capacity assessment should be completed. It says ‘the purpose of the mental capacity assessment is to establish whether the person lacks capacity to decide to remain in hospital to receive their care and treatment. It is specifically for this decision only (referring to a DOLS application).
60. The Trust’s policy says in section 5.1.1 that following the completing of the authorisation request form, this should be ‘submitted to the appropriate local authority’.
61. Based on the evidence we have seen, we consider there to be no evidence of failings in the Trust’s actions. The records document that Mrs Y was suffering with temporary delirium and following this ‘mental capacity assessments’ were completed. This is in line with the Trust’s policy.
62. The mental capacity assessments concluded that Mrs Y did lack capacity and in line with the Trust’s policy an application was submitted to the local authority. This was also clearly documented in Mrs Y’s medical records.
63. Although we cannot reach a decision about the robustness of the DOLS order being granted, given that the Trust’s requests were authorised it supports the Trust’s position that these were required for Mrs Y’s best interests.
64. We consider that the evidence suggests Mrs Y demonstrated signs (delirium) that she lacked capacity and therefore in line with the Trust’s policy it was clinically appropriate for an application to be made. We therefore find no failings in the Trust’s actions.
Issue three- concerns relating to medication allergies
65. Miss X has concerns that the Trust prescribed her mother with medications that she was allergic to which includes Penicillin and Vancomycin. She complains the Trust were aware of Mrs Y’s allergies but still administered these.
66. Miss X says following these being administered, her mother suffered a rash, confusion, swelling and spots around her mouth and feet. We are sorry to learn about this and can understand how upsetting this must have been for Mrs Y to experience.
67. We have obtained clinical advice in relation to this.
68. Having reviewed the records, we can see it is clearly document in Mrs Y’s records that she was allergic to Penicillin. There is no evidence in Mrs Y’s records that says she was allergic to Vancomycin.
69. We agree with Miss X that the records confirm Mrs Y was allergic to Penicillin. Having reviewed the records, we find no evidence to suggest that this was administered at any time during Mrs Y’s admission.
70. In relation to the Vancomycin, we can this was administered between the 22 and 25 March 2023 to treat a bacterial infection Mrs Y was suffering from.
71. Our adviser has said Penicillin and Vancomycin are not from the same family of drugs. Vancomycin is not a penicillin-based antibiotic. NICE guidance ‘Vancomycin’ details this is a ‘glycopeptide antibiotic drug’ and there is no reference to this containing penicillin.
72. GMC guidance, ‘Good practice in proposing, prescribing, providing and managing medicines and devices’ say in section one:
‘In providing clinical care you must propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs’.
73. Based on the evidence we have seen, we can see the Trust was aware and documented Mrs Y’s allergy to Penicillin. There is no evidence to suggest this was prescribed.
74. Vancomycin does not contain Penicillin and therefore there is no evidence to suggest that this should not have been prescribed because of Mrs Y’s allergies to Penicillin. We consider the Trust’s actions to be in line with the GMC guidance in prescribing this to treat the bacterial infection.
75. We find no failings in this part of the complaint.
Issue four- concerns relating to doses of medication
76. Miss X raises concerns that the Trust ‘overdosed’ Mrs Y on morphine and midazolam. She says the Midazolam staff gave her mother contributed to her death as it led to her being delirious and tired. She explained her mother did not need Morphine as she was not in pain and this caused her distress.
77. We understand how important it is to know that a loved one was given appropriate doses of medication. We appreciate how distressing this must be for Miss X.
78. We have obtained clinical advice in relation to this.
Midazolam 79. The Trust says in its response dated 29 December 2023 that Mrs Y was given ‘two small doses of Midazolam to control the symptoms of agitation which is a common symptom associated with the process of dying’.
80. The Trust provides guidance it follows on its website which is produced by North East and North Cumbria Clinical Networks. The guidance ‘Palliative and End of life care symptom control guidelines for cancer and non-cancer patients’ says on page 30 that midazolam is given to treat ‘restlessness, agitation or delirium in the last stages of life’. It says doses should be given as 5mg if given orally or 2.5mg is given subcutaneously (via injection).
81. This is in line with the BNF 85 guidance ‘Midazolam’ which says for patients who experience ‘agitation in palliative care’ a dose of ‘2.5-5mg every hour’ should be given. It also says ‘usual maximum is 60mg per day, doses higher than usual maximum occasionally used on expert advice’.
82. From the medical prescription charts we can see Mrs Y was administered 2.5mg of Midazolam subcutaneously twice. The first dose on the 24 March 2023 at 5.12pm and the second on the 25 March 2023 at 12.00am.
83. Based on this, from the records we can see the highest dose Mrs Y was given in a 24-hour period was 2.5mg which is in line with the recommended doses. There is no evidence to suggest Mrs Y was given an overdose on this medication.
84. Based on the evidence we have seen, we are satisfied the Trust provided Mrs Y with doses of Midazolam in line with national guidelines. We find no failings here.
Morphine (also referred to as Oramorph)
85. The Trust says oral morphine was first prescribed for breathlessness. Mrs Y at the time was able to express that this had not made much difference to her symptoms and was stopped. Following this Oxycodone (a painkiller for severe pain) was started as an alternative to treat the breathlessness.
86. The guidance ‘Palliative and End of life care symptom control guidelines for cancer and non-cancer patients’ says on page 32 that ‘morphine is given to treat breathlessness in the last days of life’.
87. BNF 85 guidance ‘Morphine’ provides guidance on the recommended doses. It says in section ‘pain in palliative care’ that for elderly patients a dose of ‘initially 20-30mg daily in divided doses’ should be given.
88. We have carefully reviewed Mrs Y’s medication charts. We can see she was given Morphine from the 3 March 2023 up until the 24 March 2023. We have reviewed the maximum doses that were given for each day as follows:
• 3 March 2023: 7.5mg • 13 March 2023: 5mg • 14 March 2023: 2.5mg • 16 March 2023: 2.5mg • 17 March 2023: 2.5mg • 18 March 2023: 5mg • 20 March 2023:10mg • 21 March 2023: 12.5mg • 22 March 2023: 15mg
89. Based on the evidence we have seen, there is no evidence to suggest that Mrs Y was given a higher dose of Morphine than what she should have been. The highest dose in a 24 hour period was on the 22 March which was 15mg. This is well within the recommended dose as detailed in BNF guidelines.
90. We can see on the 24 March 2023, a palliative care assessment was completed at 3.45pm. It is documented ‘had morphine today and felt it made no difference’. ‘I have stopped morphine and prescribed oral Oxycodone’.
91. Based on the evidence we have seen, we find that it was in line with national guidelines for the Trust to prescribe Mrs Y with Morphine to treat the breathlessness. We find the doses of morphine that was prescribed to be in line with guidelines and does not exceed the 15mg of dose advised in the guidance. We find no failings.
Issue five- concerns relating to care plans
92. Miss X raises concerns that there was a lack of preparation by the Trust for her mother’s death. She says this is because there were no care plans or end of life care plan in place.
93. We have obtained clinical advice in relation to this.
94. The guidance ‘Palliative and End of life care symptom control guidelines for cancer and non-cancer patients’ provides guidance on page 24 about what care should be provided in the last days of a person’s life. It says:
‘plan individualised care including attention to nutrition/hydration physical observations and investigations, regular medication and anticipatory symptom control prescribing, and holistic needs that are psychological and emotional, social and cultural, spiritual and faith-based. The plan should include specific decisions about: • cardiopulmonary resuscitation (CPR) • supporting oral food and fluid intake • starting, continuing or stopping clinically assisted nutrition and/or hydration • observations and investigations • facilitating or preventing change in place of care • review of regular long-term medication; stop those which are no longer needed and switch others to a route which ensures they continue to provide benefit • anticipatory prescribing of medication for ALL five common end of life symptoms (i.e. pain, breathlessness, respiratory secretions, agitation, nausea/vomiting) and other problems specific to the patient (e.g. seizures, bleeding)’.
95. Having carefully reviewed the records we can see there are a considerable amount of entries documented about the Trust’s plans relating to the above. The notes document the care plans that were active on each day of admission. For example, on the final day 24 March 2023, we can see the following care plans that were active:
• Privacy and dignity care plan • Personal hygiene care plan • Oral hygiene care plan • Pain control care plan • Mobility care plan • Pressure area care plan • MUST low risk care plan • Continence, bladder, bowel care plan • Enhanced patient observation care plan • Management of care plan • Delirium care plan • Personal care plan • Respiratory shortness of breath care plan • Management of diabetes care plan • Falls prevention care plan • Falls bed safety care plan
96. On the 24 March 2023 we can also see as part of the care plan, Mrs Y was seen by the palliative care team in which the plan was ‘to priotise comfort’. We can also see that CPR discussions were held and a Do not attempt resuscitation (DNAR) form was filled.
97. It is also well documented in the records, specifically the nursing notes that Mrs Y’s food and fluid intake was regularly reviewed.
98. The guidance also says on page 24 that ‘The plan should be discussed with patient (if able) and family/carers, and documented in careful detail. Review the dying person, those close to them and the associated care plans on regular and agreed occasions each day, once daily being the absolute minimum’.
99. We can see discussions were held with Miss X on the 21 March 2023 in which she was updated about her mother’s medical situation and prognosis as well as the actions going forward. This included the plan to ensure her mother is kept as comfortable as possible during her final stages of life. This discussion is documented in the records which is also in line with the above referenced guidelines.
100. We can also see the care plans were regularly reviewed for example it is documented on the care plan on the 23 and 24 March 2023 that there was an ‘ongoing team review of the active treatment’.
101. Based on the evidence we have seen, we consider the Trust have acted in line with the guidelines as relevant care plans were in place to meet Mrs Y’s needs. There is no evidence to suggest that there was a lack of preparation of Mrs Y’s death.
Issue six- concerns relating to communication
102. Miss X raises concerns that the Trust did not contact her in a timely manner following her mother’s deterioration. We understand there are concerns about the time of death noted in the records and accordingly how early she was called to attend the hospital.
103. We are sorry to hear about these concerns. We understand how important it is for a person to be with a loved one at the time of their passing. We are sorry that Miss X could not be with her mother when she passed.
104. We understand there is a dispute about the recorded time of death. It is important for us to consider this to robustly consider if Miss X was contacted in a timely manner.
105. Miss X tells us that on the 25 March 2023, she attended the hospital following the Trust contacting her because her mother was agitated, shouting and quite distressed. She says she left the hospital and received a call confirming that her mother was detoriating.
106. Miss X tells us she arrived at the hospital at 2.23am and was told her mother had died at 2.20am (3 minutes before her arrival). Miss X disputes this was the time of death as she says her mother’s clothes and the bedding had been changed and the cannula had been removed.
107. Miss X disputes how this could have been completed so soon after her mother’s death. For this reason, she disputes that the Trust called her in a timely manner following her mother’s detoriation. She alleges that the call was made after her mother had passed away.
108. In response to this the Trust says its response dated 21 June 2023 that the clinical support worker called Miss X to notify her of her mother’s detoriation. It says, ‘shortly before your arrival, your mother had passed’. It further says ‘the nursing team had changed her clothing and cleaned her as she had vomited. This was to reduce any further distress to yourself and the family, and also to maintain your mother’s dignity’.
109. In relation to the time of death noted, we understand Miss X was told when she arrived at the hospital that her mother had passed at 2.20am, the hospital records say 3.09am and the legal time of death is documented to be at 2.30am.
110. The Trust further says ‘we acknowledge your mother must have passed away earlier than 02.20 hours given the interventions that had been undertaken when your arrived at 02.23 hours.’ It says the stated witnessed time of death from the nursing notes is ‘2.30 hours’ and then a ‘formal verification at 3.09 hours’ is documented. The Trust confirm the time of 3.09am was entered in error by the junior doctor and should have read as 2.30am. It has apologised for entering this incorrectly. Despite this, there is still a dispute about time of death and accordingly when Miss X was informed.
111. We have carefully reviewed the evidence and have obtained clinical advice.
112. From the records, we can see an entry stating, ‘patient was seen around 00.25am on 25 March 2023’ where it was documented Mrs Y was ‘alert but confused’. She was also able to confirm that she was not in pain. The entry states under section ‘plan’ to ‘inform next of kin- daughter’. The entry concludes that ‘after nebuliser the patient seemed more settled, I left to review another patient’. This entry is documented to be written at 3.25am, it says ‘retrospective note due to clinical work load’.
113. The entry following this is when the nurse witnessed Mrs Y’s death at 2.30am. The Trust has confirmed the entry of 3.09am was made in error.
114. The Trust has acknowledged that given the interventions that took place, Mrs Y must have passed away prior to 2.30am.
115. Based on the evidence we have seen it is reasonable Mrs Y passed away between 12.45am (when she was last seen by the nurse) and 2.30am. Unfortunately, we are unable to reach a robust view on the exact time of Mrs Y’s death.
116. We have now considered if Miss X was called in a timely manner.
117. Our adviser says there is no specific guidance which details a time frame for when family should be informed following a patient’s detoriation. However, professionals have a duty to share information with family members who the patient wishes this to be disclosed to. GMC guidance ‘Confidentiality: good practice in handling patient information content’ says in paragraph 24:
‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support, while respecting the patient’s right to confidentiality’.
118. We can see from the records that Miss X played a vital role in supporting her mother, Mrs Y during her illness and was named as the next of kin. There was therefore no conflict relating to information being shared with her. Based on this, we consider it reasonable that Mrs Y would have wanted important information, particularly her decline in health to be shared with Miss X.
119. We have carefully reviewed the records and can see evidence that Miss X was contacted shortly after the decline in Mrs Y’s health was noted by the professionals.
120. The records show an entry at 12.49am. It says, ‘Mrs Y refusing treatment unable to settle, gave midazolam to support rest and breathlessness, doctor advised to call next of kin, has been called and is getting a taxi in, support offered and assistance continuing’.
121. From the records we can see this was the first entry where the rapid detoriation was noted in Mrs Y’s health. Prior to this, there was a discussion an hour earlier at around 10.54pm between the Trust and Miss X where the plan was still to keep her mother as comfortable as possible but there was a senior discussion to be held the next day.
122. Based on this, we consider the evidence suggests Miss X was called shortly after the professionals identified her mother’s health was declining. We consider these actions to be in line with GMC guidelines. We find no evidence to suggest any delays in her being updated about Mrs Y’s deterioration.
Our recommendations
123. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
124. Our Principles for Remedy say organisations should offer fair remedies to put things right and identify learning and use it to improve services. This can include an acknowledgement of the failings, apology, service improvements and a financial remedy.
Falls
125. In relation to the failings we have identified following the falls Mrs Y suffered, we can see the Trust has acknowledged and apologised for the failings relating to the fall on the 7 March 2023. We consider these actions to be in line with our Principles for Remedy, but consider further actions are required to put right the failings we have identified relating to both falls.
126. We consider the distress she has suffered to fall within level one of our severity of injustice scale as these were ‘one-off incidences of service failure’ which led to a ‘low impact injustice such as distress’. For level one cases we do not consider a financial remedy is appropriate. An apology is enough to remedy the distress.
127. Based on this, we recommend the Trust acknowledges that appropriate care was not provided to Mrs Y on the 4 March 2023 which caused the fall. We recommend the Trust apologises to Miss X for the distress this fall and the fall on the 7 March 2023 has caused. We will ask the Trust to share this with Miss X and us within one calendar month of the date of our final report.
128. We also recommend the Trust creates an action plan to set out how it will reduce the risk of similar reoccurrence with another patient and what learning has been taken from this. We ask the Trust shares this with Miss X and us within three calendar months of the date of the final report.