Physiotherapy during first admission
21. Mrs L says the Trust did not give her father physiotherapy during his admission between 12 December 2023 and 3 January 2024. She says he was not encouraged to get out of bed and his lack of mobility meant he remained unsteady on his feet.
22. NICE ‘Falls in older people: assessing risk and prevention’ guidance says to consider inpatients over the age of 65 as being at risk of falling and manage their care accordingly. It also says to perform a falls assessment on admission and to ensure that interventions to reduce the risk of falls are tailored to the individual, so they promptly address any falls risk factors.
23. The records show that nursing staff completed a falls risk assessment on 13 December. The assessment considered Mr D was independently mobile with the use of a stick. However, it was noted that the unfamiliar hospital surroundings may lead to him becoming disoriented. To reduce Mr D’s risk of falling, nursing staff put him on a low bed with the call bell to hand. They also made sure he was familiar with the ward area and knew how to navigate his way to the bathroom facilities. Our nursing adviser confirmed this was appropriate.
24. The records show a review of his falls assessment was done on 15 December and no changes were recorded.
25. NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’ says nurses must make timely referrals to another practitioner when any action, care, or treatment is required that is beyond the limits of your competence.
26. Our nursing adviser says there was nothing to indicate Mr D required the support of a physiotherapist to help him mobilise. This is because the assessment concluded that he could independently mobilise with the use of a stick. The interventions the nurses identified within the assessment to reduce Mr D’s risk of falling were all things the nurses could competently carry out.
27. We have found that the falls assessments carried out on 13 and 15 December were done in line with NICE ‘Falls in older people: assessing risk and prevention’ guidance because it appropriately assessed Mr D’s risk of falling. The assessment took into account his ‘baseline’ mobility out of hospital and concluded that he remained independent with the use of a stick. Further, we have found Trust nursing staff identified areas where it could reduce Mr D’s risk of falling and put appropriate interventions in place as outlined in NICE guidance.
28. We also found that nursing staff did not need to put in a referral for physiotherapy support for Mr D because they were able to meet his needs as outlined in the above NMC guidance.
29. HCPC ‘Standards of proficiency for occupational therapists’ (OT) says they must use their skills, knowledge, experience, and the information available to them, to make informed decisions and take action where necessary.
30. On 16 December, as part of the Trust’s screening process whilst in hospital, its Therapy Team assessed Mr D. The OT also concluded that he was independent with a walking stick. As this was considered his ‘baseline mobility’, and there had been no change to his mobility since admission, it discharged him from its service because it deemed he did not need any further intervention.
31. Our physiotherapy adviser says there was nothing to indicate within the OT assessment that Mr D was in need of further support from the Therapy Team to help with his mobility. The nursing documentation also shows the falls risk assessments were being reviewed regularly.
32. We consider the OT used the relevant information available to them, alongside their knowledge and skills base, and made the decision to discharge Mr D from its service. We find this decision was appropriate and in line with HCPC standards.
33. The Trust again reviewed and updated Mr D’s falls assessment on 23 Dec. This stated Mr D required minimal assistance from one person, which was mainly for support with his personal hygiene. It is documented that he had become lacking in confidence and motivation with his mobility. We recognise Mrs L also saw a big deterioration in her father during this time and we appreciate how difficult it was for her to witness her father being more ‘subdued’ and less active than usual.
34. As the nursing evaluations showed that he continued to mobilise with his walking stick, and there was no change in his ‘baseline’, our nursing adviser said a referral to the Therapy Team was still not required at this stage. We find this was in line with the NMC guidance above as the nurses were still able to assist Mr D themselves.
35. NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’ also says nurses must accurately identify, observe, and assess signs of normal or worsening physical and mental health in the person receiving care.
36. The records show that Mr D’s mobility status changed on 1 January 2024. At this time, his falls risk assessment was updated and his mobility aid was changed to a zimmer frame, rather than a stick, and that he required the assistance of one.
37. Both our nursing and physiotherapy adviser said, as this was not Mr D’s baseline mobility, he should have been re-referred to the Therapy team for further assessment. An assessment would consider whether Mr D needed any other equipment or support due to his change in mobility status.
38. We have found that the Trust continued to act in line with NICE ‘Falls in older people: assessing risk and prevention’ guidance as it continued to assess Mr D’s risk of falling and it put things in place to reduce his risk.
39. Although nursing staff put interventions in place to reduce Mr D’s risk of falling, it was outside of their competence to determine whether other things were required to support him.
40. We have found the Trust’s nursing staff did not act in line with NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’ because they did not re-refer Mr D to the Therapy Team for further review considering his worsening mobility. We find this to be a failing.
41. If a referral had been made, our physiotherapy adviser says it is unlikely any further support or equipment would have been provided by the Therapy Team as it appears Mr D was able to mobilise safely with the support of the zimmer frame and the supervision of one nurse.
42. Therefore, although we have found a failing with the lack of referral to the Therapy Team on 1 January, we cannot say that this had an impact on Mr D as it would not have led to any different support or equipment being provided.
Discharge on 3 January 2024
43. Mrs L says she is aware the Trust discharged her father on 3 January in line with statutory guidance because his observations were normal and he was considered stable. However, she says the Trust inappropriately discharged him because he was unsteady on his feet and this made the discharge unsafe.
44. Following her father’s discharge home, Mrs L says he suffered two falls. She says this would not have happened had the Trust kept him in hospital. She says, when the Trust re-admitted him just three days later, his condition had further deteriorated.
45. Annex D of the DHSC ‘Hospital discharge and community support’ guidance explains what steps clinicians should take to assess if a patient is ‘medically optimised’ (stable) for discharge. This takes into account a patient’s stability, their nursing and monitoring needs, whether oxygen and treatment needs can be managed at home, and where further tests and investigations are not required as an inpatient.
46. Annex C of the DHSC ‘Hospital discharge and community support’ guidance gives specific ‘discharge pathways’ for discharging patients. Each pathway sets out things to consider prior to discharge. This includes whether the patient has any new health or social care support needs and how these will, or can, be managed following discharge.
47. Our physician adviser says the medical review and nursing records from 2 and 3 January do not indicate Mr D was acutely unwell or raised any further concerns with regards to his medical condition. Mr D was reviewed by a respiratory failure specialist nurse, who made some changes to Mr D ’s oxygen regime, but was happy with the decision to discharge him home.
48. The records indicate Mr D was offered a package of care on discharge to help with his needs at home. Mr D declined this and it was considered he had capacity to make this decision. A discussion is documented in the records which suggests Mrs L had agreed to help him post-discharge with his personal hygiene.
49. Our physician adviser says Mr D did not meet any of the criteria that would have prevented his discharge home. This is because he was stable, did not require regular monitoring, his oxygen needs could be managed at home, and there was no clinical need for him to remain in hospital. The Trust had considered a package of care, which Mr D declined.
50. We appreciate how upsetting it was for Mrs L to see how frail and unwell her father had become over a short period of time. It is understandable she was worried about him returning home when his mobility had deteriorated and she considered he had not fully recovered from his illness. We also understand how upsetting it was for Mrs L to have her father re-admitted to hospital just three days after he was discharged.
51. Having taken everything into account, we have found the Trust appropriately discharged Mr D on 3 January because there was no clinical need for him to remain in hospital as outlined in DHSC ‘Hospital discharge and community support’ guidance.
52. We have found the Trust acted in line with DHSC ‘Hospital discharge and community support’ guidance as it considered Mr D’s new mobility need and how this could be managed, which is why it offered him a package of care on discharge. However, Mr D declined this offer. Therefore, we have not found a failing with Mr D’s discharge.
COVID-19 testing in A&E on 6 January 2024
53. Mrs L says on 30 December 2023, during her father’s first admission, the Trust moved him to an area where there had been a COVID-19 outbreak. She is aware that COVID-19 testing was not required to discharge patients home during this time. Therefore, she does not complain about this.
54. On 6 January 2024, Mr D attended A&E after suffering two falls at home. Mrs L says the Trust should have immediately tested him for COVID-19 due to his exposure during his first admission. She says it did not test her father until she requested it was done, which was a delay of approximately five hours.
55. Government ‘COVID-19: testing from 1 April 2023’ guidance says patients with symptoms of COVID-19 should be tested on admission. Some of the symptoms at the time included a continuous cough, shortness of breath, a high temperature, fever, or chills.
56. The guidance is not clear on how quickly this testing should be done.
57. Trust staff first saw Mr D at 6.23pm because he had suffered two recent falls, had shortness of breath, and a cough. The A&E doctor requested further tests and investigations to be carried out. These included a blood test, CT head scan, and chest X-ray.
58. The outcome of the chest X-ray showed changes from Mr D’s last recorded chest X-ray. The results were consistent with pneumonia. The other investigations revealed signs of infection and an acute kidney injury.
59. The Trust did not test Mr D for COVID-19 until 11.33pm. This subsequently came back positive.
60. Our physician adviser says Mr D did not have a fever on admission, but his shortness of breath and cough were symptoms of COVID-19 and could have prompted the doctors to have requested an earlier test, along with the other investigations, at 6.23pm, as recommended in the Government guidance.
61. NICE ‘COVID-19 rapid guideline: managing COVID-19’ guidance explains that corticosteroids (steroids) are part of standard treatment for COVID-19 in the UK. This is because, for adults with COVID-19 needing supplementary oxygen, evidence indicates the use of corticosteroids lowers mortality, improves discharge from hospital, and may decrease the need for invasive mechanical ventilation (IMV) and death within 28 days of starting treatment.
62. The records show the Trust treated Mr D with antibiotics and steroids for the infection and to reduce inflammation, oxygen therapy for his shortness of breath, and intravenous (IV) fluids to help with his kidney function.
63. The medication charts show the Trust first gave Mr D steroid medication at 7.36pm. Following the positive COVID-19 test at 11.33pm, no changes to Mr D’s medications were made. As Mr D needed supplementary oxygen, we have found the Trust appropriately used steroids to treat him in line with NICE ‘COVID-19 rapid guideline: managing COVID-19’.
64. We appreciate it was distressing for Mrs L to find out her father had COVID-19 and that it had not been tested for until she requested it.
65. Although there were clinical indications that could have prompted the earlier testing of Mr D, we consider he received the appropriate treatment, in line with the NICE COVID-19 guidance, soon after admission. Therefore, earlier testing would not have changed what happened and it did not have a negative impact on the clinical care and treatment he received. We hope this has provided some reassurance to Mrs L.
Monitoring in MAU
66. Mrs L says Trust staff did not adequately monitor her father’s condition while he was in the MAU. She says this meant he died alone.
67. RCP ‘National early warning score (NEWS) 2: Standardising to assessment of acute illness severity in the NHS’ explains the NEWS2 guide should be used to decide on the frequency of a patient’s monitoring. A set of vital signs, including heart rate, blood pressure, respiratory rate, oxygen levels, and conscious levels are recorded and scored. Regular monitoring and recording of the NEWS2 score helps nursing staff to see ‘early warnings’ of a patient’s potential clinical deterioration and provides a trigger for escalation of their clinical care.
68. The records indicate, at approximately 11.15pm, the Trust transferred Mr D’s care to its MAU and that Trust staff assessed his care needs. This included assessing his skin and risk of developing pressure ulcers, mobility and risk of falls, and nutrition and hydration needs.
69. At 11.46pm, a staff nurse reviewed Mr D and his NEWS2 score had quickly increased to 11. Nursing staff immediately escalated this to a doctor for review. We consider this was in line with NEWS2 guidance.
70. The Trust’s protocol on ‘Monitoring patients’ vital signs’ says patients who have a NEWS2 score of three to six should be monitored every hour. Those who score seven plus should be monitored every 30 minutes. Any patient with a NEWS2 score of seven and over, the registered nurse should urgently inform senior staff for review.
71. The doctor reviewed Mr D at 12.07am on 8 January and took his observations. The plan was to continue with oxygen therapy at 40% via a mask and he was prescribed Paracetamol for his fever.
72. The staff nurse checked on Mr D again at 1.43am, took his observations, and made him comfortable. At this stage, his NEWS had decreased slightly to nine. This again meant that observations should be taken every 30 minutes.
73. At 2am, the records indicate Mr D was trying to remove his oxygen mask. It was at this time the Trust made the decision that he was no longer for NIV.
74. As Mr D’s recorded NEWS2 score was 11 at 11.46pm and nine at 1.43am, the Trust should have monitored him every 30 minutes to be in line with its own protocol for ‘Monitoring patients’ vital signs’. The Trust failed to do this because staff only checked on him at 12.07am, 1.43am, 2am, and then 4am when he was found not breathing. It also did not record his NEWS2 score at 12.07am or 2am. This is not in line with the Trust’s own protocol and we consider this to be a failing.
75. Our physician adviser said that as Mr D was very unwell at this stage, and there was no further treatment that could have been provided to prevent his further deterioration, we cannot say that more regular monitoring would have led to any further medical reviews or any different treatment being provided. However, we can say that this would have given the staff more opportunities to note his further deterioration and prompt them to alert the family about this.
76. Mrs L feels that if the staff had been monitoring her father more closely, it is likely that someone would have been with him when he died. Unfortunately, even on the balance of probabilities, we cannot say Trust staff would have been with Mr D when he died. This is because staff would not have been constantly monitoring him. However, had staff monitored him more regularly, it could have increased the likelihood of someone being there with him. We recognise the distress this has caused Mrs L.
End-of-life plan
77. Mrs L says the Trust did not implement an end-of-life plan despite it considering her father to be nearing the end of his life.
78. GMC ‘Treatment and care towards the end of life’ guidance emphasises individualised care, dignity, and compassion when the focus of a patient’s care is changing from active treatment to managing their symptoms and keeping them comfortable. This includes prescribing anticipatory medications. These are ‘just in case’ medications that can help to make a patient more comfortable by helping with symptoms such as pain, breathlessness, nausea, or agitation. The guidance expresses the importance of ensuring these medications are prescribed as soon as possible so they can be administered as and when needed.
79. At 11.46pm on 7 January Mr D’s NEWS2 score had rapidly increased to 11.
80. The medical review at 12.07am on 8 January indicates Mr D was ‘mildly agitated’ and kept trying to remove his oxygen mask.
81. The further review at 2am again states Mr D was trying to remove his oxygen mask. It was at this time the Trust made the decision that he was no longer for NIV.
82. Our physician adviser says the records indicate Mr D’s condition was deteriorating. Although Mr D was still receiving active treatment up until 2am on 8 January, his condition was deteriorating and his prognosis was poor. Therefore, the Trust could have looked to place him on an end-of-life care pathway with consideration of anticipatory medications. The ‘just in case’ medications could have been prescribed and put on the drug chart so staff could administer them at any time when Mr D needed them. This could have helped to manage his symptoms.
83. We have found that the Trust did not act in line with GMC ‘Treatment and care towards the end of life’ guidance. This meant Mr D was not considered for end-of-life care or any anticipatory medications, which could have helped with his symptom control. We consider this could have helped lessen his agitation in his final hours.
Notification of transfer to MAU and clinical deterioration
84. Mrs L says the Trust did not notify her that it had moved her father from its ED to its MAU or about his clinical deterioration. She says it has caused significant distress to know he died alone, and she was not able to be with him and say goodbye.
85. On 7 January, the Trust completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form. This is a personalised recommendation for a patient’s clinical care in emergency situations. This is done at a time when the person has capacity as they may not be able to make decisions, or express their wishes, at a later date.
86. The ReSPECT form indicated that Mr D was very unwell and there needed to be a balance between extending his life with his comfort and valued outcomes. On medical review at 8.20am on 7 January, the records state Mr D was for non-invasive ventilation (NIV) should he decompensate. This is when an organ, or system, fails to maintain its normal function. However, the form and medical review records, state that he was not for invasive ventilation.
87. Our physician adviser says Mr D was acutely unwell and his prognosis was poor. That said, he was still receiving active treatment so the Trust did not feel that his treatment needed to end at this time. It also felt that NIV was appropriate for him and this was the balance between extending his life, but not to use invasive treatment as this could have a detrimental effect on his clinical outcomes.
88. GMC ‘Good Medical Practice’ guide says a doctor must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
89. The records show Trust staff told Mrs L at 9.30am on 7 January of her father’s condition and how he ‘may not recover’. The records show that Mrs L asked to be notified if his condition further deteriorated and the doctor said they would ensure her number was documented in the medical records and on the ReSPECT form to ensure it was available for staff if needed. We consider this was in line with GMC guidance.
90. Mr D was transferred to the MAU at around 11.15pm on 7 January. The family were not informed of his transfer. The Trust says it is not standard practice to inform patients’ families when they are being transferred between ED and MAU. Shortly after transfer, Mr D quickly declined.
91. Our physician adviser says Mr D’s quick increase in NEWS2 score at 11.43pm on 7 January was an indicator of his clinical decline. The Trust should have had further discussions with the family at this time, and these should have been clearly recorded.
92. Whilst it might not be standard practice to inform families specifically of patient transfers, this would have been an opportunity for the Trust to inform Mrs L of the transfer to the MAU. The Trust did not contact the family to discuss the deterioration or the transfer. This was not in line with GMC guidance and we find this to be a failing.
93. Our physician adviser says, deciding Mr D was not for NIV at 2am was close to conceding that there was no hope of survival. Again, the family should have been informed of this. The Trust did not do this. This was not in line with GMC guidance and we find this to be a further missed opportunity to notify them. Mrs L was only contacted after her father had died at 5.03am.
94. We have found that these failings meant Mrs L and the family were denied the opportunity to be with him in his final hours and to say goodbye. We recognise how distressing it was for Mrs L to think her father died alone without anyone there with him. We appreciate this exasperated the family’s grief and affected their ability to find closure.
Events leading up to death
95. Mrs L says she was given different times and versions of events leading up to her father’s death on 8 January. She says the information given to her by the nurse who notified her of his death was inconsistent with what was communicated within the Trust’s complaint responses. This further indicated to her that Trust staff were not appropriately monitoring him or recording information correctly in his clinical record. She says this has made it more difficult for her to find closure because she is not sure what exactly happened prior to her father’s death.
96. NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates’ says nurses must communicate effectively, keeping clear and accurate records.
97. Mrs L says Trust staff contacted her at 5.03am to notify her of her father’s death. She says they told her that her father had been ‘found not breathing’ between 4.20am and 4.40am.
98. The Trust’s complaint response explained to Mrs L that her father was ‘found not breathing’ at 4am, which was taken from the information in the nursing records. A doctor checked on him and confirmed his death shortly afterwards. The time this was documented is shown as completed at 4.30am.
99. Therefore, we can see that Mrs L was given two different time periods for her father’s death.
100. We conclude the Trust failed to communicate effectively with Mrs L in line with NMC ‘The Code: Professional standards of practice and behaviour for nurses, midwifes and nursing associates’ by giving her the incorrect information during the initial phone call.
101. This meant she was given contradictory information regarding the timings and events leading up to her father’s death. We recognise the upset and distress this caused. We hope we have clearly explained what happened during this time so she can find the closure she needs.