Therapy sessions
29. When we investigate a complaint, we first consider what should have happened. We do this by considering what the relevant clinical standards/guidelines say. We then consider whether the care and treatment provided fell short of these.
30. Guidance from the Chartered Society of Physiotherapy states that patients should receive at least two hours of rehabilitation per week (after surgery) until they have achieved their goals. It also explains that staff should make a clear record of the reasons any patient does not receive this (standard 4).
31. NICE guidance on the management of hip fractures (CG124) states clinicians should offer patients mobilisation at least once a day and ensure regular physiotherapy review (1.7.2).
32. Mrs A complains the Trust did not provide her mother with enough therapy sessions during her admission.
33. In responding to the complaint, the Trust explained Mrs B received a therapy session every working day while she was on the ward. In its comments to us, it explained rehabilitation is a collaborative process that includes not just physio sessions but wider aspects of recovery including regular mobilisation.
34. From reviewing Mrs B’s clinical records, we can see she received 13 physiotherapy sessions and two joint occupational therapy sessions during her admission. During these sessions, staff recorded that she was practising mobilising and practising using a hoist and other mobility equipment.
35. The records show that in some sessions, Mrs B was making good progress with her mobility. In others she was struggling to mobilise and needed encouragement to take part. On one occasion she declined a therapy session due to feeling too tired. We can see Mrs A called the ward on several occasions with concerns about her mobility.
36. Considering the seriousness of her injury, we recognise this would have been a worrying time for both Mrs B and Mrs A.
37. We have also seen several days where the Trust did not offer Mrs B a therapy session. She did not receive any sessions on non-working days, or for three days while the Trust waited for a consultant to review her CT scan.
38. We asked our adviser whether the Trust provided Mrs B with the correct level of therapy input considering her injury and mobility level at the time.
39. Our adviser gave their view that the Trust did not provide the correct level of therapy during Mrs B’s admission. They explained that, aside from the day Mrs B declined therapy and the day she was off the ward at the External Trust, there were eight days when the Trust did not provide her with a therapy session or help her to mobilise.
40. They explained that, because of Mrs B’s injury, it was important she be helped to mobilise at least once a day. They gave their view that the Trust’s failure to do so meant it did not act in line with NICE guideline CG124.
41. Our adviser also felt the Trust failed to act in line with guidance from the Chartered Society of Physiotherapy. They noted there were three weeks when Mrs B did not receive at least two cumulative hours of physiotherapy. From reviewing Mrs B’s notes, we cannot see any clear record of why the Trust was unable to meet this recommendation.
42. The Trust has explained that it felt Mrs B received an appropriate level of rehabilitation during her admission. It cited that while it is not commissioned to provide therapy at weekends, that did not mean that rehabilitation ceased as other aspects were constant such as mobilisation. We recognise the Trust’s position on this and accept that it offered Mrs B day-to-day rehabilitation beyond structured physiotherapy and occupational therapy sessions.
43. Despite this, Mrs A’s complaint is about the frequency and number of structured sessions her mother received. Considering the available evidence and advice received, we do feel that it failed to offer Mrs B the correct level of physiotherapy.
44. Considering the available evidence and advice received, our view is that the Trust failed to act in line with NICE and Chartered Society of Physiotherapy guidance and did not provide Mrs B with the right level of therapy during her admission. It was important that Mrs B be helped to mobilise each day and receive at least two cumulative hours of therapy each week and the guidance states this should be structured physiotherapy. As above, Mrs B did not receive the number of sessions she should have as dictated by the Chartered Society of Physiotherapy’s Guidance.
45. We have considered the impact this had on Mrs B and Mrs A.
Impact
46. Mrs A feels the insufficient number of therapy sessions hindered Mrs B’s recovery and directly contributed to her deteriorating condition. She believes her mother’s mobility would not have diminished to the degree that it has had she been offered the appropriate level of therapy.
47. She also told us the lack of input caused both her and her mother distress. She explained Mrs B was determined to complete therapy so she could walk and would often report that she had been waiting for a therapist, but nobody had been. She explained this often left her mother in tears and caused upset to her family.
48. We recognise this was a very difficult time for Mrs B and her family. It is clear that she was keen to regain her mobility and return home.
49. As set out above, Mrs B had a varying level of progress during her therapy sessions. In some weeks she was struggling to progress or progressing slowly and experiencing pain or low motivation. In others, she was recorded as making good progress and improving with her use of mobility equipment.
50. Considering these factors, it is difficult to say with certainty whether or not Mrs B would have made further progress with her mobility if the Trust had offered her further therapy sessions or if her baseline mobility would have improved. We want to stress that we are not saying that the level of therapy sessions directly impacted her possible recovery. There is simply not enough evidence available for us to ever reach that view even on balance of probability. For example, is not possible to know whether she would have made further progress in additional sessions or if she would have struggled to progress or been able to take part in all the sessions.
51. What we are saying, though, is that we feel she was denied the opportunity to make further progress. It is clear from Mrs A’s account that Mrs B was determined to improve her mobility and not receiving these sessions hindered her opportunity to do so.
52. We consider that this missed opportunity is a significant injustice to Mrs B and had an impact on Mrs A. We also consider that not receiving the right level of therapy had a significant emotional impact on both. It is clear from Mrs A’s account that her mother was very upset about not receiving enough help. Mrs A was also clearly worried about this, and it would have been difficult to witness her mother being so upset and frustrated.
53. At the end of this report, we will detail the actions we recommend the Trust take to put this right.
Chaperoned visit
54. The NHS Constitution states that patients have the right to be treated with a professional standard of care. It also explained patients have the right to receive suitable and nutritious food and hydration.
55. The NMC’s Delegation and accountability Guidance states that nurses and nursing associates are accountable for all aspects of their practice including accountability for what they choose to delegate.
56. The Trust’s policy on escorting patients says that its staff are responsible for providing medication and dietary requirements as prescribed.
57. Mrs A explained that, during a chaperoned visit to the External Trust staff failed to take Mrs B’s regular medication with them and did not provide her with any food. She also complains that staff kept her on a stretcher during the entirety of her stay and left her unattended from 5pm.
58. In responding to the complaint, the Trust apologised for the poor quality of the chaperoned visit. It explained that the student nurse who attended with Mrs B had been asked to return to the ward at 5pm and we are empathetic of this. The student nurse certainly needed a break after having been there for as long as they were and the delays that occurred were not entirely foreseeable. That said, staff should have arranged a replacement to stay with her.
59. It explained that any patient leaving the ward should have been provided with a packed lunch and offered a meal on their return. It apologised that this did not happen. The Trust also apologised that staff did not arrange for Mrs B’s medication (pain relief) to go with her on the visit to the fracture clinic.
60. We have reviewed the available records to try and establish what may have happened during Mrs B’s chaperoned visit to the External Trust. There were no records available to set out whether her lunch and medications were brought with her. Therefore, we have relied on what both Mrs A and the Trust said about what happened.
61. It is clear from both accounts that Mrs B did not receive a packed lunch during her visit. It is also clear that the Trust did not bring her pain relief medication with her. Our view is that this falls short of both the Trust’s own policy and the NHS constitution’s commitment to a professional standard of care.
62. The Trust has also acknowledged that it failed to ensure there was sufficient cover when the nurse accompanying Mrs B was asked to return to the ward. We feel this falls short of the NHS’s commitment to provide a professional standard of care.
63. The Trust’s response did not directly address Mrs A’s complaint that her mother was left on a stretcher for the entirety of the visit. Again, we do not have clear records to show whether or not this was the case.
64. However, on the balance of probabilities and considering Mrs A’s account and other available evidence, it seems likely this was the case. The referral to the External Trust details that they would arrange for Mrs B to be transferred on a stretcher to make her planned X-ray easier. We have not seen any evidence the accompanying nurse asked for her to be transferred to a bed after this took place.
65. Mrs A has also given a clear account about her mother’s experience during the visit. and that she explained a family friend reported she had been left on a stretcher. The Trust’s response also explained there were delays in the ambulance service coming to collect Mrs B so it seems likely that she was kept on the stretcher while the Trust was chasing the ambulance.
66. We consider that this will have contributed to Mrs B’s poor experience during the visit and left her and Mrs A feeling that she did not receive a professional standard of care. While the student nurse had, upon returning to the Trust, delegated responsibility for Mrs B’s supervision to staff at the External Trust, the NMC’s Guidance states that they remained accountable for her experience.
67. We have considered the impact of these failings below.
Impact
68. As above, we find Mrs B did not receive a professional standard of care during her chaperoned visit to the External Trust’s fracture clinic. The Trust has acknowledged this.
69. Mrs A explained her mother ‘had a dreadful day’. She explained it broke her heart to see the way her mother was treated and it also caused her a great deal of distress to know that there was nothing she could do about it. We are sorry to hear about the significant impact this had on both of them.
70. Our view is that both Mrs B and Mrs A would have been caused significant distress by the poor quality of the visit that day.
71. The records show Mrs B had only received two pieces of toast prior to leaving the ward that morning and we can see she did not receive any food while at the External Trust and did not receive a meal until Mrs A brought her one at around 7.30pm. Mrs B therefore likely would have been hungry for several hours.
72. Mrs B also had a leg injury and significant issues with her mobility. We do not know the levels of her pain during the visit, as this is not recorded, but she would have been unable to manage any pain without access to her prescribed medication. It also appears likely she was left on a stretcher for the entire visit. Considering Mrs B’s poor mobility and difficulty getting out of bed, we consider this would have been both uncomfortable and frustrating for her.
73. Lastly, the Trust’s records show that Mrs B sometimes found it difficult to express her needs in English. It therefore would have been very frightening for her to be left in an unfamiliar environment, unable to mobilise, unable to express her discomfort and without any support from a member of Trust staff from 5pm. Had someone remained with her, she would have been at least somewhat more reassured and less like she had been forgotten about.
74. We consider that all of this will have had a significant emotional impact on her and Mrs A, leaving them both feeling distressed and frustrated.
75. At the end of this report, we will detail the actions we recommend the Trust take to put this impact right.
Communication and discharge
76. NICE guidance (NG27) explains how clinicians should work with patients’ families in the discharge process. It explains that staff should recognise the importance of family members and involve them in the discharge planning process, respecting their wishes (1.5.29-30). It also explains staff should provide carers and family members with information and support, including hands-on training and practical support (1.5.7).
77. Further NICE guidance (CG124) also explains the need for staff to give family members information about rehabilitation and long-term outcomes (1.9.1).
78. Mrs A complains that the Trust’s communication of her mother’s condition was poor, that it did not provide her with any information to assist her in adapting her home and that it did not inform her of how to use the equipment her mother was discharged with.
79. She explained her mother was never told about her likely level of long-term mobility and that she had to spend time making adjustments at home in the midst of other difficult family circumstances. She also explained the Trust sent Mrs B home with a commode despite never having used this previously.
80. In responding to the complaint, the Trust explained that part of Mrs B’s discharge plan was for her to be able to use the commode regularly. It explained that unfortunately this wasn’t achieved while she was on the ward, and she was discharged with a view to practice this at home with support from Trust staff.
81. The Trust also explained that staff did meet with Mrs A to help plan her mother’s discharge. However, it acknowledged that some elements of staff communication were lacking, as staff did not offer her the right level of meetings or face-to-face support. It acknowledged staff should have engaged with her earlier in the discharge process.
82. The records show that the Trust did communicate with Mrs A on several occasions about her mother’s condition.
83. For example, early in the admission staff explained the aim was to build her mother’s confidence in mobilising and to progress towards use of a Zimmer frame. There were several other calls with her to explain her mother’s current mobility levels. We recognise the majority of these were initiated by Mrs A calling the ward for updates.
84. Nevertheless, our adviser felt that the Trust met some of the requirements of NG27, as they involved Mrs A, provided information about Mrs B’s condition and discussed some of the adaptations she would need at home. They noted that staff also respected Mrs A’s wishes around discharge, as they listened to her request for her mother to return home and not be transferred for further rehabilitation. We can also see that staff discussed the equipment Mrs B might need at home and that Mrs A was aware of the adaptations she might need and the space required for these.
85. However, our adviser gave their view that, overall, the Trust failed to communicate appropriately with Mrs A, or to give her enough information and support around discharge.
86. Mrs A attended the ward on 4 June for a face-to-face meeting with an occupational therapist about her mother’s discharge and the equipment she would need at home.
87. Our adviser explained that this discussion lacked clear information about any expectations for Mrs B’s family to provide care in-between visits from carers. They also explained that there is no clear evidence staff informed Mrs B or Mrs A about her potential new baseline of mobility, goals for further rehabilitation, or her likely long-term outcomes.
88. It is also clear from Mrs A’s account that she did not know how to help her mother how to use the commode the Trust provided. The Trust explained in its complaint response that this was intended to be used in future, but we cannot clearly see this was explained to them at the time.
89. Considering the available evidence and advice received, we feel the Trust failed to fully communicate the essential information of Mrs B’s discharge in line with NICE guidance. It did provide some information, but this was not enough to prepare them for discharge. The Trust has acknowledged that it should have done more to support them.
90. We have gone on to consider the impact of this on Mrs B and Mrs A.
Impact
91. Mrs A explained that she was unprepared for her mother’s discharge, because of this, she explained she could not make the necessary adjustments at home.
92. She told us that both she and her mother were unaware her mobility would remain so poor and that she would never walk. She explained her mother felt like a burden and was often in tears because of her inability to mobilise.
93. Mrs A also explained that all of this took place against the backdrop of serious medical incident with another member of her family. We recognise this, along with Mrs B’s discharge, would have made this an incredibly difficult time for her family.
94. Our view is that better communication would have meant all this difficulty would have been avoided. As set out above, Mrs B’s mobility may not have improved, and it is possible she would have struggled to mobilise at home and still found this difficult and upsetting. Beyond this, there must be a level of personal involvement to a discharge. Mrs A had specifically requested that Mrs B be discharged and turned down the offer of a place at a rehabilitation centre. We understand her reasoning and that she was dissatisfied with the care and treatment her mother had received up until that point.
95. However, had the Trust’s communication been better, it is clear that both she and her family would have been better prepared for this and aware of the difficulties she might face in the short and long term. This might have prevented Mrs B feeling quite so frustrated and upset and like she was a burden to her family.
96. We consider that Mrs A also experienced distress and frustration because of the above failings in communication. It would have been very difficult to witness her mother so upset. We also recognise that Mrs B’s sad death around two months after discharge would have intensified this, as she witnessed her mother’s distress in the last months of her life.
97. Lastly, we feel she would have been better prepared to care for her mother had the Trust’s communication been better. It would have been frustrating for her to not understand why she had been discharged with a commode and to not know what level of support she would need.
Recommendations
98. In considering our recommendations, we have referred to our Principles for Remedy. These are embedded within the NHS complaint standards and state that where poor service has led to injustice or hardship, the organisation responsible should take steps to put things right.
99. We recognise that Mrs B has sadly died since the events of this complaint and there are no actions we can recommend which will remedy the impact to her. However, we can make recommendations to remedy the impact to Mrs A, which includes her witnessing her mother’s distress and missed opportunities for improvement.
100. We have considered the steps the Trust has already taken as a result of the complaint and in its correspondence with Mrs A.
101. The Trust has apologised to her for the poor level of care Mrs B received during the chaperoned visit to the External Trust. It has also apologised that aspects of its communication around discharge were not of the level it would expect. It has not apologised for not providing enough therapy sessions to Mrs B. The apologies it has so far given also do not fully recognise the impact of the above on Mrs B and Mrs A.
102. With this in mind, we recommend the Trust write to Mrs A to apologise for the failings we have detailed above and the impact these had on her and her mother. We recommend it do so within one month of the date of our final report.
103. The Trust has also taken some steps to improve its services as a result of the complaint. It explained it arranged an internal supervision session with its therapy team. We do not feel this is comprehensive enough to address the failings we have identified and prevent this happening again.
104. With this in mind, we recommend the Trust create an action plan to explain how it will prevent failings in the following areas from reoccurring:
• ensure the appropriate level of mobilisation for patients on non-working days and sufficient weekly levels of therapy to meet the needs of the patients • arranging and chaperoning visits to other hospitals, including care and nutrition needs • communicating with patients and their families about discharge and equipment.
105. This should include details of who is responsible for each action, timescales for completion and who will be responsible for implementation. We recommend the Trust write to us and Mrs A with details of this within three months of the date of our final report.
106. We recognise the events of this complaint happened several years ago and the Trust may have naturally made improvements and changes to processes in the intervening years. The action plan can therefore include details of any changes it has already made, if applicable.
107. Lastly, the Trust has not made any financial payment. This is not something Mrs A requested during the local complaint process but is something we can consider recommending. In this case, we feel the injustice to her is significant enough to warrant financial remedy.
108. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our guidance on financial remedy (the ‘Severity of injustice scale’).
109. Following this consideration, we recommend the Trust pay her £1000 within one month of the date of our final report.