Assessment of needs following admission
22. Ms U complains the Trust failed to assess her father’s needs following admission to ward one. She says the Trust failed to conduct several assessments when her father arrived on ward one or put in place adequate provisions to communicate with him, as he suffered from profound hearing loss.
23. Ms U says as a result, staff failed to provide adequate supervision and care resulting in her father falling and sustaining a significant injury. Ms U says staff were also not monitoring his blood pressure which she also feels may have contributed to his fall.
24. In its response to this complaint, the Trust advised Mr L should have had a falls risk assessment completed (the Trust’s falls review found this did not occur) as well as a mental capacity assessment. It said staff completed a 4AT assessment, which is a screening instrument designed for rapid initial assessment. However, it said following this staff did not implement a cognition management plan which Mr L required. It also acknowledged staff should have nursed Mr L under ‘level 2’ cohort supervision which did not happen.
25. The NICE falls guidance is clear that anyone over the age of 65 should be deemed to be at high risk of falls. In this case, Mr L had also had falls prior to admission and was admitted as he was unsafe at home. Social services had assessed him in the community as not having capacity and he had a recent diagnosis of Alzheimer’s disease. Taking all this into account our nurse adviser he was at extremely high risk of falls.
26. The Trust’s falls policy says nurses should carry out a multifactorial falls assessment within four hours of admission to a ward. This includes looking at things like standing blood pressure, checking hearing and whether the patient requires nonslip socks. Following this, nurses should complete a falls prevention care plan to make sure any risk is mitigated.
27. From review of the medical records, the Trust did not act in line with the NICE falls guidance or its own policy. From what we have seen so far, it appears Mr L had a 4AT completed in A&E however the Trust’s policy says Mr L should have had his standing and lying blood pressure checked, a mental capacity assessment, falls assessment, and falls care plan within four hours of admission. This did not happen following admission and only occurred after Mr L had fallen.
28. Our nurse adviser said Mr L required an increased level of supervision. The ward staff put him under ‘level 1’ supervision however our nurse adviser said he should have been under ‘level 2’ supervision in line with the Trust’s falls policy.
29. Our nurse adviser said Mr L did not need one to one supervision (where a member of staff is always within arm’s reach). However, they said he did require someone in the bay keeping an eye on him at all times due to his cognitive impairment which would have happened under ‘level 2’ supervision. The Trust have already acknowledged this as a failing in its response to the complaint.
30. Our nurse adviser said there is nothing documented to say nurses had given Mr L nonslip footwear or that they communicated to him to pull his call bell. They explained a sign language interpreter is unlikely to have been used if he did not know sign language however, they could have checked if he required his hearing aid (if he had one). Ms U also she understands the hospital had picture cares they could have used but staff did not use them.
31. Taking all the above into account, we consider the Trust failed in this aspect of Mr L’s care. The Trust did not act in line with NICE falls guidance or its own falls policy in assessing Mr L’s risk from falls or in putting appropriate provisions in place to prevent him from falling.
32. We have considered the impact of this failing in care. Had staff conducted the appropriate assessments and placed Mr L under ‘level 2’ supervision this would have meant he would have been under constant and uninterrupted supervision in line with the Trust’s enhanced supervision policy. The staff member responsible would have had Mr L within their line of sight and would be close enough to respond immediately should an incident occur.
33. Our nurse adviser said had this happened, on the balance of probabilities, Mr L’s fall would have been prevented. This is because under the Trust’s enhanced supervision policy, a member of staff would have got to Mr L before he fell.
34. Mr L had a head scan following the fall which showed there was no damage and his cause of death at postmortem was documented as bronchopneumonia. We understand why Ms U is so concerned the fall played a role in Mr L’s death.
35. We can say there is reference in the medical records the treating team suspected Mr L had aspirated blood from his broken nose which he sustained during the fall.
36. However, Mr L’s postmortem is conclusive there was no evidence of aspirated blood in his lungs. Our physician adviser said this suggests Mr L had developed a chest infection during his hospital stay rather than his death being caused by aspirating blood from his broken nose. They explained patients are prone to developing chest infections during hospital admissions.
37. Taking this advice into account, we consider, on the balance of probabilities, Mr L’s death was not caused by his fall.
38. We also understand Ms U is concerned about there being bacteria in the blood in the back of Mr L’s throat following his fall which may have contributed to his pneumonia. However, our physician adviser explained there is always bacteria in the throat and so it is unlikely the additional blood would have contributed to Mr L’s infection.
39. Whilst we do not consider the failings caused Mr L’s death, we consider the failings caused him to sustain a significant injury. A post falls review found Mr L had three lacerations on his face following the fall. Staff noted the laceration above his right eyebrow was incredibly deep and was profusely bleeding.
40. Staff completed an abbey pain score (a tool used to assess pain in patients) and found Mr L’s score to be a ‘6’ indicating he was in severe pain. Staff gave him pain relief following this. Staff also noted Mr L continued to be distressed and was shouting out following the fall. Mr L’s X-ray reported he had multiple right sided rib fractures. However, the Trust were unable to say if these were old or new as Mr L had sustained falls at home prior to admission.
41. We are also aware that following the fall, Mr L was unable to eat or drink for several days. This was because he was waiting for the oral health team to visit and clear the blood from the back of his throat and for the SALT team to assess if he could safely swallow.
42. Ms U has also provided us with images of her father’s injuries following his fall showing he had significant bruising. These images highlight the extent of the injuries, and we can see this must have caused incredible alarm and distress to Ms U. We also understand how incredibly distressing it must have been to witness her father in pain and distress. This is a significant injustice to Ms U.
43. We acknowledge the Trust has already taken some appropriate actions to address this complaint. It has appropriately acknowledged there were failings in Mr L’s care in relation to assessing him for risk of falls and putting appropriate measures in place. It offered a sincere apology that the fall occurred.
44. However, we consider an acknowledgement of failings, and an apology alone is not sufficient to address the impact on Ms U. Due to the serious injuries sustained by Mr L, we consider a financial remedy is also appropriate in recognition of the distress caused. We have outlined this in the recommendations section of our report.
45. The Trust has also taken steps to improve its service following the fall including:
• work to improve compliance in recording postural blood pressures including discussion at huddles daily for two weeks and an audit of ten random patient records monthly (for six months) • concerns regarding cognition management care plan shared in clinical governance meeting and steps taken to ensure all staff are aware of how to initiate this plan • message sent to all staff reminding them to ensure call bells are in reach
46. Whilst we are reassured these actions will help prevent similar mistakes occurring again in future, there is no mention of ensuring staff complete the appropriate falls risk assessment and falls management plans. We have therefore made additional recommendations to the Trust to address this.
Medication
47. Ms U says following admission, staff had not prescribed her father with his previously prescribed medications including fludrocortisone to manage his blood pressure. We understand why Ms U is concerned this may have contributed to Mr L’s fall.
48. In its response to this, the Trust acknowledged Mr L had missed early pharmacy review due to several factors for which it apologised. It said this should have occurred within 24 hours of admission. This is in line with the NICE guidance for medicines reconciliation in acute settings which explains staff should reconcile medicines within 24 hours.
49. The records show doctors did not start Mr L’s fludrocortisone until 23 January which is the fourth day after admission. Our physician adviser said it is not uncommon following admission for doctors to stop certain medications or to wait to prescribe them. This is because they may wish to focus on addressing the most serious presenting issues first.
50. However, our physician adviser said as there is nothing written in the records to say why the treating team did not prescribe fludrocortisone immediately following admission, this was more than likely an error. We consider this to be a failing.
51. We considered the impact of this. Ms U feels the delay in prescribing fludrocortisone may have contributed to Mr L’s fall.
52. Our physician adviser explained orthostatic hypotension (which is what Mr L was taking his medication for) is a common condition where a patient’s blood pressure falls when they stand up.
53. The Cochrane review concludes the evidence is uncertain about the effects of fludrocortisone on blood pressure. Our physician adviser explained this review shows there is no robust evidence fludrocortisone is effective. They explained doctors often give other advice to patients around managing orthostatic hypotension (such as having good fluid intake and getting up more slowly), only prescribing fludrocortisone as a last resort.
54. There is evidence in the records Mr L was unsteady on his feet and had fallen at home several times since his last hospital admission even whilst on this medication.
55. The BNF guidance also says this medication is not a licensed drug for orthostatic hypotension. Our physician adviser explained that prescribing clinicians can justify its use in some patients for this reason. However, they explained that its absence from the BNF guidance further supports the argument this medication makes no significant difference.
56. Taking all the above into account, on the balance of probabilities, the delay in prescribing this medication did not contribute to Mr L’s fall. We were reassured that in response to this complaint, the Trust has taken action to ensure staff reconcile medicines within 24 hours of admission. This includes the pharmacy working with the Medical Care Group to provide a broader clinical service at weekends. We have made no further recommendations to the Trust for this part of the complaint.
Referral to community dental team
57. Ms U says following the fall on 21 January, her father suffered a fractured nose and had blood pooling in the back of his mouth and throat. Ms U says staff informed her they had referred Mr L to the community dental team who would clear the blood.
58. Ms U says this referral did not happen for several days meaning the SALT team were unable to be assess Mr L to see if he could swallow safely. She says as a result, Mr L was unable to eat or take in any nutrition which impacted his frailty. She also feels the blood and bacteria at the back of his throat contributed to him developing pneumonia.
59. Ms U said as part of the complaints process the Trust said they had not received the referral until later because the doctor had initially sent it to the wrong place.
60. In response to this part of the complaint, the Trust said the community dental service received the referral on 24 January at 4.33pm. It said medical staff on the ward had not made any contact with the dental team prior to this for input or advice. It said the ward staff had not sent the referral by the standard referral pathway. Instead, they sent it to a dental nurse colleague and a member of the oral health promotions team, both of whom had finished their working day at the time.
61. The Trust said subsequently, the community dental service picked up the referral the next morning. It said they made an appointment for a nurse to attend the ward at 1.15pm. The Trust said this referral was acted on as soon as received and the community dental service saw Mr L in less than 24 hours from receipt of referral.
62. Mr L’s fall occurred on the evening of 21 January. However, the medical records show the ward team did not make the referral to the community dental team until 24 January.
63. The GMC guidance says doctors should promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer a patient to another practitioner when this serves the patient’s needs.
64. Ms U recollects the referral to the community dental team was made on 22 January. We can see no evidence of this in the medical records. Mr L’s medical records show the first point at which it became clear Mr L needed the referral was on 23 January at 11.17am. This was after SALT had attended Mr L and were unable to clear the blood from the back of his throat with mouth care alone. They advised he required suctioning and would benefit from a referral to the community dental team. Given the level of detail in this medical entry, we consider this is likely an accurate reflection of what occurred.
65. The community dental team did not receive the referral until 24 January at 4.33pm. As such there was a delay of over a day where the ward staff did not send the referral to the correct place. However, our physician adviser said that referrals to community teams are not usually urgent and so this was not a significant delay. Taking this advice into account, we do not consider this delay was so significant it amounts to a failing in the care provided as per the GMC guidance.
Response to deterioration
66. Ms U complains the Trust failed to recognise her father was deteriorating following the fall and provide appropriate treatment. Again, we understand why Ms U is so concerned about this.
67. In its response to the complaint, the Trust said Mr L was showing cautious signs of improvement, such as not being on oxygen. It said the medical team therefore felt there was evidence of improvement and decided to continue antibiotics. It said Mr L’s deterioration later that day was sudden and not expected.
68. The GMC guidance says doctors must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations, or treatment • refer a patient to another practitioner when this serves the patient’s needs.
69. The medical team saw Mr L during a ward round at 9.45am on 25 January. Our physician adviser said the medical records show he had a thorough review, and he was not showing signs at this time he was seriously unwell. Our physician adviser said his observations were normal although he did have an early warning score of ‘3’ due to a slightly low temperature. Early warning scores are clinical tools used to assess patient conditions and predict deterioration. Other than the low temperature, all Mr L’s other observations were normal.
70. Another doctor saw Mr L at 11.21am and noted an even more detailed review. They documented he was hallucinating, had delirium, and was a bit confused. Ms U also recollects her father was extremely distressed. However, our physician adviser said the reviewing doctor was not overly concerned as he did not appear that unwell and again his observations were mostly normal (although his temperature was a little low). His bloods were also improving.
71. Our physician adviser said it can be common for patients with Alzheimer’s dementia to become confused and delirious quickly, but this does not indicate the severity of an illness. They explained there was nothing within the assessment at 11.21am which suggested Mr L was seriously unwell or deteriorating rapidly.
72. Mr L also had a physiotherapy review at 12.33pm. Our physician adviser said there is nothing within the notes from this assessment to suggest he was rapidly deteriorating or that someone needed to review him further.
73. Less than two hours later at 2.10pm, staff documented Mr L had a cardiac arrest. Our physician adviser said this was a sudden deterioration and there was nothing within the previous few hours to suggest staff could have predicted this or that there was an opportunity to intervene. Taking this advice into account, we have found no failings in this aspect of Mr L’s care, nor have we seen the Trust acted outside of GMC guidance.
74. Ms U also raised a concern that towards the end of her father’s life, a nurse recorded her father’s blood oxygen levels incorrectly. Ms U witnessed these were lower (77 percent) than what the nurse later documented (96 percent).
75. Our nurse adviser said Mr L’s oxygen levels had not been dipping throughout his stay. They explained they had also been at 100 percent previously and so it is unlikely they would have gone down so rapidly. In addition, they said an alarm would have sounded on the machine if they went below 80 percent and Mr L would have appeared incredibly distressed. We can see no evidence of this in the medical records.
76. Having taken all the evidence into account, we consider it is unlikely, on the balance of probabilities, that Mr L’s oxygen levels were this low. We have therefore found no failings in this aspect of care.
Communication
77. Ms U complains that right up to her father’s death, doctors advised Mr L would make a full recovery, despite him showing signs of deterioration. Ms U feels staff missed opportunities to identify and advise the family he was dying.
78. The GMC guidance says doctor should communicate effectively, be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
79. There is evidence of frequent communication from the clinical team with Ms U. We can see on the morning of 25 January, a doctor noted they had cautiously explained the hope was still to get Mr L home once they had sorted his infection and eating situation. Our physician adviser said this was a reasonable conclusion based on Mr L’s presentation throughout this day. They explained Mr L’s deterioration was an unexpected deterioration, and they did not think staff could have predicted this at an earlier stage.
80. Taking this advice into account, we do not consider the Trust missed an opportunity to explain Mr L was going to die. We have therefore found no failings in the way the Trust communicated with Ms U about this. In reaching this decision, we are in no way underestimating how unexpected and distressing it was for Ms U when Mr L suddenly suffered a cardiac arrest.
Complaint handling
81. Ms U complains the Trust delayed in responding to her complaint about the above issues and delayed in arranging a complaints meeting.
82. The NHS complaints regulations state organisations should respond to complaints within six months from the date it receives the complaint. The regulations state if the organisation cannot do this, it should notify the complainant in writing and explain the reasons why. They also state organisations should send the complainant a response as soon as reasonably practicable thereafter.
83. Our principles of good complaint handling state organisations should:
• deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate • acknowledge the complaint and tell the complainant how long they can expect to wait to receive a reply • keep the complainant informed about progress and the reasons for any delays.
84. Ms U complained to the Trust on 14 April 2023. On 21 April, the Trust acknowledged her complaint in writing in line with the NHS regulations and our principles of good complaint handling. The Trust explained to Ms U it expected to provide a response by 28 July. It explained it may require additional time to conclude its investigations, but it would contact her the week the response was due if that was the case.
85. On 27 July, the Trust wrote to Ms U by email and explained it unfortunately needed extra time to investigate her complaint. It explained the Trust was undergoing a review of the complaint response process which was impacting current timescales. It said the new target date for response was 11 September.
86. Up to this point, we have no concerns about how the Trust handled this complaint as it correctly contacted Ms U to explain the delay and provided a new target date.
87. However, following this, the Trust continued to miss deadlines for responding to Ms U’s complaint, extending the target date on nine occasions in total. We can see on some occasions, the Trust appropriately advised Ms U of the extensions in a timely manner as well as the reasons for this. However, on other occasions the Trust failed to do this ahead of the new deadline being missed.
88. On multiple occasions, the Trust only informed Ms U of the need to extend the deadline after she chased this. In addition, on some occasions we can see Ms U did not receive a response to her emails, causing her to have to email the Trust multiple times.
89. The Trust sent its response to Ms U on 27 April, over a year after Ms U had raised her complaint. We can see the Trust has explained some of the reasons for this delay and apologised for this.
90. We acknowledge Ms U’s complaint raised 37 points for investigation spanning across multiple clinical specialities. Therefore, we do not consider the delay wholly unreasonable or outside of NHS complaints regulations which acknowledge investigations can at times take longer than six months.
91. However, we consider the Trust should have done more to keep Ms U updated during this time. We consider the Trust failed to manage this aspect of Ms U’s complaint in line with the NHS complaints regulations or our principes of good complaint handling.
92. Following this, on 13 May, Ms U requested a complaint meeting with the Trust. The Trust acknowledged this request and explained it may take a little while to get a date. On 12 September, the Trust contacted Ms U to offer her a meeting on 1 October. It took almost four months to arrange this meeting and again we can see no evidence of the Trust updating Ms U during this time.
93. We note from internal emails the complaints team did not contact the involved clinicians for their availability until 6 August, almost three months after Ms U made the request. We consider the main reason for the delay in arranging the meeting was because the Trust did not act on the request promptly in line with our principles of good complaint handling. We again consider this to be a failing.
94. We can see these delays have caused Ms U additional distress and caused her to feel her the Trust did not take her complaint seriously. Whilst the Trust apologised for some of the delays, we have made some additional recommendations to the Trust to address this.