Next of kin
14. Miss B complains the Trust changed Mr B’s next of kin details, by removing her as next of kin, and using the details of Mr B’s stepsister instead. Miss B said the Trust’s actions were inappropriate as she should have been consulted before any changes were made, especially as she had concerns that the changes made were not in Mr B’s best interests. Miss B said the Trust put Mr B’s health at risk by changing the next of kin details.
15. Miss B was known to the Trust as she was very involved in her brother’s care. We recognise how stressful it would have been for Miss B to have been removed as her brother’s next of kin without prior discussion or knowledge of the changes, especially given her concerns about the named contact.
16. Where something serious could have happened but did not happen, we consider the actual distress caused as opposed to any impact that could have happened. Therefore, as Mr B’s health was not impacted by this, we will only consider the distress this caused Miss B.
17. In its complaint response, the Trust acknowledged it should not have changed Mr B’s next of kin. It says it accepts that any changes to this should be discussed with the existing next of kin beforehand. It apologised to Miss B for its lack of communication when changing Mr B’s next of kin and the distress this caused. It has also explained that it has discussed this with the whole team to ensure they are all aware of the process to minimise the risk of this happening again.
18. Our Complaint Standards state that organisations should be open and honest when things have gone wrong and give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned. They also say that organisations should identify what learning can be taken from a complaint and be clear about how the learning will be used to improve services and support staff.
19. We can see that the Trust has already acknowledged that this should not have happened and apologised for the distress that this caused Miss B. It has also put in place improvements to try and prevent this from happening again.
20. We consider the Trust has already put right the impact caused in line with our Complaint Standards. Therefore, we will not take any further action in relation to this aspect of the complaint.
Feeding and eating support
21. Miss B complains about the support Mr B received with his feeding and eating during his admission in May until his feeding tube was inserted in August. She says Mr B lost the ability to hold cutlery and feed himself and she had to take time out of her schedule to feed him because he was not getting the right feeding support from the Trust.
22. The Code gives information on the professional standards that nurses, midwives and nursing associates must uphold. It says nurses must deliver the fundamentals of care effectively and this ‘includes making sure that those receiving care have adequate access to nutrition and hydration and making sure that you provide help to those who are not able to feed themselves or drink fluid unaided’.
23. We can see from Mr B’s food charts (a structured record of daily consumption of food and drink to facilitate a balanced, nutritious diet) that the Trust recognised that he was dependent on assistance in order to eat and drink. The nursing notes make it clear that he required assistance with feeding.
24. The food charts show Mr B was assisted with eating and drinking throughout his admission by both his family and the ward staff. This was often a mixture of both on the same day with common entries such as ‘patient fully assisted with eating and drinking’, ‘family supported’ and ‘visitors assisted with food and medications’.
25. Our adviser said the information in Mr B’s food charts demonstrate Mr B received adequate assistance with his feeding as it is documented within most of the chart that he received assistance with eating and drinking. Our adviser identified there were some administrative gaps in the food chart where the Trust should have indicated the specific details of support given with eating and drinking but concluded the food chart was mostly completed with details of the feeding support with entries such as, ‘spoon fed’ and ‘full support given’.
26. We can also see that where there are administrative gaps in the ‘details of support given’ section, it is clearly highlighted on each of the days that Mr B was dependent on feeding support. Taking into consideration the entries on the food charts, our adviser concluded Mr B was offered appropriate feeding support during this admission.
27. Therefore, we consider the records show the Trust was providing appropriate feeding support to Mr B during this admission in line with the Code.
28. Miss B also said Mr B’s food intake was not regular enough for someone with diabetes.
29. We can see from the food charts that throughout May, Mr B was eating quite well. However, the deterioration in his appetite and oral intake is evident from the beginning of June where it is recorded that Mr B’s estimated food intake ranged from none to all, with very few entries indicating that he ate all his food. Unfortunately, generally Mr B was only managing to eat between a quarter or half of his meals on most days with some food chart entries noting, ‘patient refusing all hot food’.
30. This was understandably a concern for Miss B who said Mr B’s food intake was not regular enough for someone with diabetes. She said his nutritional needs were not met, causing him to lose an unhealthy amount of weight.
31. The Nutrition support for adult guidance says all patients admitted to hospital should have a malnutrition risk assessment undertaken using a validated screening tool such as the Malnutrition Universal Screening Tool (MUST).
32. MUST is a five-step tool used by healthcare professionals to identify adults who are malnourished. There are three risk categories; low risk (score 0) which means routine clinical care should continue, medium risk (score 1) which requires observation and dietary advice, or high risk (score 2 or more) which requires referral to a dietician or nutritional support.
33. The records show that Mr B was risk assessed on admission in May 2023 and noted to be low risk of malnutrition. In line with this, the Nutrition support for adult guidance says no further action regarding his oral nutrition was required at that time apart from weekly weight checks and MUST assessments, which were undertaken.
34. As a result of his decreased nutritional intake, the records show Mr B’s weight declined in June and July and his MUST score was reassessed as 2 on 28 July 2023. The Trust referred him to the dietician team at this stage in line with the above guidance.
35. We can see that Mr B was reviewed by a dietician on 28 July 2023 who felt he had an inadequate oral intake, with a large calorie deficit. The dietician commenced Mr B on supplement drinks (to provide extra nutrients for people who are unable to meet their nutritional requirements through their usual meals and drinks), a high protein and high calorie diet, and recommended he had full assistance with all meals and maintain good hydration and asked for strict food charts.
36. According to the notes, Mr B was supported with feeding in accordance with the dietician’s advice and Mr B was actively encouraged to eat and drink more, however he continued to eat very little. Though it was noted that he seemed to eat more when Miss B was present and he preferred family members and familiar faces to feed him.
37. Our adviser said there is enough information in the records to show that the Trust were consistent in encouraging Mr B to eat and drink, however due to the deterioration in his health condition, he was reluctant to do so.
38. It is clear Mr B’s food intake was unfortunately too low to provide the required nutrients and sustenance he needed. Miss B had concerns about her brother’s diabetes and the impact of his low nutrition. Our adviser said given Mr B was not taking insulin, the records show that the reduced amount of food did not affect his blood glucose levels negatively.
39. Miss B also shared concerns about the consistency of Mr B’s meals. She said as part of his feeding support, he needed to have thickened meals, had to be fed upright and with a teaspoon.
40. The IDDSI Framework provides terminology for food textures and drink thickness to improve safety for individuals with swallowing difficulties. It consists of a continuum of 8 levels (0-7), where drinks are measured from levels 0-4, while foods are measured from levels 3-7.
41. We can see from the notes that Miss B had stated that Mr B required level 5 (consisting of minced and moist food and is the first step to transitioning from liquidised meals) foods as his baseline although prior to Mr B’s admission, the Speech and Language Therapy (SALT) team had assessed him as requiring level 2 (classed as mildly thick) fluids and level 6 (soft and bit-sized) foods.
42. During Mr B’s admission, the Trust made recommendations regarding his swallow and consistency of his meals. The records show he was referred to SALT on 13 May 2023, five days after his admission. SALT provides assessment, diagnosis and treatment for children and adults with difficulties in communication, speech, language, eating and drinking. We can see Mr B was assessed on many occasions during his admission.
43. Our adviser said comprehensive assessments were undertaken by SALT on 19 and 29 July and directions were given about the suitability and consistency of Mr B's food and drink. The assessment also included advice about Mr B’s feeding posture and prompts to aid his feeds. For example, it was noted on 19 July that Mr B had to be ‘sitting upright in midline’ and the recommended technique was to ensure he was fully awake for all oral intake. On 29 July the recommended posture was ‘upright, alert, in midline’ noting he needed ‘full assistance and prompt to swallow’.
44. We can see that on 24 July following a SALT assessment, Mr B was advised to have level 4 pureed diet via teaspoon, level 2 thickened fluids, liquid medications and full assistance due to a deterioration in his swallow and high risk of aspiration pneumonia.
45. The records show the consistency of Mr B’s meals was closely monitored, and the Trust were aware of associated risks such as aspiration pneumonia. The changes made to Mr B’s feeding, after SALT assessments, also demonstrate that the Trust ensured the feeding support they offered Mr B was in line with his needs at the relevant time. For example, further changes were made to Mr B’s nutrition on 8 August as SALT advised Mr B should be nil by mouth (meaning a person must not consume any food or drinks) as his swallow had deteriorated further.
46. The food charts demonstrate that the advised thickness and levels of food and drink were adhered to by the ward staff. For example, on 19 May 2023 it is documented that Mr B was on a level 5 diet, however this changed to level 6 by 30 May, following SALT advice.
47. Our adviser said the consistency of Mr B’s food and drink was appropriate for a patient with high risk of developing aspiration pneumonia.
48. We understand Miss B’s concerns about Mr B’s food intake especially as he began to deteriorate to the extent that a nasogastric tube (a thin, flexible plastic tube inserted through the nose, down the throat, and into the stomach to provide essential nutrients, hydration, or medication directly) was fitted on 8 August 2023, in an attempt to meet his nutritional requirements. Our adviser said the decline in Mr B’s food intake was not from a lack of understanding or effort from the ward staff, rather, due to a deterioration in his condition and reduced appetite.
49. Taking into account all the evidence, we consider the Trust acted in line with the Code and the Nutrition support for adult guidance when providing nutritional support to Mr B during this admission.
50. We are very sorry to hear of Mr B’s deteriorating health and the impact on his nutrition. We understand it would have been very distressing for Miss B to witness her brother’s declining health. We hope our decision provides Miss B with assurance about what happened with her brother’s care.