Restraint and lorazepam
46. Miss W complains staff restrained her and gave her lorazepam without her consent.
47. Clinical records show nurses asked a doctor to review Miss W was she was becoming increasingly agitated. The doctor assisted nurses in attempting to give Miss W lorazepam. Documentation from this time states ‘Miss W acutely distressed, attempting to hit nurses, so didn’t manage to give’.
48. We have taken full consideration of the evidence available to us. The Trust says there is no evidence staff restrained Miss W during this admission and explained that staff do not administer injections via the ankle. The clinical records are consistent with this account.
49. Clinical records show staff attempted to give Miss W lorazepam when she was acutely distressed but were unable to do so as she tried to hit them. We have not seen any evidence staff attempted this again.
50. We recognise Miss W found this experience distressing and has concerns about how staff treated her.
51. Based on the available evidence, we do not think staff restrained Miss W or gave her lorazepam without her consent.
52. We therefore cannot say anything went wrong in this regard. For this reason, we are not continuing our consideration of this part of her complaint.
Contacting Rotherham Doncaster and South Humber NHS Foundation Trust (RDSH)
53. Miss W complains staff contacted RDSH for mental health input. She considers they should not have done this as she did not have a history of mental health concerns.
54. Our adviser said there are no specific standards or guidance doctors should follow when referring a hospital inpatient for mental health team input. In lieu of specific standards, we sometimes refer to the GMC’s Good Medical Practice. This says doctors must provide a good standard of practice and care. They must adequately assess the patient’s conditions, take account of their history and refer to another practitioner when this serves the patient’s needs.
55. RDSH provide mental health liaison services for patients and clinicians in Hospital A (where Miss W was based for all three admissions). Mental health liaison services are specialised teams who act as a bridge between physical and mental healthcare. These services provide mental health assessment and treatment for people who are in a general hospital for a physical illness.
56. Our adviser said it is standard clinical practice for doctors to consider making a referral to mental health liaison services if they suspect a patient may have an underlying mental health condition.
57. Miss W tells us she did not have a history of mental health concerns. Clinical records suggest this was not the case. We can see her GP had referred her to the community mental health team (CMHT) for support prior to her admission.
58. Clinicians regularly documented Miss W’s poor mental health throughout the December admission. Some examples of this are on 5 and 6 December when she was attempting to hit nurses and claiming the nursing team were trying to harm her.
59. We can see the medical team requested mental health input after a ward round. Clinical records suggest Miss W continued to experience poor mental health after this.
60. RDSH carried out a mental health review. They noted Miss W was already under the CMHT. RDSH advised staff could discharge her and CMHT would provide follow up care.
61. We understand Miss W considers staff should not have referred her for mental health support in December. We have seen evidence she was experiencing agitation, hallucinations and paranoid ideas during the admission. Our adviser said these symptoms are often caused by an underlying mental health condition.
62. GMC guidance says doctors must assess patient’s conditions and refer them to another practitioner when this serves their needs. In this instance Miss W was experiencing symptoms of poor mental health, and her treating clinicians were unsure why this was.
63. It is clear doctors needed RDSH’s input to help determine whether Miss W’s symptoms were due to her physical health condition or an underlying mental health condition. Having reviewed all the evidence, we consider it was in line with GMC guidance for staff to seek RDSH’s support. We have seen no indication anything went wrong in this aspect of the complaint.
Lack of NAVIGO involvement
64. Miss W also complains that staff involved RDSH in her care during her third admission. She considers they should have maintained contact with NAVIGO who she says were initially involved in her care during this period.
65. RDSH provides mental health liaison services to Hospital A, where Miss W was a patient for all three admissions. NAVIGO provides a similar service, but not to Hospital A. We have reviewed clinical records from all three admissions and cannot see NAVIGO were responsible for any care Miss W received.
66. Miss W sent us a bundle of information when she brought her complaint to us. Within this was an email from a doctor to a local authority. We can see NAVIGO is in this doctor’s email signature. We consider it is likely this is what led Miss W to believe NAVIGO were involved in her care.
67. Clinical records show the above doctor was present at two mental health reviews during the third admission. This doctor does sometimes work for NAVIGO. In Miss W’s case they were there in an independent capacity to conduct a mental health assessment on behalf of the local authority. They were not representing NAVIGO.
68. We appreciate why this caused Miss W confusion.
69. We cannot say the Trust should have involved NAVIGO in Miss W’s care during her third admission as NAVIGO does not provide mental health liaison services to the hospital Miss W was in. We have not seen evidence that anything went wrong here.
70. We hope this explanation helps Miss W to understand what happened and why staff continued to involve RDSH in her care.
Investigation of morphine pump
71. Miss W complains during her second admission staff did not investigate why she was suffering from electric like pain under her morphine pump.
72. In this case Miss W’s GP had already referred her to Hull University Teaching Hospitals NHS Trust for (where the team who looked after her pump were based) for concerns about her pump prior to her first admission.
73. During her first admission Miss W again reported sensations around her pump. Staff found no issue with the pump and noted she was experiencing hallucinations linked to a urinary tract infection at the time.
74. Emergency department staff noted Miss W was still waiting for an MRI from Hull when she returned to hospital in January. This suggests the GP’s referral remained open and there was no need for the Trust to refer her again. A doctor attempted to examine Miss W on the second day of her admission, but she refused all intervention.
75. Miss W continued to report worsening pain throughout the admission. We can see three consultants assessed her and found no acute neurological or abdominal issues. Staff contacted her treating consultant at Hull who said they could discharge her if she had no acute issues. They said clinicians at Hull would review her in the outpatient clinic and decide on next steps.
76. Clinical records indicate staff explained the above plan to Miss W who was satisfied with this. They discharged her for outpatient follow up at Hull University Teaching Hospitals NHS Trust. We understand this Trust later reviewed her. We cannot comment further on its actions as this organisation does not form part of Miss W’s complaint.
77. Our adviser said the records suggest clinicians did not know how to manage Miss W’s pump. The evidence suggests this is because the specialist team responsible for managing this were based at a different organisation.
78. We can see clinicians recognised this and were actively trying to transfer her care. This was not possible due to a lack of beds at Hull and not because of any lack of action on staff’s part. A clinician from Hull decided Miss W should be seen at Hull’s outpatient clinic. This was not something the Trust could control.
79. We recognise Miss W was worried something was wrong with her pain pump and wanted to know what was causing this. We understand how frustrating and distressing it must have been that staff were unable to give her answers during her second admission.
80. On balance we consider this was because she was waiting for investigations from another Trust.
81. We can see staff contacted the team responsible for Miss W’s pump and followed their advice. This was in line with GMC guidance which says doctors must refer patients to another practitioner for treatment or advice when this serves their needs. For this reason, we have not seen an indication of failing in the Trust’s actions.
82. We understand Miss W went on to have outpatient follow up about her pump with Hull University Teaching Hospitals NHS Trust. We are not able to comment on this organisation’s actions as they do not form part of this complaint.
Intravenous fluids
83. Miss W complains that in January 2022 staff gave her IV fluids without her consent. She is concerned that these contained medication that made her feel very drowsy.
84. In its response to the complaint the Trust said staff prescribed Miss W IV glucose to be administered over 12 hours due to her reluctance to eat and drink. It said staff administered this at 4.16pm on the second day of the admission. It explained Miss W did not receive IV glucose again as she declined it.
85. Clinical records support the Trust’s account of events. They show staff commenced IV fluids at around 4.18pm on the second day of the admission and stopped these at 2am the following day.
86. Miss W’s consent for medications is well documented in her records. She initially declined her morning medication on the second day of the admission. IV fluids did not begin until the afternoon. We could not identify any record of Miss W declining IV fluids nor can we see she received these again during her admission.
87. Our role is to analyse evidence to determine what happened, what should have happened and whether there are indications that something went wrong.
88. There is a clear difference between the Trust’s and Miss W’s account of events. Miss W says she received IV fluids without her consent. The Trust says she did not. Clinical records support the Trust’s account of events.
89. For us to investigate further we have to have seen indications that something went wrong with the care, treatment or service complained about. In this instance we have not seen compelling evidence that staff gave Miss W IV fluids without her consent. Therefore, we cannot say anything went wrong. For this reason, we are not continuing our consideration of this aspect of the complaint.
Medications
90. Miss W complains that between March and May 2022 staff gave her amlodipine, diazepam, lorazepam and haloperidol. She says she should not have received these medications.
91. We reviewed Miss W’s clinical records to understand what medications she received during this admission. There is no evidence clinicians prescribed or gave her amlodipine. Similarly, clinicians noted that haloperidol could be a suitable option. There is no evidence they prescribed or administered this.
92. The relevant guidance for this part of the complaint is GMC’s good medical practice. This says doctors must provide suitable treatment. They must prescribe drugs only when they are satisfied these serve the patient’s needs.
93. Diazepam formed part of Miss W’s regular long-term medication before the admission. Our adviser explained that patients who take diazepam for a long time are at risk of withdrawal symptoms they suddenly stop taking this. We consider the decision to continue prescribing Miss W diazepam was therefore in line with good medical practice.
94. Clinical records show Miss W received lorazepam on three occasions during the admission. The first was at the beginning of April after she had been shouting all night and refusing all medical intervention. Clinicians noted she wanted to harm nursing staff and had taken very little medication for around 11 days.
95. Clinicians agreed nurses could provide lorazepam as needed. Miss W received this a further two times in May.
96. Our adviser explained that doctors often use antipsychotics to manage agitation in hospital settings. They confirmed diazepam is commonly used for this. They explained lorazepam (an antipsychotic) was an appropriate alternative for clinicians to prescribe as Miss W was often refusing her regular diazepam.
97. The records show Miss W was frequently agitated and our adviser said they would expect doctors to treat this. Our adviser told us what happened is what they would have expected to see.
98. We understand Miss W was very distressed throughout her third admission. This may have affected how she remembers events. We do not dismiss her account of what happened. In this case, the available evidence shows on the balance of probabilities clinicians acted in line with GMC guidance.
99. For this reason, we will not be taking further action on this part of the complaint. We recognise how upsetting this experience was for Miss W. We hope this explanation helps her understand how and why clinicians made decisions about her medication at the time.
Nutrition and hydration
100. Miss W complains that staff did not provide her with sufficient nutrition and hydration between March and May 2022. She says she was suffering from significant dehydration and malnutrition during this period which led to kidney damage.
101. We saw the Trust acknowledged failings around the way staff provided Miss W with nutrition and hydration during her third admission. We also saw the Trust addressed the impact of the failings in line with our complaint standards.
102. We use our Complaint Standards to determine our approach to securing remedy. We also have regard to what outcome(s) the person complaining wants to resolve their complaint. Our Complaint Standards say the things Miss W wants (explanation and service improvements) are appropriate remedies for complaints. Therefore, we checked whether the Trust provided these things during its complaints process.
103. In its response to the complaint the Trust noted there are significant gaps in the recording of food and fluid intake in Miss W’s records despite nurses noting her refusal to eat or drink. It accepted that staff missed several opportunities to highlight her inadequate fluid and nutrition intake and refer her onto the nutritional team and for further support.
104. Miss W is concerned that this poor intake led to her suffering from kidney failure. The Trust’s discharge letter notes that she did develop stage 2 kidney failure during her admission. We can see this was resolved during prior to her discharge. Miss W has not explained she currently still has kidney failure. This appears to have been resolved.
105. We recognise how distressing it must have been for Miss W to experience this deterioration in her health at a time when she was already unwell. We understand the worry this will have caused her.
106. Our Complaint Standards say to learn lessons, improve, and support their staff organisations can train or supervise their staff.
107. In its complaints response the Trust says it has two nutritional support nurses who support the wards on a full-time basis and work closely with multidisciplinary team members to ensure the best and safest nutritional care and treatment options for patients.
108. It said in June 2022 it carried out training to improve its services which covered the importance of timely referrals to the nutritional nurses. In addition to this, staff now hold daily huddles to discuss patients who are at nutritional risk with the senior nursing staff and medicine matrons.
109. The Trust explained staff also carry out stop and check huddles, which is a mid-shift huddle in order for vulnerable and at-risk patients to be identified to the nurse in charge and ensure any actions and specialist team referrals are completed.
110. We contacted the Trust during our enquiries, and it confirmed it has since carried out all agreed actions. This is in line with our Complaints Standards.
111. Considering all the above, we can see there is nothing further for us to do in relation to this issue. The Trust has given Miss W explanations about why failings around the nutrition and hydration occurred. It apologised for the impact to Miss W and has taken steps to improve its service.
112. This helps put matters right for Miss W and we have seen no evidence of any further injustice to put right. For this reason, we are taking no further action.
Paranoid schizophrenia
113. Miss W complains that in April a junior doctor wrote she had undiagnosed paranoid schizophrenia in her medical records.
114. GMC guidance states doctors must keep clear, accurate and legible records. Our adviser said clinical records show Miss W had displayed symptoms of paranoia at several times during her various admissions. They said they would not expect the junior doctor to diagnose Miss W with paranoid schizophrenia as this would require a psychiatrist assessment.
115. Our adviser said paranoid schizophrenia is one of many causes of paranoia. The evidence suggests the junior doctor thought Miss W’s paranoia may have been caused by paranoid schizophrenia. This means their documentation of undiagnosed paranoid schizophrenia was an accurate record of their clinical opinion. Our adviser told us the decision to document this as a possible diagnosis was justifiable.
116. Miss W also complains a discharge summary from May includes schizophrenia as a diagnosis. She says this is inaccurate as she does not have schizophrenia.
117. We have seen that during a joint meeting in May 2022 RDSH asked NLG to remove schizophrenia as a diagnosis as staff did not believe it was accurate. Despite this, the diagnosis remained on Miss W’s records when she later raised her complaint. This was not in line with GMC guidance which says doctors must keep accurate and up-to-date records. We have seen an indication of failing in this aspect of the complaint.
118. When we see an indication that something went wrong, we go on to consider how the person says this has impacted them. Miss W says the incorrect diagnosis affected how she was treated at other hospitals and stopped her seeking care.
119. We can see she has several hospital admissions since the period of complaint. We do not consider we could say the Trust’s actions prevented her from seeking care. There is also no way for us to say with any certainty that this changed how other hospitals treated her.
120. Miss W also said the Trust’s actions negatively affected her relationship. Clinical records show she was already experiencing mental health difficulties before the period of complaint, and her partner was finding this challenging to manage. We consider these difficulties may have placed pressure on the relationship.
121. To link Miss W’s claimed impact with the indication of failing we have seen, we would have to be able to say there would have been no pressure on the relationship without the incorrect diagnosis. We do not consider the evidence supports this.
122. We cannot link the specific impact Miss W describes to the indication of failing we have seen. We recognise having an incorrect diagnosis on her record will have caused her frustration and worry.
123. Our Complaint Standards say when something has gone wrong organisations should take steps to prevent it from happening again. The Trust has since placed a letter at the front of Miss W’s records confirming she does not have schizophrenia. It has also given her a patient passport for future admissions.
124. We consider these actions are sufficient to minimise any ongoing risk of her care being affected. We also understand the Trust has involved the matron and the vulnerabilities team in Miss W’s care since the period of complaint.
125. Miss W told us she wanted the Trust to provide explanations and service improvements. She has already received six separate complaints responses and attended a meeting with the Trust where she was able to discuss her concerns. We are satisfied the Trust has provided as much explanation as possible and put in place sufficient service improvements.
126. There is nothing further we can achieve on this aspect of the complaint. For this reason, we are not continuing our consideration.
Deprivation of liberty safeguards
127. Miss W complains that staff requested an urgent deprivation of liberty safeguards authorisation be implemented during her third admission. She considers this was not in her best interests.
128. We saw the Trust acknowledged failings around its implementation of DoLS. Our Complaint Standards say when something has gone wrong organisations should take steps to prevent it from happening again.
129. We have already explained above why we cannot link the specific impact Miss W describes. We recognise the indications of failing we have seen will have caused her some distress.
130. Miss W says she would like the Trust to provide explanations and service improvements. We consider it has already provided as much explanation as it can. Our Complaint Standards say service improvements are an appropriate remedy when something has gone wrong.
131. In its responses the Trust said it planned to strengthen staff understanding of the Mental Capacity Act and DoLS. We recognise around four years has passed since the period of complaint. We contacted the Trust to check what it has done since then.
132. The Trust explained it now delivers mandatory Mental Capacity Act and DoLS training several times each month. This training lasts three hours and staff can also complete e-learning modules to stay compliant. The Trust said the focus of this training is on improving staff confidence and compliance with the principles of the Mental Capacity Act.
133. Given the length of time that has passed, it would not be proportionate to expect the Trust to provide detailed evidence of every piece of training it has delivered. We are satisfied what it has told us shows there has been sufficient service improvement since Miss W made her complaint.
134. As explained above, we consider the Trust has provided Miss W with as much explanation as possible. We are also satisfied it has put in place appropriate service improvements. The Trust has taken the steps Miss W asked for. There is nothing further for us to do on this complaint.
135. We appreciate how difficult these three admissions were for Miss W and the ongoing impact they have had on her confidence in seeking care. We also recognise she has continued to experience health problems and remains dissatisfied with aspects of the care she has received since this time.
136. We hope the contents of this statement reassure Miss W we have carefully considered her concerns and all of the evidence available. We thank her for bringing her complaint to us.