Medication
15. Mrs L complains a nurse forced Mr L to take medication orally even though he was struggling to swallow.
16. The NICE Medicines Optimisation guidelines says that medicines optimisation applies to people who may or may not take their medicines effectively. There are many routes of administration that can be considered for patients that are having trouble swallowing. This includes intravenously, subcutaneously or via a nasogastric tube. A nasogastric tube is a thin, flexible tube which is inserted through the nose into the stomach and can be sued for feeding and medication. The method of medication administration should be patient centred, with the patient involved in the decision.
17. The records show the Trust referred Mr L to the SALT team, as Mr L was having difficulty taking medication and food. The possibility of using a nasogastric tube was raised, however Mr L did not wish to have one. SALT were unable to fully assess Mr L as he was having to lie flat. The SALT team noted Mr L wished to remain in IV fluids, without any oral intake.
18. The Trust’s actions here, in considering Mr L’s needs when he was experiencing difficulties swallowing, and his preference for how medication, including fluids, should be administered is in line with the NICE Medicines Optimisation guidelines.
19. The NMC Code also says people should be treated as individuals and with kindness, respect and compassion. Nurses should also respect, support and document a person’s right to accept or refuse care and treatment.
20. Mrs L has told us how Mr L was struggling to swallow, but a nurse forced him to take his medication orally. There is no record of this occurring in the records but in the Trust’s response to the complaint, the nurse has acknowledged this happened.
21. Putting medication into Mr L’s mouth against his wishes is not in line with the NMC guidance. We have found a failing in the actions of the Trust here. We have gone on to consider the impact of this failing for Mrs L and Mr L.
22. Mrs L told that that this incident caused both her and Mr L a great deal of distress.
23. We acknowledge the failing we have identified here would have caused Mr L discomfort and distress. We understand how this in turn caused Mrs L distress and worry that this could happen again. We acknowledge this made them feel anxious. We also acknowledge that it would have been distressing for Mrs L to witness this event and see her father in distress.
24. We have gone on to consider the Trust’s response to this issue, and whether it has done enough to remedy the impact of this identified failing. Our NHS complaint standards set out how organisations providing NHS care should approach complaint handling.
25. These standards say that organisations should see complaints as an opportunity to develop and improve its services and people. It says responses should be fair and accountable, setting out what happened and whether mistakes were made. It should set out how the organisation is accountable and take action to make sure any learnings are identified and used to improve services.
26. The Trust has said that the nurse felt she had to encourage Mr L to take his medication. On reflection, the nurse acknowledged that this could have appeared like she was forcing him to take them, and this was not the correct way to administer the medications.
27. The nurse confirmed they have learned from the incident and has attended an up-to-date end of life course on how to communicate with patients who are at the end of their life and their families. They have also written a reflective piece to learn about their practice and where they need to improve.
28. The Trust has also apologised that Mrs L and Mr L had a poor experience at the hospital.
29. We consider the response from the Trust is in line with the Complaint Standards. It acknowledged it made mistakes, and it was accountable for them. It apologised to Mrs L for the distress its actions had caused, and it identified learning and set out actions taken to improve services.
Injured back
30. Mrs L tells us she and her father requested he was not moved due to the pain in his spine. Mrs L tells us the nurse entered his room and said he had to be moved. After rolling Mr L, Mrs L tells us that the nurse then rubbed his back very hard directly down his spine which caused him extreme pain.
31. The NICE Spinal Metastases guidance says the patient should be immobilised, keeping the spine as straight as possible at all times. Our nursing adviser explained that rubbing a patient’s back could cause involuntary movement of the spine.
32. Log rolling is a method of safely moving a patient while maintaining spinal alignment and preventing further spinal injury. If a patient needs to be moved, using a log roll would preserve spinal stability. We have found the Trust’s decision to log roll Mr L during his admission was in line with the NICE Spinal Metastases guidance.
33. There is no record of the nurse rubbing Mr L’s back in the records. In the Trust’s response to the complaint, the nurse accepts this happened. They explained they did this due to markings on his back from the bed sheets.
34. We think rubbing Mr L’s spine risked an involuntary movement of his spine and so was not in line with the NICE Spinal Metastases guidance. We have found a failing in the actions of the Trust here. We have gone on to consider the impact of this failing.
35. Mrs L tells us this caused her father a great deal of pain. She tells us he was in pain from this time until his death. She believes he was still in a lot of pain when he passed. This has caused her a lot of distress from witnessing her father in severe pain. It has made her anxious to seek medical care.
36. We can see that throughout Mr L’s admission, Mr L already had back pain as he had been diagnosed with spinal metastases and a spinal fracture. As mentioned above, the spine should have been kept immobile due to this.
37. We think the failing we have identified would have increased the pain he was already experiencing, and we think this additional pain was avoidable. It was understandably distressing for Mrs L to witness her father in pain due to his illness. We acknowledge witnessing Mr L in additional and avoidable pain would have added to Mrs L’s distress.
38. Mr L passed away four days after the event considered in this report. We think the failing we have identified impacted Miss L’s last memories of her father. Her lasting impression of his final days is one which he was in severe pain and suffering, some of which could have been avoided.
39. We have gone on to consider the Trust’s response to this issue. Our NHS complaint standards set out how organisations providing NHS care should approach complaint handling.
40. These standards say that organisations should see complaints as an opportunity to develop and improve its services and people. It says responses should be fair and accountable, setting out what happened and whether mistakes were made. It should set out how the organisation is accountable and take action to make sure any learnings are identified and used to improve services.
41. The Trust has said that the nurse felt rubbing Mr Carrington’s back would have benefitted him from preventing the sheets from marking the skin. On reflection she ‘acknowledges it may not have been the best idea to do that’ and apologises for the distress.
42. We consider the response from the Trust goes someway to put things right here. It acknowledges mistakes were made and apologises for the distress these mistakes caused. However, we do not think the Trust’s response goes far enough to put things right here.
43. The Trust’s response acknowledged and apologised for the distress caused. However it does not mention the severe pain which Mr L felt as a result of the nurse’s actions, and so it cannot recognise the distress this caused Mrs L.
44. The Trust’s response does identify learning, but again it does not recognise the full extent of the learning needed. It also does not outline any steps it has taken to prevent the same mistake from happening in future.
45. We therefore think there is more the Trust can do to recognise the full impact the failing had on Mrs L, and to reassure Mrs L that something similar would not happen again. We have set out our recommendation in relation to this below.