Hydration
19. Mrs A says the Trust failed to monitor and attend to Mrs N’s hydration needs through her inpatient stay.
20. The Trust explained it administered IV (intravenous) fluids to Mrs N on admission for 24 hours. It then prescribed IV fluids for two days during her admission. The Trust said it was taking regular blood samples which would help determine whether Mrs N required IV fluids or not. It said it monitored Mrs N’s fluid intake and regularly encouraged her to drink.
21. The NMC standards says nurses must observe, assess and optimise hydration status and determine the need for intervention and support. They should also record fluid intake and output and identify, respond to and manage dehydration or fluid retention.
22. The records show Mrs N was clinically dehydrated on admission. The nursing team completed a hydration risk assessment that day and identified Mrs N as high risk. This assessment is in line with the NMC standards.
23. The records indicated the Trust prescribed and administered IV fluids on admission, as well as additional IV fluids on a further two days.
24. The nursing staff monitored Mrs N’s fluid intake and output on fluid balance charts, as well as daily nutrition and hydration charts. This is in line with the NMC standards.
25. Our nursing adviser has said Mrs N’s fluids charts indicate a reasonable intake during the time she was in hospital. They have noticed that during one day of Mrs N’s time in hospital, the Trust’s monitoring of Mrs N’s fluid intake was poor.
26. Our nursing adviser also says the records show the Trust met Mrs N’s hydration needs on 12 days out of the 15 she was in hospital. They continue to say that given two of those days would have been shorter due to admission and discharge, this would explain the lack of hydration provided. It is noted throughout the medical records Mrs N needed assistance with her oral intake, with regular encouragement needed.
27. Considering the evidence in the medical records, as well as the advice from our nursing adviser, we think there are no indications of failings here. The nursing staff followed the NMC standards in assessing Mrs N’s hydration status, which then indicated the need for IV fluids on admission. It also responded to another occasion where further IV fluids were required. It also followed the NMC standards in recording Mrs N’s fluid intake.
28. We recognise the lack of hydration on the days our nursing adviser has pointed out. Overall, however, we think the Trust did monitor and attend to Mrs N’s hydration needs.
Nutrition
29. Mrs A says the Trust failed to monitor and attend to Mrs N’s nutrition needs through her inpatient stay.
30. The Trust explained it monitored Mrs N’s dietary intake and noted a decline in her intake early on during the admission. It made a referral to the dietician and it prescribed Fortisip supplement drinks. The Trust said Mrs N declined to eat at times when she felt unwell, and it agreed for Mrs A to bring in food from home or for someone to assist Mrs N at mealtimes. It said the records indicate that nursing staff encouraged Mrs N to eat each day.
31. The Nutrition guidance says all hospital patients on admission should be screened for malnutrition and the risk of malnutrition. One way to do this is by using the MUST tool. This screening should be repeated weekly, or when there is clinical concern.
32. One of the steps of the MUST tool is to measure a patient’s height and weight to calculate BMI (body mass index). The MUST guidance provides alternative methods in calculating BMI (including weight) and one way is measuring the mid-upper arm circumference.
33. The Nutrition guidance goes on to say nutrition support should be considered for people who have eaten little or nothing for more than five days, or who are likely to eat little or nothing for the next five days or longer. Similarly, the MUST guidance says if a patient is identified as being high risk of malnutrition (a score of two or more), it says to refer to a dietician. A score of zero is low risk of malnutrition.
34. The records show the Trust performed the malnutrition screening on Mrs N’s admission to the Trust. The Trust recorded Mrs N’s weight as 45.6kg and estimated her height as 1.6m, which gave Mrs N a BMI of 17.8. The record of this screening does not contain a MUST score.
35. Using the MUST tool, our nursing adviser says Mrs N’s BMI alone would give her a score of two. This is a high risk of malnutrition. In line with the Nutrition guidance, we think the Trust should have taken action here.
36. The Trust repeated this screening a week later. This is in line with the Nutrition guidance. The Trust did not conduct another screening a week later when Mrs N was still in hospital. This is not in line with the Nutrition guidance.
37. The record of the second screening does not list Mrs N’s weight and gives Mrs N a MUST score of zero. Our nursing adviser says the records show evidence or little, or no, nutritional intake on the food and hydration charts five days prior to the second screening. This means it is unlikely Mrs N gained weight. As such, we think Mrs N’s BMI is unlikely to have changed and therefore her correct MUST score would still be two.
38. The Trust referred Mrs N to a dietician the day after the second screening. The dietician reviewed Mrs N the next day. The notes outline the discussion of nutrition between the dietician and the doctor. They both agreed a short-term, supplementary nasogastric (NG) enteral feeding regime to start the next day.
39. Prior to this referral, the records show the Trust prescribed Mrs N Fortisip supplementary drinks a week after her admission. Fortisip is typically a milkshake-style drink. The Trust also prescribed Fortijuice towards the end of Mrs N’s admission to be given three times a day. Fortijuice is a juice-based drink. It is unclear whether the doctors prescribed Fortisip due to advice from a dietician, or whether it was because they recognised she was underweight and not eating sufficiently.
40. In summary, the Trust did not correctly identify Mrs N being at high risk of malnutrition. This was due to its error in completing the MUST screening tool. This error also meant that there was a delay in the Trust referring Mrs N to a dietician due to her high risk of malnutrition. The Trust did not follow the MUST guidance. Nor did it document Mrs N’s weight during the second screening.
41. In terms of the Nutrition guidance, it initially followed this as it screened Mrs N nutrition weekly. However, it did not continue to follow the guidance as it should have screen Mrs N a third time. We think the Trust followed the Nutrition guidance in arranging nutritional support when it identified Mrs N’s poor oral intake.
42. Overall, there are indications of failings here in the Trust’s monitoring and assessment of Mrs N’s nutrition needs. We will now consider the impact of this.
43. Mrs A says her mother was left to waste away due to the Trust not fulfilling Mrs N’s nutrition needs, which she says was inhumane. Mrs A believes her mother may have lived longer if the Trust provided the care she should have had. She says the Trust neglected her mother.
44. Our nursing adviser explained that if a dietician had been involved sooner, they would have been able to recommend a nutritional plan for Mrs N from admission. This may have included the dietician identifying nutrient-rich foods, and food Mrs N preferred and would be more likely to eat. They can recommend additional supplementary drinks, and to liaise with a patient’s family to bring in their favourite foods.
45. A dietician would therefore monitor Mrs N, make changes to her plan if needed, and could have suggested an NG feed sooner. We acknowledge here the Trust was providing Fortisip drinks a week after Mrs N’s admission, prior to the dietician seeing Mrs N.
46. Our physician adviser explained that in the short-term, generally, poor nutrition can be linked to a longer stay in hospital, poor mobility and a number of other factors. For patients recovering from illness, they say encouraging patients to increase their intake of food is beneficial to increase their overall strength.
47. The records show that Mrs N did not refuse all food and was having some oral intake. On the balance of probabilities, our physician adviser says that given Mrs N was eating some food, it is unlikely that having an NG feed sooner would have made much difference. The main reason for using an NG tube is if a patient is having difficulty swallowing.
48. It is also difficult for our physician adviser and our nursing adviser, to say whether if a dietician been involved sooner, this would have improved Mrs N’s outcome. This is because we do not know whether Mrs N would have still refused some food. There is a missed opportunity here to know what would have happened if the Trust had acted in line with the relevant guidance or standards. We understand this uncertainty may cause Mrs A further distress and frustration.
49. The Complaint Standards says organisations should explain why things went wrong and identify suitable ways to put things right for people. Organisations should also give meaningful and sincere apologies.
50. We put to the Trust what we had seen regarding Mrs A’s complaint about her mother’s nutrition needs. As such, we asked the Trust whether it would be willing to apologise to Mrs A and provide a financial remedy to resolve this part of Mrs A’s complaint.
51. The Trust has agreed to apologise to Mrs A and pay her £200 in recognition of the uncertainty caused by the Trust’s actions. We will ask the Trust to provide this payment within four weeks of when we issue our decision.
Monitor and call bell
52. Mrs A complains the Trust failed to monitor Mrs N on a ward on one day during Mrs N’s time in hospital. Mrs A is concerned that she found her mother slumped in a chair and in pain following a physiotherapy visit, which was two hours before she visited. Mrs A also complains the Trust placed Mrs N’s call bell out of reach.
53. The Trust explained the physiotherapy team assisted Mrs N into a chair during its session. After the physiotherapy session, it left Mrs N in the chair with the table and call bell in reach. It then assisted Mrs N back to bed around two hours later as she requested to return to bed, and the physiotherapist helped with this. The Trust also explained it prescribed Mrs N paracetamol on an ‘as needed’ basis and administered this in the afternoon.
54. The NMC code says nurses must treat people with kindness, respect and compassion. They must make sure that any treatment, assistance or care for which they are responsible is delivered without undue delay.
55. On admission, the Trust assessed Mrs N as being independent for moving in bed and could transfer herself with supervision from one to two members of staff. This was also the case with walking where Mrs N could walk with the supervision of one to two members of staff. The Trust assessed Mrs N as needing repositioning every four hours.
56. On the day before Mrs N complains about, the Trust assessed Mrs N has requiring physical assistance from staff to move and for transfers, suggesting Mrs N’s mobility had decreased.
57. After the physiotherapy session, the notes show the physiotherapist left Mrs N in a chair, with a table and call bell in reach. We know from the assessment the previous day that Mrs N would have needed assistance to move to and from the chair. The repositioning charts also say the physiotherapist assisted Mrs N to her chair at 11am and assisted her back to bed at 1.11pm.
58. Prior to Mrs A arriving on the ward, there is no note in the records of Mrs N complaining of pain or of being uncomfortable in her chair. Nor is there any record of Mrs N requesting to go back to bed, or anything suggesting she was in pain or distress.
59. We understand Mrs A’s concerns that she says she found Mrs N slumped in her chair and we recognise it would not have been nice to see her mother like that. Mrs A says Mrs N was in her chair for hours, slumped and was crying with pain. We can also see from the Trust records later that day, Mrs A reported her son-in-law had to lift Mrs N back into bed.
60. If Mrs N was slumped in her chair and crying out in pain as Mrs A has said, in line with the NMC Code, we would expect nurses to respond promptly to this. Furthermore, as the Trust had concluded Mrs N needed physical assistance of staff for transfers and movement, we would also expect the nurses to be alert to Mrs N needing support, and to respond to requests from Mrs N to move or change positions (chair to bed).
61. We do not think, even on the balance of probabilities, that we can reach a decision on what happened here. We have Mrs A’s account saying Mrs N was slumped over and crying out in pain. The Trust’s records at the time Mrs N was moved do not reflect this, only that the physiotherapist assisted Mrs N back to bed.
62. The evidence is here is conflicting and is not stronger on one side or the other. This does not mean we disbelieve what Mrs A is saying happened. Only that we cannot reach a view on whether there was a failing here, and how serious it was. We are unable to come to a conclusion, as an independent organisation, as to what happened here.
63. In terms of the call bell, similarly, there are conflicting accounts here. Mrs A says the Trust left the call bell out of reach for Mrs N. As outlined in paragraph 57 the physiotherapist’s note says that it left the call bell within Mrs N’s reach.
64. Without any further independent evidence to say what happened, we do not think we can reach a view here, even on the balance of probabilities. We appreciate not being able to come to decision here may cause Mrs A frustration.
65. Overall, we have been unable to reach a view on the monitoring of Mrs N and also on the placement of Mrs N’s call bell.
Discharge
66. Mrs A complains the Trust did not discuss Mrs N’s discharge with her. She also complains the Trust discharged Mrs N without a care plan and no package of care in place.
67. The Trust explained it did discuss Mrs N’s discharge with her, as discussions were held with the physiotherapist and a doctor about what input Mrs N and the family wanted. It said Mrs N declined physiotherapist input and equipment and support at home. It agreed with Mrs N it would make a referral to the community therapist team to assess Mrs N’s mobility in her own home. The Trust said Mrs N declined a package of care.
68. The Discharge guidance says patients should be asked who they wish to be involved or informed in discussions and decision about their hospital discharge, with appropriate consent received. This may include a person’s family members.
69. Practitioners should consider a range of factors when supporting the patient and their family to decide an individual’s care pathway and post-discharge support. This includes the individual’s preferences, and whether family members are willing and able to support an individual’s recovery.
70. On Mrs N’s admission to the Trust, it recorded Mrs N’s living arrangements and current level of care. It noted Mrs N lived in a house with her daughter and son-in-law. Mrs N’s family helped her in all aspects of daily living, but she was independent with her toileting. Mrs N did not have a package of care in place.
71. The notes show the Trust first discussed discharge with Mrs N and her family approximately two weeks into Mrs N’s time in hospital. Mrs A expressed her concerns and unhappiness with the care her mother had received at the Trust so far. The notes said Mrs A asked to take Mrs N home so she and her husband could better care for Mrs N. Mrs N also expressed her wish to go home.
72. In another discussion, the Trust recorded that it explained to Mrs A that her respiratory and kidney injury symptoms had resolved so it could focus on physical rehabilitation. This was with a view to discharge Mrs N home once it was safe to do so.
73. The next day, the ward manager spoke with Mrs A and her husband about their concerns with Mrs N’s care. The notes of this conversation show Mrs A wanted Mrs N home as she felt she would be able to get her mother to eat. Following this conversation, the ward manager spoke with Mrs N. The ward manager noted that Mrs N wanted to go home. It advised Mrs N that the doctors would need to discuss this further to ensure all appropriate measures were taken.
74. The notes say Mrs N had advised the physiotherapist that she was happy for her daughter to made decisions on discharge planning. Later in the day, the physiotherapist noted a conversation they had with Mrs A about discharge. Mrs A reiterated she was willing to have Mrs N at home as soon as possible. She says they could feed Mrs N better at home and then Mrs N could engage more with her rehabilitation.
75. The physiotherapist noted a discussion around equipment needs and offered several options, as Mrs N was not very mobile at the time. They noted Mrs A declined equipment but agreed for a community therapy referral for an assessment of Mrs N in her own home to see what was needed. The physiotherapist and Mrs A agreed, however, to order a bed lever for Mrs N.
76. They continued to discuss the risk of musculoskeletal injuries if inappropriate manual handling is carried out. The records say Mrs A was aware of this and was happy to continue support Mrs N like they did before this admission. The physiotherapist also discussed whether Mrs N needed formal carers. The physiotherapist noted Mrs A declined formal care at that point, as Mrs N was reluctant, and they had had issues with previous carers due to animals at home.
77. It was noted the aim was to discharge Mrs N home when she was medically stable with family support, no package of care, and community therapy input. A nursing note also documents a discussion with a doctor which says there will be plans to discharge ‘as family are able to persuade [Mrs N] to eat, drink, and move better than we can’.
78. On the day of discharge, an occupational therapist (OT) saw Mrs N about the bed lever following the previous discussions with the physiotherapist. The OT noted that Mrs N had capacity and declined all other equipment despite recommendations. They also noted Mrs N and her family had declined a package of care and agreed with the physiotherapist about the community referral to take place in their own home.
79. The records show the Trust acted in line with the Discharge guidance. It communicated with Mrs A about Mrs N’s discharge, and the planning around it, with Mrs N’s consent.
80. The Trust considered Mrs N’s preference to return home, as well as Mrs A’s wish that Mrs N returned home as well. Mrs A said she could care for her mother better there. The notes also show Mrs A and Mrs N’s family were willing to support Mrs N at home. The physiotherapist and OT agreed and actioned a referral for a community therapy assessment once Mrs N was at home.
81. We recognise Mrs A has a different view on what happened here. She says the Trust did not discuss discharge with her, and the Trust discharged her mother with nothing in place.
82. Mrs A is correct in that Mrs N did not have a package of care in place, nor any equipment or further support aside from the community referral. The records indicate that these things were offered to Mrs N and Mrs A, but these were declined. We are sorry that we are unable to reconcile the different accounts as the evidence in the records indicate the Trust followed the Discharge guidance.
83. There are no indications of failings regarding the Trust’s discharge of Mrs N and its communication with Mrs A.
Complaint handling
84. Mrs A says the Trust’s communication during the complaints process was poor, and it continually missed deadlines.
85. The Complaint Standards say organisations should discuss timescales with everyone involved in the complaint, and it should agree how people will be kept informed and involved. It should also provide regular updates as agreed with the parties, throughout.
86. Mrs A complained to the Trust in late-June 2022. The Trust contacted Mrs A three days later to confirm receipt of her complaint. It acknowledged Mrs A wanted to pursue this as a formal complaint. In the note of this call, the Trust noted that a response would take up to 65 working days or longer. This was confirmed in writing by the Trust. 65 working days would mean the Trust had until the end of September to provide a response.
87. The Trust contacted Mrs A two weeks before its deadline of 65 working days. It advised Mrs A that it was taking longer than it had expected to complete its investigation of her complaint. The Trust said it would contact Mrs A as soon as possible.
88. Mrs A contacted the Trust a week later and asked the Trust to give an exact date for providing a response to her complaint. Mrs A contacted the Trust again at the beginning of December as she had not received a response from the Trust.
89. The Trust contacted Mrs A at the beginning of December and apologised for not responding to her previous email in September. It said it was unable to provide Mrs A an exact date for providing its response to Mrs A’s complaint. However, it committed to providing Mrs A an update on the stage of its investigation before Christmas.
90. Mrs A contacted the Trust the day after the Trust had told her it would provide an update to ask for an update. The Trust responded on the same day.
91. The Trust issued its first response to Mrs A’s complaint towards the beginning of February 2023. Mrs A sent in her concerns and her response to the Trust’s investigation two weeks later. The Trust acknowledged this at the beginning of March and clarified with Mrs A what questions she wanted the Trust to answer.
92. The Trust issued its second response to Mrs A’s complaint in mid-May. Mrs A responded at the end of June with further concerns about the Trust’s investigation. Mrs A emailed the Trust a week later asking if the Trust had received her email as she had received no response. The Trust responded on the same day explaining that it had logged her outstanding concerns and that someone would be in touch soon to discuss the next steps.
93. The Trust contacted Mrs A in mid-August to advise it had nothing further to add to its previous responses, and it directed Mrs A to our organisation.
94. As set out above, we can see the Trust contacted Mrs A in September 2022, before the deadline, to advise that it would be unable to meet its original deadline and that the investigation was taking longer than anticipated. However, it did not advise her when it would provide the next update.
95. We understand investigations can take longer due to the amount of work involved, as well as complexity of the case. We think had the Trust done this, it would have managed Mrs A’s expectations. The Trust was able to provide a date of an update when it responded to her at the beginning of December. It is unclear why the Trust did not do this in September.
96. The Trust responded to Mrs A the day after its pre-Christmas deadline, and only after Mrs A had contacted the Trust for an update. We acknowledge this would have been frustrating for Mrs A.
97. Following the issue of the Trust’s first complaint response in February 2023, we do not think there are any missed deadlines, nor was there a significant delay in communication.
98. For the instances outlined before February 2023, we do not think the lack of timescales given in September 2023, and the response after the December deadline is enough to say the Trust’s actions fell below our Complaint Standards. The Trust appears to have act in line with the Complaint Standards, as it discussed the timescales involved and it provided updates.
99. Overall, we think there are no indications of failings in the Trust’s handling of Mrs A’s complaint. We understand the Trust could have taken steps to better manage Mrs A’s expectations during the complaints process.
100. We have been working closely with the Trust’s complaints department over the last couple of years, and we have seen a marked improvement in its handling of complaints. This includes the time taken to respond to complaints and in communication with complainants. We hope this provides Mrs A with some reassurance.