Falls
19. Mr R said staff failed to prevent his grandmother from falling when she was admitted to hospital in April 2022. Mr R said Mrs R had multiple falls at home prior to her hospital admission, and the Trust should have done more to reduce the risk of her falling.
20. The Trust said it was sorry to hear that Mrs R suffered a fall whilst in its care. It said it was committed to reducing patient falls while in hospital and was continuing in its efforts to do so. The Trust said it completed an incident report in line with its procedure.
21. The Trust did not explain the actions it had taken to reduce the risk of Mrs R falling, and whether it had carried out a falls risk assessment for her.
22. NICE guidelines on preventing falls in older people say:
• ‘older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s • older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment’.
23. This guidance adds that falls interventions should also:
‘promptly address the patient’s identified individual risk factors for falling in hospital and take into account whether the risk factors can be treated, improved or managed during the patient’s stay’.
24. Mrs R’s records show she was a known falls risk, having had multiple falls prior to this admission. The records also show nursing staff asked her about her history of falls when admitting her, in line with the relevant guidance. The family had also expressed their concern to staff about Mrs R’s risk of falling.
25. The Trust’s ward admission checklist shows that staff should conduct a falls risk assessment within six hours of transfer to the ward. Although the records show staff appeared to be aware of Mrs R’s risk of falling, we have not seen any evidence that staff documented a falls risk assessment on the day of her admission. This is not in line with national guidelines.
26. Under the guidelines, a typical falls risk assessment will identify any actions that staff need to carry out to focus on immediate care, environmental safety and comprehensive fall prevention strategies.
27. The records show that prior to Mrs R’s fall on the ward, staff were conducting one to two hourly intentional rounding and Mrs R was using bed rails while in bed. Our nursing adviser said this showed staff were carrying out some falls interventions despite a falls assessment not being documented.
28. A national audit from the Royal College of Physicians says:
‘There are no single or easily defined interventions which, when done on their own, are shown to reduce falls. However, research has shown that multiple interventions performed by the multidisciplinary team and tailored to the individual patient can reduce falls by 20–30%. These interventions are particularly important for patients with dementia or delirium, who are at high risk of falls in hospitals’.
29. Although there is some evidence staff were carrying out general falls prevention measures, we have not seen any evidence there was an individual tailored plan from the Trust to reduce the risk of Mrs R falling. This would have been especially important given Mrs R’s falls prior to her admission.
30. Mrs R suffered a fall the day after her admission. The fall took place when Mrs R was using the toilet in private. This was similar to how Mrs R had fallen at home.
31. Falls prevention strategies in hospital inpatient settings can include discussions of how patients can move around safely and when and how to seek help (for example, if they need to call for assistance to go to the bathroom).
32. If staff had done a falls risk assessment with Mrs R on her admission, she may have been more aware of the risks and necessary precautions when moving around on the ward.
33. British Geriatric Society guidelines say that people, whatever their age and physical ability, should be able to use the toilet in private in all care settings.
34. Our adviser said in line with these guidelines, it is important to respect patients’ privacy and dignity, and it would not be usual practice for a nurse to remain with a patient while using the toilet.
35. We are unable to say with any certainty that if the Trust had completed and documented a falls risk assessment in line with guidelines, this would have prevented Mrs R from falling. However, we do consider this may have reduced the likelihood of her falling.
36. Once Mrs R had fallen, staff completed a post falls review form and documented that Mrs R was in pain, but this was no worse than her previously existing hip pain.
37. Following this, staff continued to monitor Mrs R on a regular basis even though her mobility became significantly reduced and she was unable to move around the ward independently.
38. We have reviewed the incident report the Trust completed after Mrs R’s fall. The report does not appear to be comprehensive and does not detail the specific actions staff planned to take to avoid a repeat of the incident.
39. Although Mrs R did not have a second fall during her admissions, the records show her mobility was significantly reduced and she was not walking around the ward independently anyway. We are not reassured by the Trust’s incident report that staff had documented the measures they had taken to avoid Mrs R falling again.
40. Mr R and his family were concerned there was a lack of urgency from staff to reduce the risk of Mrs R falling, especially considering she had suffered several falls at home. We recognise this added to the distress and worry they experienced from the admission alone.
41. We consider staff should have carried out and documented a falls assessment when Mrs R arrived on the ward. We are unable to say that doing so would have prevented Mrs R’s fall. However, we consider staff missed opportunities to reduce the risk of Mrs R from falling.
Personal care
42. Mr R said staff failed to attend to Mrs R’s personal hygiene during her admission. Mr R said his grandmother was struggling to eat using her hands and could not clean herself due to her back pain. He said staff left her in an unclean state.
43. The Trust apologised if Mr R had witnessed instances of staff not attending sufficiently to Mrs R’s personal hygiene. The Trust also apologised for a specific instance where Mr R witnessed a dirty hoist sling.
44. NMC guidance says that nursing staff should:
• ‘observe, assess and optimise skin and hygiene status and determine the need for support and intervention • assess needs for and provide appropriate assistance with washing, bathing, shaving and dressing’.
45. Additionally, NICE guidelines on patient experience in adult NHS services says that staff should:
‘Ensure that the patient’s personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. Regularly ask patients who are unable to manage their personal needs what help they need. Address their needs at the time of asking and ensure maximum privacy.’
46. Mrs R’s records document that staff were aware she needed assistance to meet her personal hygiene needs. Mrs R had a urinary catheter and used incontinence pads. It was especially important for staff to provide support to Mrs R due to her mobility issues as she was unable to manage her personal care needs independently.
47. The adviser said the records show nursing staff were regularly supporting Mrs R with her personal care and proactively communicating with her to ensure they were meeting her needs, especially taking into consideration her lack of mobility.
48. Informed by our adviser’s comments, we consider staff addressed Mrs R’s personal needs in line with NICE guidelines. The adviser also said staff regularly asked Mrs R if she needed a wash, and although there were times when she refused this, generally she accepted nurses’ support.
49. We recognise the Trust’s assistance with Mrs R’s personal care did not meet Mr R’s expectations. Mr R told us he witnessed instances where Mrs R had not been cleaned after eating, and we can appreciate this would have been frustrating and worrying. We have no reason to doubt Mr R’s account of events.
50. That said, records made at the time by nursing staff show they were consistently and regularly offering Mrs R support with personal care in line with NICE guidelines. The records also do not show any evidence of Mr R or his father raising any concerns about lack of personal care from staff.
51. We have not seen sufficient evidence to say the level of care staff provided consistently fell below the required standard.
52. Mr R also said as his grandmother was bed bound during her admission due to her back injury, and had diabetes, he asked the Trust if she could be referred for podiatry. Mr R said that Mrs R was under podiatry care at the diabetic centre as an outpatient, the family asked if staff could refer her to podiatry as her nails were long.
53. The Trust said it referred Mrs R at the family’s request but the podiatry team did not feel it was necessary to see her as she did not have any foot wounds.
54. The Trust expanded on this in the local resolution meeting. It said as its podiatry team is small, it follows specific criteria based on how the patient’s feet are, which includes for example if there are any deep wounds or infections on the feet. It said the podiatry team assessed Mr R and decided she did not meet these criteria.
55. The NMC Code says that nursing staff should:
• ‘make a timely referral to another practitioner when any action, care or treatment is required • ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’.
56. The records show nursing staff acted on the family’s request by making the original referral to the podiatry team.
57. Our nursing adviser said Mrs R did not have any documented concerns that would require inpatient podiatry care. The adviser said inpatient podiatry care is generally for patients with high podiatric needs, such as foot ulcers, infections and complex biomechanical problems, none of which affected Mrs R.
58. Mrs R did have some lower leg ulcers and staff referred her to the Tissue Viability Nurse (TVN). The TVN made recommendations which included toe to knee bandaging. This referral shows staff were responsive to Mrs R’s condition and were proactive in arranging a specialist review.
59. We understand that Mrs R had longstanding podiatry needs due to her diabetes which she had been receiving treatment for as an outpatient. We recognise Mr R’s view that due to the length of time Mrs R had been in hospital, staff should have taken action to manage this.
60. The Trust acknowledged it did not properly communicate with the family to explain why Mrs R did not meet the criteria for inpatient podiatry care. Mr R’s father said if he had been aware the podiatry team had reviewed Mrs R, he may have been able to arrange bringing someone in. Mr R said they only found out on Mrs R’s discharge and had to pay to have Mrs R’s nails cut once she was in the nursing home.
61. We recognise the Trust’s inpatient podiatry team is a limited service and therefore has strict criteria to assess patient’s needs. We do not consider Mrs R met these criteria. However, we acknowledge the Trust could have communicated better with the family so they could arrange the necessary support.
Mental health needs
62. Mr R said there was a noticeable change in Mrs R’s condition during her admission, with unusual moods, confusion and depression. Mr R said staff did not attend to Mrs R’s mental health needs. Mr R said he and his father kept asking for a mental health assessment to be done but staff did not carry this out.
63. The Trust explained that it is not always possible to understand or know why thistype of behaviour occurs, but in Mrs R’s case, it could be related to her liver cirrhosis (hepatic encephalopathy) due to her advanced liver disease, as well as side effects from medications.
64. The Trust said it carried out abbreviated mental health tests and Mrs R scored perfectly on these. It said it then referred Mrs R to the Older People’s Mental Health (OPMH) team because of her low mood, tearfulness, lack of engagement with therapies and low motivation. The Trust said Mrs R engaged with the OPMH team and there was no clinical indication to change her medications at that stage.
65. The Trust said it then referred Mrs R for a second time when her behaviour became more aggressive, agitated and confused. It said staff felt her behaviour was more likely to be from a physical cause rather than a mental health problem.
66. GMC Good medical practice says doctors should recognise and work within the limits of their competence, and consult and take advice from colleagues, where appropriate.
67. The records show Mrs R’s son first spoke to staff to express concerns about her mental health in July. Staff responded to this request and referred Mrs R to the liaison psychiatry team. Two days later a consultant psychiatrist reviewed Mrs R and recorded her behaviour was likely due to her pain and delirium, but that she appeared to be responding to analgesia for the pain. The psychiatrist noted the OPMH team would continue to monitor Mrs R.
68. In August, the mental health liaison (MHL) nurse reviewed Mrs R again and noted that she appeared to be more settled, but recommended lorazepam for her increased agitation. The MHL also recommended a CT head scan and a referral to the memory clinic, due to her background of memory issues predating her admission.
69. Mrs R had several significant medical conditions. Our physician adviser said some of these, such as her liver disease, are likely to have influenced her mood and contributed to her increasing delirium, and it was important that the Trust manage these symptoms appropriately, at the same time monitoring any concerns with her mental health. The adviser added that some of the medications Mrs R was taking could have also been a contributing factor to her delirium.
70. Our adviser explained that inpatient psychiatric assessment and treatment is generally for patients with emergency and urgent psychiatric problems, and those who have less urgent problems are seen by community mental health services.
71. The adviser added there was little support or interventions that staff could have given to Mrs R as an inpatient, and the bulk of the Trust’s management of her psychiatric symptoms would have been to treat her existing medical conditions and be seen by community mental health teams after discharge.
72. We understand Mr R and his family were concerned and worried when Mrs R did not seem her usual self, and may have been suffering from low mood, confusion and agitation. We appreciate the family feel the Trust was not communicating with them to explain the reasons for this.
73. The evidence we have seen shows staff were continuing to manage Mrs R’s symptoms of confusion and agitation throughout her admission. The staff were proactive in referring Mrs R to have a mental health assessment and carried out the appropriate referrals. We do not consider the Trust failed to attend to Mrs R’s mental health needs.
Communication regarding end-of-life
74. Mr R said the Trust failed to communicate with him and his family that Mrs R was likely approaching end of life. Mr R said he and his family understood that due to her multiple health issues, Mrs R may not live much longer but they said they did not realise her end-of-life would be as rapid as it turned out to be.
75. Mr R said if they had known and had conversations with the Trust about this, they could have done more to make Mrs R feel more comfortable and make preparations.
76. The Trust acknowledged that documentation about Mrs R’s care and communication with the family should have been better, especially as the clinical evidence suggested Mrs R was nearing the end of her life.
77. The Trust acknowledged the difficulties around having such frank conversations with families about their loved ones nearing the end of their life, but also the importance of being open and honest, to enable families to prepare and plan the next steps. It apologised that communication, and documentation was not as clear and consistent as it should have been and for the impact caused to the family.
78. The GMC defines patients approaching the end of life as likely to die within the next 12 months. It says:
‘This includes patients whose death is imminent (expected within a few hours or days) and those with:
• advanced, progressive, incurable conditions • general frailty and co-existing conditions that mean they are expected to die within 12 months • existing conditions if they are at risk of dying from a sudden acute crisis in their condition • life-threatening acute conditions caused by sudden catastrophic events’.
79. Our physician adviser said recognising someone is approaching end-of-life can be difficult and subjective to an extent. The adviser said in Mrs R’s case, there were clearly indicators that she was significantly unwell. Mrs R had the following conditions:
• spinal cord compression (possibly due to pathological fractures) • pressure areas on her lower back (indicating poor mobility and making her likely to develop into pressure sores, a source of sepsis) • diabetes • congestive cardiac failure • ulcerative colitis (a long-standing chronic inflammatory bowel condition) • cirrhosis of the liver • oesophageal varices (when cirrhosis causes enlarged veins in the gullet that risk gastrointestinal haemorrhage) • osteoporosis (thinning of the bones that makes them more prone to fractures) • frailty (a general decline in physical and mental reserve making her more vulnerable to deterioration and less able to recover).
80. Our adviser added the evidence shows Mrs R was deteriorating and reaching the end of her life, although towards the end of her inpatient stay in hospital, she remained stable and did not appear to be imminently dying.
81. The adviser explained it is difficult to accurately predict when somebody is close to dying and this can be a subjective judgement based on several factors.
82. The GMC guidelines on the role of relatives, and others close to the patient explain that:
‘It is important that the healthcare team acknowledge the role and responsibilities of people close to the patient. You should make sure, as far as possible, that their needs for support are met and their feelings respected.
Those close to a patient may want or need information about the patient’s diagnosis and about the likely progression of the condition or disease, in order to help them provide care and recognise and respond to changes in the patient’s condition’.
83. The records show staff were having some discussions with the family during the time Mrs R was in hospital, about her condition and prognosis.
84. In August, staff discussed a Recommended Summary Plan for Emergency Care and Treatment (RESPECT) form with Mrs R. A RESPECT form creates a personalised recommendation for a patient’s clinical care in emergency situations. It is generally used for patients with complex medical needs or at risk of sudden deterioration or end of life, who may not be able to make decisions or express their wishes independently.
85. The records document that staff spoke with Mrs R’s son the same day and explained that she had made the decision regarding the RESPECT form and had the capacity to do so. However, these records are not detailed and do not show the family properly understood the extent of Mrs R’s illness and her poor prognosis.
86. The records show the Trust planned to complete the RESPECT form after discussing this with Mrs R. However, this did not
87. Our adviser said generally these conversations would have included conveying an understanding to Mrs R and her son that there would likely be a deterioration in her health and there would be limits on how much treatment would be given. The records do not explain in detail if Mr R had understood exactly what this meant.
88. In September shortly before Mrs R’s discharge, there was a further discussion with Mrs R and the responsible clinician, which explained the emphasis on Mrs R’s care would be symptom management to ensure she was comfortable, and that if there was any further deterioration in her health, staff would not consider any aggressive investigations or treatment.
89. The record of this conversation shows that staff then intended to update Mrs R’s son as the next of kin. It is not clear from the evidence if this conversation then took place.
90. Although the evidence shows staff were attempting to have these challenging discussions with Mrs R and her family, we consider they could have been clearer in their communication to ensure the family properly understood the gravity of Mrs R’s situation.
91. We recognise this added to the family’s distress when Mrs R’s health began to decline further, and they felt they were not fully prepared.
92. Mr R said as the Trust did not fully communicate the advanced nature of Mrs R’s condition to both Mrs R and her family, she did not get a proper opportunity to make choices about where she wanted to spend her final months.
93. The records of the discussion the Trust had with Mrs R regarding the RESPECT form state Mrs R acknowledged and agreed with the plan to discharge her to a nursing home in the future and there were no concerns about her capacity at the time of this discussion.
94. Based on the evidence we have seen, we do not find Mrs R missed an opportunity to make her own decisions about her end-of-life care.
95. We find the Trust did not fully and clearly communicate Mrs R’s diagnosis and the likely progression of her illness to her family, in line with GMC guidelines.
96. We have carefully considered the impact this caused. Mr R has acknowledged the family was aware Mrs R would likely not live much longer. Mrs R was also independently able to decide where she wanted to be discharged to.
97. We understand it was a very distressing situation for Mr R and his family to see Mrs R’s health decline. We have not seen any evidence the family missed an opportunity to make decisions about Mrs R's end-of-life care.
98. The Trust also addressed this matter in more detail during the local resolution meeting. It recognised there was no documented conversation that explicitly stated Mrs R was entering the last few months of her life.
99. The Trust apologised for the upset this caused. It said Mr R and his family sharing their experience had enabled staff to share the feedback with the ward teams and clinical staff for reflection and learning.
100. Our principles of good complaint handling say organisations should learn from complaints to help improve public service and increase the trust among the people who use its service. The principles explain that the organisations should tell the complainant when lessons have been learnt as a result of their complaint.
101. We are pleased to see the Trust has reflected on what it could have done better in this situation in line with our principles.
Complaint handling
102. Mr R said the Trust did not respond to his complaint in a timely manner and refused to provide a written apology.
103. In the local resolution meeting, the Trust explained it was challenging to respond to Mr R’s complaint because of the number of nursing and medical specialists involved. It said this made the process lengthy and apologised if it appeared convoluted. The Trust also apologised for any delays in the complaint response due to staff sickness.
104. NHS complaint regulations say organisations must investigate a complaint in a manner appropriate to resolve it speedily and efficiently, and during the investigation, keep the complainant informed, as far as reasonably practicable, of the progress of the investigation.
105. Mr R and his family first raised their concerns about Mrs R’s treatment in July 2022, while Mrs R was still in hospital. The Trust acknowledged Mr R’s complaint at the time and said it would investigate and aim to respond in 40 working days.
106. The Trust then contacted Mr R in October 2022 to say its enquiries were taking longer than anticipated and it also needed to get Mrs R’s consent for the family to bring a complaint on her behalf.
107. Mr R continued to communicate with the Trust’s complaints department over the following weeks, and in November 2022 the Trust arranged a meeting for the ward manager to discuss the various concerns the family had. The meeting took place in December. The Trust then agreed to issue a response in writing, which it sent to Mr R in January 2023.
108. Mr R contacted the Trust after receiving the response to express his dissatisfaction. The Trust arranged a local resolution meeting (LRM) with Mr R and his father to discuss the outstanding concerns he had. The LRM took place in March 2023.
109. After the LRM, Mr R said he was expecting the Trust to provide a written summary of, and apology for, the failings it had admitted to during the meeting. The Trust instead wrote to Mr R and provided a recording of the LRM.
110. Mr R then approached us with the complaint in May 2023. After some initial enquiries, we contacted the Trust in October 2024 to ask if it would be willing to provide a further written response which summarised what it had discussed with the family in the LRM. The Trust agreed to our request and issued the further response in December 2024.
111. In this response, the Trust apologised to Mr R and his family for not discussing with them in clearer detail that Mrs R was approaching the end of her life.
112. We recognise Mr R’s frustrations with the length of time the Trust took to respond to his complaint. There was clearly a large amount of detail involved in the complaint and Mr R had expressed his concerns with various areas of treatment. We consider it was correct that the Trust took its time to investigate and speak to the members of staff involved. The Trust responded to Mr R within six months and continued to update him on the progress of his complaint.
113. Once Mr R had contacted the Trust to request a further response in January 2023, the Trust arranged the LRM within two months and followed this up with a copy of the recording in April. The Trust’s responses to Mr R’s complaint were both within the six-month timeline for NHS organisations to respond, under the regulations.
114. We understand Mr R’s frustrations that the Trust did not provide a written response following the LRM. We appreciate he was expecting this.
115. There is no requirement under the NHS complaint regulations for the Trust to have done this. The Trust had already provided a written response to Mr R in line with the regulations. Once we contacted the Trust to ask if it would consider issuing a written summary of the meeting, the Trust was responsive to our request and provided this within one month. In the summary it reiterated its apologies for the communication issues.
116. We have also listened to the recording of the LRM. The Trust agreed there were areas where it did not meet its expected standards, although it did not commit to issuing a written apology for any failings in care.
117. We understand Mr R’s reasons for wanting a written outcome of what he had discussed with the Trust in the LRM, and to have a written apology. We recognise this was important to the family.
118. Our principles for good complaint handling say organisations should give clear, evidence-based explanations, and reasons for their decisions. When things have gone wrong, organisations should explain fully and say what they will do to put things right as soon as possible.
119. Although the Trust responded in the time set out in the regulations and was responsive to our request to provide a further written response, our investigation indicates it has not adequately accepted what went wrong with Mrs R’s care and taken steps to put this right.
120. For this reason, we are proposing to recommend the Trust writes a letter of apology to Mr R and his family that acknowledges the areas we have found failings.
Conclusion
121. We appreciate this was a very difficult experience for Mrs R, and it was distressing for Mr R to see his grandmother’s health declining.
122. We find the Trust failed to put measures in place to reduce the risk of Mrs R falling. We cannot say this caused Mrs R to fall. However, our view is that the Trust did not do enough to avoid the likelihood of this happening. We also recognise this in itself caused Mr R and his family some distress.