Medication on 7 April
35. Ms F says Mr F’s cannula fell out, but this was not noticed by the team until the family brought it to their attention. She recalls the cannula was not replaced for several hours and is concerned this meant Mr F did not receive the medication he needed.
36. In response to the complaint, the Trust identified a request for the physician’s assistant to re-site a new cannula at 06:05am, and it was documented Mr F received his IV medication as prescribed later that morning.
37. The Trust acknowledged there was a delay in the cannula being replaced due to pressures on the staff on the ward. The Trust provided an apology for the delay and explained that a PICC line was introduced later in the day to ensure continuous IV access.
38. The GMC’s Good Medical Practice guidance says doctors must promptly provide treatment where necessary (point 15b).
39. In our review of the medical records, it is detailed that the cannula was removed on 7 April at 06:05am. Within the medication administration records, it is documented that Mr F received co-amoxiclav intravenously at 07:19am. We consider this was a shortcoming, rather than a service failure, as this was a short period of delay.
40. We recognise the medical records differ from the family’s recollection of events, and it is possible there was a longer delay than what we have identified. We have not seen independent evidence which gives us a clear timeline of events showing there was a longer delay than what is recorded in the medical records.
41. Our physician adviser explains that in general, a delay of one to two hours in receiving a dose of co-amoxiclav will not cause harm. Where two or more doses are missed, there is a risk of treatment failure or resistance, however, we have not seen any evidence this was the case in Mr F’s care. We hope this information is reassuring for Ms F and her family.
42. Our final decision is to not uphold this part of the complaint.
Management of CPAP mask on 8 April
43. Ms F says the consultant had told the family the CPAP mask was not to be removed until authorised. Despite this, overnight on 8 April, she recalls the CPAP mask was removed without permission, causing Mr F’s oxygen saturation levels to fall. It then took several attempts to fit the mask correctly and ensure it was working as it should. Ms F explains by the time it was working correctly, Mr F had become very distressed.
44. In response to the complaint, the Trust explained that patients who undergo therapy with a CPAP mask are allowed short periods of time off the mask, so assessments of their oxygen levels without the assistance of the CPAP can be assessed. The Trust apologised for the distress caused to Mr F by the re-adjustment of the CPAP masks.
45. The BTS guidelines say patients should be taken off CPAP at least four hourly to allow for eating, drinking, mouth-care and pressure sore prevention. The guidelines stress the importance of getting the correct fit for the treatment to work, and we understand changing the mask to ensure effective treatment would be appropriate.
46. We have reviewed the medical records and we can see there was an attempt to wean Mr F off the CPAP at around 1pm on 7 April, but as he was desaturated the pressure level was maintained. At around 2am on 8 April, the notes say Mr F’s CPAP mask had been changed, and he appeared more comfortable.
47. A nursing note from 7am on 8 April states the team had spoken with the family to discuss attempting to wean Mr F off the CPAP again. A review from the rapid response team at 2pm indicates Mr F was doing well on the CPAP but struggled when on normal oxygen levels.
48. We consider the actions taken by the clinical teams were in line with BTS guidelines. It was appropriate to give Mr F breaks from the CPAP mask, and to re-adjust it when necessary to ensure the treatment was effective. Our physician adviser explains that when weaning patients off the CPAP mask, the process would usually include reducing the pressure and checking oxygen saturation levels during breaks from the mask.
49. We did not identify any entries in the records relating to several mask changes at the same time. However, we recognise that CPAP masks are tightly fitted and include the use of face straps which go behind the head. We can see how this could cause distress when being changed or adjusted, and we recognise it was distressing for the family to watch Mr F in discomfort when the mask was removed, and again when the mask was being re-adjusted.
50. For these reasons, we have not identified a service failure, and we do not uphold this part of the complaint.
Raised heart rate on 8 April
51. Ms F says on 8 April Mr F’s heart rate was continually rising whilst they were watching the monitor. She recalls approaching the Sister and asking her to call a doctor. Ms F says on 9 April the screens had been turned off.
52. In response to the complaint, the Trust explained the Sister raised the concerns with the medical team on the family’s request. There was no indication the management plan changed following the escalation.
53. The Trust added that the cardiac monitor in the room is for use by qualified staff. It recognised that sometimes visitors can become worried by the information shown on the screen, and so sometimes staff will turn the monitors off and continue to monitor them at the nurse’s station. It reassured the family this meant professional assessments were continually done.
54. The NMC’s Code says nurses must accurately identify, observe, and assess signs of normal or worsening physical (and mental) health in the person receiving care, and make timely referrals to other practitioners when any action, care, or treatment is required (points 13.1, 13.2). They must also treat people with kindness, respect, and compassion, and listen to people and respond to their concerns (point 1.1, point 2).
55. Our nursing adviser noted Mr F’s heart rate had been elevated since the point of admission. He was being monitored through ECGs and the monitoring system, and the medical team were aware and were treating and monitoring Mr F’s heart function.
56. Mr F had been reviewed overnight on 7 April by the cardiology registrar, and a treatment plan was put into place for IV medication (digoxin and magnesium) to control his heart rhythm. This plan was to be discussed with the on-call cardiologist. We can see that Mr F’s heart rate was documented regularly on 8 April, showing evidence of ongoing monitoring.
57. We can also see the nurse’s entry from this interaction with the family. It is noted the family had concerns, and that Mr F had been assessed and reviewed by the on-call doctor. The nurse noted reassurance had been provided to the family, and the on-call cardiologist had been informed of Mr F’s condition. The cardiology review took place at approximately 11am on 8 April. We understand there were no indications a more urgent review was needed.
58. The medical records do not detail the circumstances in which the monitor in Mr F’s room was turned off. We understand this must have caused concern for Ms F and her family. It is noted that reassurance was given about Mr F’s care. We consider this is in line with the NMC’s Code. Despite this, we appreciate we were not present at the time to know exactly what and how this was communicated. We recognise the family may have felt more reassurance was needed.
59. Overall, we have not identified a service failure in the nursing care provided on 8 April. There is evidence within the records that the nursing team were continually monitoring Mr F’s condition, that they reached out to the on-call doctor and cardiologist when indicated, and that they provided reassurance to the family regarding Mr F’s presentation and the plan of care.
60. For this reason, we do not uphold this part of the complaint.
Calling the family on 10 April
61. Ms F complains the family were called to say goodbye to Mr F on 10 April only to later find out he was dehydrated instead of this being an end-of-life event. The family recall he doctor making a final clinical assessment and noted Mr F’s pulse was still quite strong. After he was rehydrated with fluids, he was markedly improved.
62. We have reviewed the medical records and note an entry from the rapid response team on 9 April at 12:18pm. This entry explains Mr F was comfortable, but frail and unwell, and nearing the end of his life.
63. On 10 April at 2:53pm, the FY2 recorded their impression that Mr F had a very poor prognosis, and his deterioration was likely a terminal event. It is noted the family agreed with the care plan to stop active treatment and provide palliative care.
64. Despite this, we can see treatment continued through the day, and advice was sought from the microbiology team on clinical management. The nurses continued to monitor Mr F, and a management plan was noted at 4pm to provide fluid resuscitation and antibiotics.
65. By 7:23pm, the cardiology SpR noted there had been an improvement in Mr F’s condition, and there was further scope for the provision of IV fluids.
66. During a review at 10:30pm, it was noted that Mr F was most likely in multi-organ failure which was progressing despite optimal treatment. It was felt he was approaching the end of his life rapidly. The doctor noted Mr F’s care had been escalated and considered it reasonable to give him some time to recover on the current regimen. It was agreed Mr F would receive 24 hours of escalated treatment, and if there was no progress or further deterioration, they would focus on comfort care only.
67. The GMC’s Good Medical Practice guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support (point 33).
68. Our physician adviser explained that when looking at Mr F’s presentation on 10 April, he had an elevated troponin level, an elevated brain natriuretic peptide (BNP – an indicator of heart failure) level, low blood pressure, and an acute kidney injury. The ESC explains these conditions are all poor prognostic markers for patients with heart failure and are associated with a very high mortality rate. In addition to this, Mr F’s blood pressure and renal output had been deteriorating. Therefore, Mr F’s clinical picture suggested he was deteriorating despite continuing treatment.
69. For this reason, we consider it was appropriate and in line with GMC guidelines for the clinical team to contact the family to communicate the likelihood of a poor outcome as there were signs of a poor clinical condition more significant than dehydration. Our final decision is to not uphold this part of the complaint.
Visiting policy from 14 April onwards
70. Ms F complains that from 14 April, the family were told they could not stay with Mr F around the clock anymore. In response to the complaint, the Trust explained Mr F’s condition had stabilised prior to being moved to a new ward, and as such, 24/7 visiting was placed on hold. The Trust says the family were still able to visit every day from 11:45am to 8pm.
71. The Trust’s visiting guidance at the time advised it allowed two visitors at a time for patients in adult inpatient and critical care wards within the hours of 11am-8pm. It stated additional visiting may be allowed on compassionate grounds, which was to be discussed and arranged directly with the ward.
72. The GMC’s Good Medical Practice guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support (point 33).
73. We can see from the medical records that a discussion took place between the family and the clinical team caring for Mr F on 15 April. They agreed that a member of the family could stay during each day between 9am and 8pm but stated they could not stay overnight. We recognise the family would have preferred to stay around the clock with Mr F to ensure he received all the care and support he needed. We have not identified any exceptional circumstances which required further consideration at that point of the admission.
74. We consider the Trust has acted in line with its visiting guidance at the time and with the GMC guidance. When Mr F had stabilised, the team had a discussion with the family and agreed upon visiting times. We can see the team allowed the family additional visiting hours outside of the policy. For these reasons, we do not uphold this part of the complaint.
Physiotherapy input
• Level of support during admission and after the hip operation
75. Ms F raised concerns that the physiotherapy team only saw Mr F a couple of times a week, and she does not feel this was sufficient for his needs. Ms F also says she was told it was imperative Mr F got up and mobilised as soon as possible after his surgery to aid his recovery. She complains this did not happen.
76. In response to the complaint, the Trust explained a referral to physiotherapy was made on 12 April. It explained the occupational therapy and physiotherapy teams provide joint therapy based on their assessment of patient priority needs during inpatient stays.
77. The Trust said Mr F was reviewed by the physiotherapy team on 13 April, and later on the same day by the occupational therapy team. Mr F was then seen five days the following week. It added that from 25 April onwards, Mr F was encouraged to sit out every day. The Trust concluded that whilst the physiotherapy input appeared ad hoc, there was a plan of care in place with goals for Mr F to work towards.
78. The CSP quality assurance standards for physiotherapy practice say physiotherapists should use all available information and evidence to assess risk and make decisions, they should formulate a treatment plan based on the best available evidence, and constantly evaluate the plans for intervention to ensure they are effective and relevant to the patient’s circumstances and presentation (points 8.4, 8.6).
79. We have reviewed the physiotherapy input with our physiotherapy adviser. We can see there were 28 contacts in total between the physiotherapy team and Mr F. Physiotherapy sessions occurred on 24 of the 28 contacts.
80. 15 sessions (out of 16 contacts over two months) happened before Mr F’s hip operation, and nine sessions (out of 12 contacts over five weeks) happened after the operation. This shows us physiotherapy input was more frequent in the following five weeks after the hip operation than before.
81. Our physiotherapy adviser explained that patients who are staying long-term for multiple problems and require on-going rehabilitation are seen as often as possible depending on staffing availability, other patient priorities, and the treatment plan in place.
82. We understand that the sessions focused on improving mobility, balance, and ability to transfer as independently as possible. Our physiotherapy adviser explained the assessment and treatment plan was appropriate for Mr F, given his complex medical presentation and changed throughout the admission in accordance with his changing presentation.
83. For these reasons, we consider the level of physiotherapy input was appropriate, when taking into consideration Mr F’s complex medical history, and his active medical problems including persistent infection, delirium causing agitation and confusion, colitis, falls, oedema, and a fracture.
84. We have not identified a service failure in the physiotherapy input in Mr F’s care, and therefore do not uphold this part of the complaint.
• Delay in obtaining a recliner chair
85. Ms F complains that the physiotherapy team ordered a recliner chair for Mr F on 14 April and it was not delivered until 18 May. She recalls the family having to keep chasing staff to source the chair.
86. In response to the complaint, the Trust explained the recliner chair was requested by the physiotherapist on 14 April and it was thought the chair would arrive shortly, following Mr F’s move to another ward. Unfortunately, this did not occur, and the chair had to be re-ordered on 15 May, before arriving on 18 May. The Trust provided an apology for the time it took to resolve this.
87. Our Principles of Good Administration say organisations should do what they say they are going to do. If they make a commitment to doing something, they should keep to it, or explain why they cannot. The CSP quality assurance standards say physiotherapists should communicate effectively with patients and those outside of the physiotherapy service to ensure effective and efficient services.
88. It is not clear what the reasons for delay were, and we have not seen any evidence that the family were kept updated on the reasons for delay, nor that their expectations were managed as to when the chair would arrive. We consider there was a service failure here, as the Trust did not do what it said it was going to do, and did not communicate effectively about the delay or reasons for delay.
89. With regards to impact, we consider not having the chair did not have an impact on the physiotherapy sessions. Our physiotherapy adviser explained that the sessions, regardless of the chair being there or not, focused on Mr F’s clinical presentation and we understand appropriate goals were set in relation to his current capabilities. Appropriate equipment was utilised when needed during treatment sessions, which focused on improving his mobility.
90. For this reason, on the balance of probabilities, we consider it is unlikely not having the recliner chair directly contributed to Mr F’s ongoing deterioration when considering he had multiple co-morbidities which were impacting upon his presentation and that he continued to receive an appropriate level of physiotherapy input.
91. Despite this, we recognise the delay in obtaining the chair caused frustration and concern for Mr F’s family. We can see the Trust provided a proportionate remedy by way of apology during the local resolution process, in line with the NHS Complaint Standards.
92. Based on these findings, we partly uphold this part of the complaint. We will not be making a recommendation linked to this part of the complaint, as we consider the Trust has already put things right for the family by providing an apology.
93. During our investigation, the Trust advised it has now purchased two additional recliner chairs. It explained recent projects have raised staff awareness of patients’ needs for different aids which support mobility, and that it has increased the use of rented recliner chairs for appropriate patients. We consider this demonstrates ongoing service improvements in this area and hope this additional information is reassuring for Mr F’s family.
NG feeding tube
• There was a delay in deciding to feed Mr F through a nasogastric (NG tube) when he was admitted to hospital and NG tube was not replaced when Mr F removed it on 19 April, until 19 July
94. In response to the complaint, the Trust says there was an order for NG tube placement following a recommendation by SaLT on 19 April. This was placed by a doctor but removed by Mr F. He was noted to be confused and restless. The Trust says Mr F subsequently passed the ward swallow assessment and was allowed to eat as per SaLT recommendations.
95. NICE CG32 says healthcare professionals should consider enteral (NG) tube feeding in patients who are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake (1.7.1). Those at risk of malnutrition include patients who have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer (1.3.2).
96. NICE CG32 also says enteral tube feeding should be stopped when the patient is established on adequate oral intake (1.7.3).
97. We can see from the records there were early discussions with the dietitians around considering the trial of an NG tube. On 8 April during a review, the dietitian noted this was to be discussed with the medical team. It was noted Mr F was very unwell and was a high-risk patient. His intake had been minimal since his admission. We consider this early recognition of Mr F’s nutritional risk was in line with NICE CG32.
98. By 10 April, it was thought Mr F was at end of life as he appeared to be deteriorating despite continuing treatment. As this was the clinical picture at the time, our physician adviser explains it would have been appropriate in line with NICE 142 to reduce the burden of additional treatment, as the medical team thought Mr F was dying.
99. On 11 April, the dietitian saw Mr F again. At the time of review, Mr F was eating, with the assistance of his daughter, and it is noted this was the first time he had eaten something since his admission. They discussed the plan of NG feeding, but the family said they preferred trying food and will provide support. The dietitian agreed they would try food and supplements first as NG feeding can be very distressing. We consider it was reasonable, and in line with the GMC’s Good Medical Practice guidance on being considerate to those close to the patient (point 33) and taking all possible steps to alleviate pain and distress (point 16c), to trial this approach first as Mr F was able to swallow with some modifications to consistency and posture.
100. On 19 April it was agreed following a SaLT review that Mr F should trial NG feeding as his swallow had been deemed unsafe. We note that the insertion of the NG tube was completed promptly following the recommendations by the SaLT. The records show us that the tube was inserted at 3pm, but removed at 4pm as Mr F was unable to tolerate it.
101. The records state the doctor was informed of this, but we cannot see any further records to advise if re-insertion took place or what the decision making was at this time. On 20 April it was noted there had been a clinical improvement, and a review from 21 April details a plan to trial thickened fluids and a modified diet. The nursing notes from the same day explain that the team had spoken with the SaLT and the dietitian to agree a new plan for Mr F’s nutrition.
102. The SaLT review from 21 April details a swallowing review took place, with the conclusion that Mr F was able to resume taking food and drinks orally, with modified consistencies. Our SaLT adviser explained it is unlikely, at this early stage of the admission, that two days without nutrition had a significant impact on Mr F’s presentation or his ability to recover from the nutritional loss once he began eating again on 21 April.
103. We consider this was in line with NICE CG32, as enteral feeding was stopped when he was established on oral intake. We can see from this point on, Mr F was documented to be eating on average two thirds of each meal and eating and drinking well within the nursing notes.
104. For these reasons, our final decision is to not uphold this part of the complaint.
Nursing care
• Inconsistencies in the provision of food and drink
105. The family raised concerns about the inconsistency of Mr F being offered food and drink throughout his admission.
106. In response to the complaint the Trust has explained that the only meal Mr F had when not supervised by the family was breakfast. This is because the family were with him from 11am to 8pm every day except on 18 June. The senior sister on the ward recalled always providing food, and the family helped Mr F with food and drink. The Trust explained that during the period when Mr F was not allowed to eat or drink because of the risk of aspiration, it was not offered and this was explained to the family at the time.
107. The NMC’s Code says nurses must treat people with kindness, respect, and compassion, and make sure they deliver the fundamentals of care effectively. The fundamentals of care include, but are not limited to, nutrition and hydration. It includes making sure those receiving care have adequate access to nutrition and hydration and making sure they provide help to those who are not able to feed themselves or drink fluid unaided (points 1.1 and 1.2).
108. The Code also says nurses must pay special attention to meeting the changing health and care needs of people during all life stages (point 3.1).
109. We have reviewed the evidence available to us with our nursing adviser. The nursing notes and daily care plans consistently document that Mr F was offered food and drinks throughout his admission in line with the NMC’s Code with regards to delivering the fundamentals of care effectively.
110. We have identified some exceptions, as detailed by the Trust in its response, where Mr F was awaiting a SaLT review due to intermittent issues with his swallow, and when he was thought to be potentially aspirating the food/fluids. We understand this was appropriate in the circumstances, to mitigate any possible risks of harm to Mr F, in line with the guidance in NMC’s Code regarding meeting a patient’s changing needs.
111. Based on the evidence available to us, we have not identified a service failure, and our final decision is to not uphold this part of the complaint.
• Poor compliance with recommendations made by SaLT for thickened fluids
112. The family complained about a lack of consistency from the nursing team with the SaLT’s recommendations for Mr F to have thickened fluids only. Mr F also reported having thickened fluids intermittently, depending on who was giving it to him.
113. In the Trust’s response to the complaint, it explained it was documented in the records that the thickener was at the bedside, and nursing staff were aware of the need for thickened fluids. The SaLT had discussed the importance of this with the nursing team and the family. The Trust apologised the provision of thickened fluids was not always well documented or supervised.
114. The NMC’s Code says nurses must deliver the fundamentals of care effectively. The fundamentals of care include, but are not limited to, nutrition and hydration. This includes making sure those receiving care have adequate access to nutrition and hydration and making sure that they provide help to those who are not able to feed themselves or drink fluid unaided (point 1.2).
115. Within the medical records we can see the SaLT team noted there had been variable compliance with the recommendations for thickened fluids, and variable documentation of this. There were concerns noted by the SaLT team that this reduced compliance contributed to Mr F developing a chest infection which was aspiration related.
116. In our review of the medical records with our SaLT adviser, we can see there were references to thickened fluids. Some notes state they were used, and others state the level, which we understand is correct as per the SaLT assessment. However, the inconsistencies of these notes make it difficult to gauge the extent of the non-compliance with the recommendations.
117. The notes show us that Mr F had fluctuating capacity to manage his own wellbeing, and his cognition varied throughout the admission. We consider he should have been given support from the nursing team with the fundamentals of care to prevent any negative health consequences.
118. Overall, we have identified inconsistences in the provision of thickened drinks both from the nursing team and on occasion from the family. We recognise that Mr F’s family dispute this, and state they did not provide him with any non-thickened fluids. We have included this information to represent the evidence available to us.
119. We consider the inconsistency from the nursing team was a service failure, as Mr F was not consistently provided with the support he needed in line with the NMC Code.
120. We have considered what impact this had on Mr F. As we cannot gauge the full extent of the non-compliance with the SaLT recommendations, it makes it difficult to fully gauge the impact this may have had on Mr F and his other health conditions.
121. We understand it is likely the inconsistencies in provision of thickened fluids had a detrimental impact on Mr F’s presentation. This is because the videofluroscopy carried out on 16 June 2022 showed that Mr F was experiencing aspiration of fluids into his airway. Mr F did not demonstrate appropriate sensation that he knew this was happening (i.e., coughing), and therefore he, his family, and the nursing team would be unaware this was happening.
122. There were also occasions where Mr F did not consistently accept or receive oral care from the nursing team, and therefore there may have been additional bacteria in his mouth which, if aspirated, would have been detrimental to his chest health.
123. Our SaLT adviser explained the inhalation of fluids into the airway coupled with oral bacteria can contribute to recurrent chest infections and impact directly on recovery. Mr F also had an ongoing generalised physical health decline, known COPD, and was at significant risk of dysphagia. We understand these factors would have a detrimental impact on his presentation and potential for recovery.
124. Based on the information we have reviewed so far, we consider the inconsistency of the provision of thickened fluids is not solely responsible for Mr F’s decline. However, we recognise it has contributed to his ongoing deterioration and likely made it more difficult for him to recover. We also recognise this caused concern for the family at the time.
125. For these reasons, we partly uphold this part of the complaint. We cannot see the Trust has addressed this within its responses to the complaint, and so we are making recommendations for the Trust to put things right for the family by way of an acknowledgement and apology.
126. During our investigation, the Trust has provided us with information regarding the measures it has put into place to ensure service improvements in this area. These measures are:
• SaLT recommendations are now written on the nurses’ handover sheet • Recommendations are printed daily from the EPIC system, so it is shared with the housekeeper • The information is also updated on the patient board and in the kitchen • Staff receive verbal reminders at twice daily Safety Huddles and twice daily Team handovers • Team nurses are also tasked with reminding their team members on every shift
127. We are satisfied these measures directly address the failings we have identified here and will ensure service improvements occur. For this reason, we will not be making a recommendation for service improvements on this part of the complaint.
• Poor compliance with mouth care
128. Ms F told us she visited her father on 23 July and his mouth and lips were dry, scaly, and had a lining of a brown substance. She complained to staff about this, and says oral hygiene was carried out regularly from this point onwards.
129. In response to the complaint, the Trust says Mr F was on an NG feed in the early morning of 23 July. The feeding regime started at 7:15pm on 20 July. It was documented at 10am on 23 July that he refused mouth care and was agitated when staff tried to get him to drink. His lips were also noted to be dry. The Trust says the family discussed this with the medical team, and an apology was offered about the perceived lack of care. The Trust considers it has been recorded throughout the notes that Mr F was encouraged to drink whenever he was awake, even during the night.
130. The NMC’s Code says nurses must treat people with kindness, respect, and compassion, and make sure they deliver the fundamentals of care effectively (point 1.1 and 1.2). It says nurses should pay special attention to promoting wellbeing, preventing ill health, and meeting the changing health and care needs of people during all life stages (point 3.1).
131. NHS England’s ‘mouth care matters’ toolkit explains that supporting patients with regular mouth care is a fundamental part of care. Hospitalisation can often be associated with a deterioration of oral health in patients.
132. We have reviewed this part of the complaint with our nursing adviser. We understand mouthcare should have been provided regularly throughout the admission. In our review of the records, we cannot see evidence of mouthcare being documented daily.
133. Mouth care appears in the notes intermittently until 23 July, which suggests it was either not carried out consistently, or not recorded consistently. Mouth care is then documented daily from 23 July to the time of discharge.
134. We consider this was a service failure in the nursing care provided to Mr F. When considering the impact this had on Mr F, we understand that poor oral care is linked to an increase in complications such as hospital acquired pneumonia, poor nutritional uptake, and longer hospital stays.
135. We do not consider this is solely responsible for Mr F’s ongoing deterioration, but we consider it is likely that the lack of adequate oral care increased Mr F’s risk of these complications and contributed to feelings of pain and discomfort in the mouth. We also recognise this caused concern for the family at the time.
136. For these reasons, we partly uphold this part of the complaint. We cannot see the Trust has addressed this within its responses to the complaint, and so we are making recommendations for the Trust to put things right.
• Care provided when Mr F developed a C Diff infection on 11 July and was moved into a side room
137. The family raised concerns that when Mr F was moved into a side room, staff gave up on him. They say there were times he was left with no drinks at all and was not helped to drink. They were also concerned about the lack of hygiene on the ward.
138. In response to the complaint, the Trust explained that Mr F was moved into the side room due to his infection, as per the protocol from infection control, this helps to prevent any cross contamination to other vulnerable patients. It says the nursing team continued to ensure Mr F received all care, and the family continued to visit during this time.
139. The NMC’s Code says nurses must treat people with kindness, respect, and compassion, and make sure they deliver the fundamentals of care effectively. The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling, and making sure that those receiving care are kept in clean and hygienic conditions. It includes making sure those receiving care have adequate access to nutrition and hydration and making sure they provide help to those who are not able to feed themselves or drink fluid unaided (points 1.1 and 1.2).
140. We have reviewed this part of the complaint with our nursing adviser. We have carefully considered the daily nursing notes and care plans from the time Mr F was in the side room. We can see that all personal care was provided daily, with daily bedding changes, in line with the NMC Code. We have not identified any omissions in the personal care provided.
141. Based on these findings, we do not uphold this part of the complaint.
Falls management
142. Ms F complains that her father had four falls during his admission due to a lack of monitoring and poor management of his delirium. She says her father fell from his bed three times and fell once from his chair. This was despite them telling the nursing staff repeatedly that he was suffering from delirium and would try to get out of bed not realising he was unable to walk. They were concerned that their father needed to be watched when they were not visiting. Between the three daughters, they visited every day from 11:45am – 8pm.
143. In response to the complaint the Trust explained that Mr F had been identified as at risk of falls due to his age, history of falls, delirium, impaired mobility and postural hypotension. It explained that several measures were in place to assess and review Mr F’s risk of falls. It explained these measures determined the level of observations required, and that they were carried out utilising the resources it had available at the time.
144. The Trust’s response says Mr F had intermittent enhanced observations based on his daily specialling scoring tool (SST) assessment. This assessment determines if a patient is to be at arm’s length, within eyesight, or being checked intermittently.
145. The Trust’s response recognises that the availability of additional staff to support enhanced observations may have potentially avoided any falls, but also that it is not possible to completely predict the behaviour of a patient at all times.
146. The Trust also acknowledged that documentation relating to enhanced observations and behaviour charts were not completed to the expected standard as there were gaps in completion and poor documentation related to the rationale for changing Mr F’s enhanced observation levels.
• Delirium
147. NICE CG103 explains those who are at risk of, or have delirium, should be given a tailored multicomponent intervention package (point 1.3.2). Patients should be reoriented by staff, and regular visits from family and friends should be facilitated (1.3.3.1). Any issues with dehydration, constipation, oxygen saturation, infection, limited mobility, nutrition, and/or pain, should be addressed by the relevant clinical teams (1.3.3.2 – 1.3.38).
148. Furthermore, the guidance recommends regular medication reviews should take place for those on several medications (1.3.3.7). It also says for patients diagnosed with delirium, efforts should be made to identify and manage the possible underlying cause or combination of causes (1.6.1).
149. With regards to the recognition and management of Mr F’s delirium, we have reviewed the medical records with our physician adviser, and we have identified numerous entries within the medical records which confirm the team were aware of the issue and were making efforts to manage it.
150. There were regular reviews of his medication, electrolytes, input from the physiotherapists and input from the microbiology team regarding infection. The family were visiting daily for long periods, which would have also helped with reorientation.
151. We consider there is evidence the delirium was recognised and that attempts were made to address any underlying illness contributing to the delirium and therefore contributing to the falls risk.
• Falls risk assessment and monitoring
152. NICECG161 says patients who are identified as at risk of falls should be offered a multifactorial falls risk assessment and should be considered for multifactorial interventions (1.2.2.2). The assessment should identify individual risk factors for falling in hospital that can be treated, improved, or managed during the hospital stay (1.2.2.3). Any interventions should address the identified risk factors and take into account whether the risk factors can be treated, improved or managed (1.2.2.4).
153. The NMC’s Code says nurses must pay special attention to promoting wellbeing, preventing ill health, and meeting the changing health and care needs of people during all life stages (point 3.1). It also says they should keep clear and accurate records and identify any risks that have arisen and the steps taken to deal with them (point 10, 10.2). We consider this is relevant here given Mr F’s fluctuating confusion and delirium, which would have meant his needs were often changing.
154. We have reviewed this part of the complaint with our nursing adviser. We can see from the medical records that a multifactorial risk assessment was completed upon admission in line with NICE CG161.
155. We also reviewed the nursing documentation around the time of each fall. For the falls on 19 April, 8 May, and 18 June, we cannot see an SST assessment had been done to determine what level of observation Mr F required. It was not done daily, as indicated in the Trust response. Because of this, we do not know what the observation requirements were on those days for Mr F, and we cannot say if they were met or not. We consider this was not in line with the NMC Code, or the NICE guidance with regards to identifying risk and implementing interventions.
156. For the fall on 8 June, an SST assessment had been done, and Mr F was to be observed within eyesight of the ward team. It is recorded that the nursing staff were attending to another patient in the bay who was at risk of falling and heard Mr F trying to get out of bed. Mr F had fallen before the nurse was able to reach him. On this occasion, we consider the nursing team had identified the level of risk and were monitoring Mr F with the resources they had at that time.
157. Overall, we consider there was a service failure as the SST assessments were not carried out consistently, we recognise this means it is possible Mr F required closer supervision than he received at the times he fell on 19 April, 8 May, and 18 June.
158. We recognise that the ward was facing challenges with the levels of staffing, and in the context of the presence of multiple patients on the ward who were identified as at risk of falls and requiring various levels of observation, it was challenging to get the balance right.
159. We acknowledge that not all falls are preventable, and whilst we cannot conclude Mr F’s falls would have been avoided, we recognise the risk of the falls occurring was increased by inaccurate falls risk screening, poor documentation around observation levels, and a lack of availability of staff.
160. The Trust has apologised that there was insufficient staff available to remain with Mr F around the clock. The Trust also explained that it had a Falls Quality Improvement Plan (FQIP), which is a continuous process of identifying and actioning areas for improvement in relation to falls prevention and management.
161. During our investigation, the Trust has provided us with sufficient evidence that it has taken the actions set out in the FQIP. We are satisfied this demonstrates the Trust has taken steps to ensure compliance with best practice guidance. We are also reassured the Trust will continue to monitor these actions. For this reason, we will not be making any further recommendations for service improvements.
Communication with the family throughout the admission
• Continuity of care and communication regarding a diagnosis and the severity of Mr F’s condition
162. Ms F complains that as a family, they were given several different explanations throughout Mr F’s admission as to the cause of his illness and deterioration and so did not know exactly what was causing him to become so unwell. The family also complained there was a lack of continuity of care. Ms F also complains the family were not told of the severity of Mr F’s condition until it was too late.
163. In response to the complaint, the Trust explained that Mr F had a complex combination of diagnoses throughout his admission, and developed several complications. The Trust said the family were involved in discussions at multiple time points during the course of the admission and due to the combination of medical issues and complications, the priority of acute issues changed over the course of the admission.
164. Mr F was in hospital over a four month period, and six different consultants looked after him during this time, in addition to the team of junior doctors. In addition to this, several specialists were called upon for advice regarding the various conditions impacting upon Mr F’s health. This inevitably meant there were differing opinions and discussions regarding Mr F’s care over the course of his admission.
165. The Trust explained that the decision to prioritise symptom and comfort control was made after multiple attempts to treat his conditions and complications, and after advice had been sought from other specialists.
166. The GMC’s Good Medical Practice guidance says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support (point 33). It also says doctors must work collaboratively with colleagues (point 35), consult colleagues where appropriate (point 16d), and refer patients to other practitioners when this serves the patients needs (point 15c).
167. The GMC’s guidance on treatment and care towards the end of life says healthcare teams should acknowledge the role and responsibilities of those close to the patient, and provide information about the patient’s diagnoses and likely progression of the condition (points 18 and 19).
168. NICE CG138 recommends, where consent has been given, sharing key information with and involving family members in key decisions about the management of the patient’s condition (point 1.3.10). It also recommends assessing the requirement for continuity of care, and ensuring continuity within the healthcare team through clear and timely exchange of information (points 1.4.1, 1.4.3).
169. We have reviewed the medical records with our physician adviser. We can see from the notes there is evidence of structured handovers and communication between the doctors and nurses involved in Mr F’s care. We can see evidence of good recording of what was happening, what the plans were for Mr F’s active medical problems, and advice sought from different specialisms when required. We have seen good evidence of appropriate transfer of information and agreed plans of care.
170. There is documentation of discussions and engagement with Mr F’s family where we can see relevant information, diagnoses, management plans and prognosis were shared. The discussions appear within the records at all stages of Mr F’s care.
171. There were several clinicians involved in these discussions, including more junior members of the team, the consultant, the dietitian, and the palliative care team. The documentation of the discussions is consistent in terms of the message given, and the assessment of the overall benefit of treatment, nutrition and hydration, and the role of the family.
172. Overall, we consider the clinical and nursing teams acted in line with the GMC and NICE guidance we have referenced above. There is evidence of effective handovers, care planning, and communication with the family at key points of the admission. For this reason we do not uphold this part of the complaint.
• Communication regarding the cause of swollen arms
173. Ms F says Mr F’s arms became so swollen he could not lift his arms to eat or drink. They eventually started blistering and leaking fluid. Towards the end of the hospital admission, Ms F recalls being told Mr F’s body was not retaining or processing protein, and this had been ongoing for weeks, but it was the first time they had been told about this.
174. In the Trust’s response to the complaint, it explained that Mr F had a low albumin level at admission, but it was stable compared to levels measured in 2021. The medical team sought dietitian input, but the albumin level continued to decline over the course of the admission. By 19 July, it had dropped even further and was causing issues with the swelling of Mr F’s arms. At this point it an explanation was given to the family.
175. The relevant guidance here is the GMC’s Good Medical Practice guidance, which we have referenced in paragraph 166 and 167 above.
176. We have also considered the GMC’s guidance on treatment and care towards the end of life with regards to managing a patient’s nutrition and hydration needs. This guidance says the nutrition and hydration status of patients must be kept under review (GMC point 109). Where a patient has problems eating or drinking, any underlying causes should be assessed and addressed through treatment which may include clinically assisted nutrition or hydration in order to meet their needs (GMC points 110, 111).
177. We have reviewed this part of the complaint with our physician adviser. There is evidence within the medical records of ongoing dietitian reviews throughout Mr F’s admission. There was a focus on trying to meet his nutritional needs, which would help with his albumin levels, and we can see an NG tube was trialled, and a modified diet was recommended.
178. As we have addressed above, Mr F had a complex admission due to several diagnoses and complications. This meant his presentation changed several times throughout the admission, and various symptoms presented which required attention.
179. When the low albumin levels caused oedema in Mr F’s arms, the clinical team took action to investigate this to ensure there was no other underlying issue. A doppler scan was carried out, and a further review from the dietitian team was requested. There is evidence of the clinical teams discussing these actions with the family, and providing explanations of the symptoms Mr F was presenting with, as well as what this meant for his ongoing deterioration and prognosis.
180. Overall, we consider there is evidence of effective communication in line with the guidance we have referenced above. The clinical teams kept the family updated on Mr F’s presentation, what investigations were being done, what interventions were planned, and what this meant looking forward.
181. Whilst low albumin levels may not have been discussed prior to Mr F’s arms becoming swollen, we can see the clinical team were aware of this, and the dietitians were making recommendations to improve Mr F’s nutritional status.
182. For these reasons we do not uphold this part of the complaint.
• Communication regarding whether Mr F would be discharged to a rehabilitation unit
183. Ms F says the possibility of transfer to a rehabilitation centre was offered and withdrawn at least three times by various members of staff. The family felt there was a roller coaster of indecision between departments and felt this contributed to Mr F’s extended stay in hospital.
184. The GMC guidance outlined in point 166 and 167 of this report is relevant here, as well as NICE CG138, outlined in point 168 of this report.
185. We can see the possibility of discharge to a rehabilitation centre was discussed several times during Mr F’s admission. On 21 April, the occupational therapy team noted Mr F would need further rehabilitation with occupational therapy, physiotherapy, and speech and language therapy. Subsequent notes from the physiotherapy team also indicate they felt Mr F would benefit from further rehabilitation.
186. We can see this was noted to be discussed with the neurology consultant, and that the medical team caring for Mr F were aware of the ongoing consideration. On 12 May, the physiotherapy team noted Mr F would be appropriate for rehabilitation once his delirium had resolved. This was an ongoing issue throughout his admission.
187. On 18 May, there was a meeting between some members of the clinical team, discharge planning teal, PALS, and the family. They discussed concerns about Mr F’s care and asked about the discharge plan. It was explained at that time Mr F was not ready for rehabilitation due to his ongoing delirium. This was discussed again in another meeting with the family on 20 May.
188. During a ward round on 25 May, we can see the doctor spoke with the family about the back and forth regarding discharge to a rehabilitation unit, acknowledging their frustration. The doctor explained that because Mr F’s delirium/confusion was intermittent, it made the consideration more difficult. However, we can see Mr F was then referred for a rehabilitation bed.
189. The medical records show us that on 2 June, the referral was declined on the basis that Mr F required constant supervision and still had intermittent confusion, and the rehabilitation team felt they would not be able to keep him safe at night. This was communicated to the family on the same day. The doctor acknowledged this was frustrating for the family, and that the decision would be disappointing. We can see reassurance was given that the medical team would discuss Mr F’s options for discharge with the wider team (physiotherapists, discharge team, nurses, ward team).
190. Overall, we can see evidence of ongoing updates to the family about the discharge planning options. It was evidently an ongoing consideration, which was dependent on Mr F’s progress. We can see the clinical team explained the reasons why it may/may not be suitable for Mr F, and that the reason for the referral being declined was explained. We consider the level of communication with regards to discharge to a rehabilitation unit was in line with the GMC’s Good Medical Practice guidance and NICE CG138.
191. For this reason, we do not uphold this part of the complaint.
Management of IV fluids during last week of admission
192. Ms F says during the last week of Mr F’s admission, he was prescribed a steady flow of IV fluids, but this was forgotten for 30 hours, and when the family questioned it, Mr F was given excessive doses of IV fluids via his PICC line. They are concerned this flooded his lungs.
193. In the Trust’s response to the complaint, it explained it had not found any significant delays between the prescription and administration of IV fluids.
194. We have reviewed the medical records with our physician adviser. Mr F was taking medication for heart failure, and this along with his postural hypotension and recent diarrhoea would have made his fluid balance difficult to manage. We can see from the information recorded in the ward rounds that Mr F was hypernatraemic. This is a condition where sodium levels in the blood are too high.
195. The BMJ Best Practice guidance explains the main cause for this is usually a water deficit or dehydration, and it is treated through correcting the water deficit, so by re-hydrating a patient.
196. We can see Mr F was treated with IV fluids and extra water flushes through his NG tube, and this led to his sodium level gradually improving. We have not seen any evidence of a service failure in the management of his fluids during the last week of his admission, and we consider the steady improvement of his sodium level evidences this.
197. For this reason, our final decision is to not uphold this part of the complaint.
Discharge with morphine patch
198. Ms F complains that when Mr F was discharged on 1 August, he had a morphine patch in situ, despite the family requesting it was not used. The family recall that within 24 hours of removing the morphine patch, Mr F was sitting up and asking for a cup of tea, and he improved somewhat over the next few weeks.
199. In response to the complaint, the Trust said Mr F was prescribed, and had, used, the morphine patch whilst in hospital. It said the suggested management from the palliative care team was to ensure the patch was in place prior to discharge as his care became supportive comfort care. The Trust stated it was recorded in the records that the family agreed with this.
200. NICE 197 provides guidance on shared decision making. Shared decision-making means making sure the person understands the risks, benefits and consequences of different options through discussion and information sharing. Where family members are involved in a patient’s care, they should be included in the decision-making process (point 1.2.3).
201. We can see from the records that the palliative care consultant carried out a remote triage and review on 25 July. In this review the consultant suggested the use of the butrans patch if pain was ongoing. Our physician adviser explained it is not unusual to change an opiate from one form to a different form, in this case from oral to transdermal.
202. During a discussion with one of the nursing team on 27 July, the family said they were concerned about the use of the butrans patch, as they felt Mr F was not in pain, and this was only to be used at the end-of-life stage. The nurse explained Mr F was on small dose of oxycodone, but he was now unable to take it. The nurse observed that whilst Mr F said he was not in pain, upon moving and turning he did complain of pain. It was noted he was given IV paracetamol, and the plan was for the family to discuss this with the doctors the next morning.
203. In a discussion with the palliative care consultant and nurse, it was agreed that a butrans patch may not be necessary, and that they would continue with regular paracetamol for now and consider regular opioid if the pain worsened. We consider this was in line with NICE 197, as the family were involved in the decision-making process.
204. We cannot see there was any further discussion amongst the team or with the family about the initiation of the butrans patch, and it does not appear to have been a shared decision to apply it upon discharge.
205. The palliative nurse notes from 28 July state the teams suggested management for discharge and noted the butrans patch should be applied on discharge. The palliative care reviews on 30 and 31 July state the same recommendation. An entry on 1 August from the pharmacist states “please ensure butrans patch is applied before discharge as per palliative team’s note”. Similarly, the entry from the palliative care consultant and nurse on the same day states “please ensure butrans patch is applied”. The wording within the reviews is the same, suggesting this is standard wording used in discharge notes.
206. Additionally, the medical records do not detail that Mr F was in any pain at the point of discharge, and there was a reported improvement from Mr F’s daughters. Our physician adviser confirmed that there was not a documented indication for ongoing pain relief at the point of discharge.
207. Overall, we consider that in the absence of ongoing symptoms and without further discussion with the family in the context of a patient who lacked capacity, starting the new medication was not in line with NICE 197.
208. Our adviser explained a butrans patch takes up to three days to reach a steady state. This means the onset is slow and the dosage would build gradually to full effect before becoming stable over seven-day period. Our adviser confirmed Mr F was on the lowest dose and that the dosage was equivalent to what he was previously taking orally. Therefore, we consider it is unlikely this would have had a significant impact on Mr F.
209. Despite this, we recognise it caused the family a level of concern and anxiety about the medication Mr F had been given, in the absence of their agreement.
210. We cannot see the Trust has addressed this within the complaint responses so far. Its response is to this part of the complaint is inaccurate, as it is evident from the medical records the family had not agreed to the use of the butrans patch.
211. For this reason, our decision is to partly uphold this part of the complaint. We are making a recommendation for the Trust to put things right and provide a proportionate remedy.