Pressure ulcer care
15. Mr G complains that from 5 July 2023 when his mother was transferred to another ward, up until she was discharged back to her care home on 24 July 2023, she did not receive the right care to prevent the pressure ulcers she sustained in hospital. He says when she was discharged to her care home, she had noticeable extensive skin damage to her right calf, ankle, and toes which led the care home to raise a safeguarding report.
16. Mr G says the injury to Mrs G’s right calf was so severe, her tendon was visible, and bone was visible in the pressure ulcer on her ankle. He says Mrs G’s pressure ulcers could have been prevented had the Trust taken preventative action such as frequent repositioning.
17. In addition, Mr G complains the Trust did not properly document the pressure ulcers on Mrs G’s calf and ankle while she was in its care and it did not carry out an independent review of the pressure ulcers she sustained.
18. The NICE guidance on pressure ulcers says clinicians should carry out and document an assessment of pressure ulcer risk for adults who have been admitted to hospital. It says clinicians should use a validated score and reassess pressure ulcer risk if there is a change in clinical status (for example, after surgery, on worsening of an underlying condition or with a change in mobility).
19. The NICE pressure ulcer guidance also says clinicians should encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every six hours. It says if they are unable to reposition themselves, clinicians should offer to help using appropriate equipment, if needed. It also says clinicians should document the frequency of the repositioning required.
20. NICE ‘Advice on repositioning’ defines repositioning as, where the person moves into a different position in a chair or bed. This aims to reduce or stop pressure on the area at risk.
21. The records indicate that in line with the above NICE guidance, the Trust assessed Mrs G’s risk of pressure ulcers using a validated score shortly after she was admitted to hospital on 29 June 2023. This showed that she was at high risk of developing pressure ulcers.
22. In line with the above NICE guidance, as she was assessed as at risk of developing pressure ulcers, Mrs G required frequent repositioning and the details of how often this was done should have been clearly documented.
23. In addition, the tissue viability team’s advice, after assessing Mrs G in July 2023, was clear that clinicians should document each of Mrs G’s positional changes, including the position Mrs G was in and if necessary, any time she refused to comply with repositioning.
24. In its complaint response, the Trust said the plan of care for Mrs G was to reposition her every four hours. The Trust said she was seen regularly by the nursing staff, physiotherapists, the medical team, and the tissue viability team so she would have been repositioned often. The Trust acknowledged that there were gaps in times and inconsistences in its record keeping and as such, it could not be certain that Mrs G was repositioned every four hours as it had planned, and it offered an apology for its lack of records.
25. The records do not show how often Mrs G was repositioned. Due to the Trust’s lack of record keeping we cannot determine whether the Trust repositioned Mrs G every six hours in line with the NICE guidance.
26. The NMC code says nurses must keep clear and accurate records relevant to their practice. As the Trust did not keep clear and accurate records of when and how Mrs G was repositioned, it did not act in line with the above NICE and NMC guidance. We find this to be a failing.
27. Given Mrs G was at high risk of developing pressure ulcers, we understand why Mr G would have been concerned that the Trust were not accurately recording how often she was repositioned and closely monitoring her wound care.
28. Due to the lack of records, we cannot say whether Mrs G received the preventative repositioning care she needed, and whether her risk of developing her pressure ulcers could have been reduced. This is an injustice to Mr G, as he will never know whether his mother’s pain and suffering could have been lessened or prevented. This will be distressing and frustrating for him. This has also prevented us from reaching a conclusion on this point, which again will be frustrating and disappointing for Mr G.
29. Mr G said the Trust did not properly document Mrs G’s pressure ulcers. He said the pressure ulcers on Mrs G’s right ankle and calf identified by the district nursing team, occurred when Mrs G was in the Trust’s care.
30. The NICE pressure ulcer guidance recommends that clinicians should document the surface area of all pressure ulcers in adults and to document an estimate of the depth of all pressure ulcers.
31. We can see that Mrs G was reported to have a leg ulcer on 30 June 2023. On 7 July 2023, the tissue viability team assessed Mrs G’s wounds, and 10 wounds were documented. However, there was no mention of the leg ulcer observed a week before on the list of wounds. Images taken on 6 July 2023 by ward staff show that the leg ulcer wound was still present and improving. This is inconsistent and not in line with the NICE guidance which requires all wounds to be documented and assessed.
32. The Trust’s discharge documentation did not mention any wounds to Mrs G’s ankle or calf even though they had been identified and documented by the district nursing team approximately three hours after Mrs G was discharged from hospital. Furthermore, the skin integrity body map was last updated on 9 July 2023 which was 15 days prior to Mrs G’s discharge from hospital and the last images of Mrs G’s wounds were uploaded to the Trust’s systems on 11 July 2023.
33. Due to the Trust’s incomplete and outdated records, it could not definitely state if any wounds occurred during Mrs G’s last days of her admission or when the injuries to her ankle or calf occurred. We consider that given the district nursing team documented a consultation with Mrs G just three hours after she was discharged citing the wounds to her ankle and calf, on balance, they are likely to have been present at the point she was discharged from hospital on 24 July 2023.
34. To act in line with the above NICE guidance, the Trust should have documented all of Mrs G’s wounds from admission through to when she was discharged from their care. Our adviser said better record keeping by the Trust would have helped to identify and record the cause of all the wounds sustained and the extent of deterioration, when Mrs G was discharged. We have found the Trust did not appropriately document all of Mrs G’s wounds in line with the above NICE guidance. We find this to be a failing.
35. We find this meant Mr G and his family were left not knowing the true extent of Mrs G’s skin damage when she was discharged from the Trust, and how and when this damage occurred. This would understandably have caused frustration and upset.
36. Mr G complains the Trust did not complete an independent review of his mother’s pressure ulcers. In particular, he questioned the findings made by the Pressure Ulcer Review Panel meeting convened on 23 August 2023 and said it erroneously downgraded his mother’s calf injury from a pressure sore to non-pressure related injury and said the pressure sore to her ankle did not happen when she was under the Trust’s care.
37. Our NHS Complaint Standards say where possible, staff who have not been involved in the issues should conduct a review of the care.
38. The Pressure Ulcer Review Panel is the Trust’s internal review process which runs weekly to discuss learning and actions for its clinical areas; its members have no previous involvement in the cases it reviews. It is a peer-to-peer discussion forum designed to help focus on learning from events and identify themes from pressure ulcers that develop or those that deteriorate while a person is receiving care in the Trust.
39. The notes show that the Panel which was convened on 23 August comprised of the Tissue Viability Operational Lead, Head of Nursing for Community Services Business and previous Tissue Viability Service Lead, Data Manager, and the Ward Matron. The notes show the Panel concluded that the damage to Mrs G’s right calf was not consistent with typical pressure damage but said the wound to her right ankle was pressure damage that had deteriorated in her care home as there were no reports of it on discharge.
40. In its complaint response, the Trust further explained that having reviewed its wound care documentation and the lack of timely recording of Mrs G’s wounds leading up to her discharge from hospital, it was not able to give a definitive answer about where Mrs G’s ankle or calf wound occurred.
41. Our Principles of Good Administration say organisations should seek continuous improvement and review their processes regularly to ensure they are effective and to improve their public service delivery and performance.
42. Having considered the aim of the Pressure Ulcer Review Panel and the fact that none of the members of the panel were involved in Mrs G’s care, we are satisfied that the Panel carried out an independent review of Mrs G’s pressure damage in line with Our NHS Complaint Standards and Our Principles.
43. We appreciate that Mr G feels that there were inconsistencies in its conclusions when compared to other clinical notes. We consider this was due to the poor record keeping whilst Mrs G was an inpatient which prevented the panel reaching definitive conclusions which we have found a failing with above. As such, we have not found a failing with the independent review of Mrs G’s pressure ulcers.
Failure to complete a ‘This is me’ introductory meeting
44. Mr G says when Mrs G was transferred to a new ward on 5 July 2023 staff did not carry out a ‘This is me’ introductory meeting. He said there was no introduction or discussion with the family to better understand his mother’s needs.
45. This is me is for anyone receiving professional care who is living with dementia or experiencing delirium (sudden, often reversible, acute state of severe confusion and rapid mental changes, lasting between a few days to weeks) or communication difficulties.
46. According to the Alzheimer’s Society, ‘This is Me’ is a support tool to enable person-centred care and helps health and social care professionals better understand who the person really is, which can help them deliver care that is tailored to the person’s needs. It can be filled in by patients’ families and can be used in different settings such as at home in hospital, in respite care or in a care home.
47. There is no record of a ‘This is me’ document from the notes or that the Trust had asked for one to be completed during Mrs G’s inpatient stay.
48. The NMC the code says that nurses should put the interests of people using or needing nursing services first. They should make the patients care and safety their main concern and make sure that their dignity is preserved and their needs are recognised, assessed and responded to.
49. Our adviser said a ‘This is me’ should have been carried out to ensure Mrs G’s needs were met and responded to as it helps to identify the patient’s likes, dislikes and personal routines that support their cognition.
50. Our adviser explained an introductory meeting is important to help reduce distress for people with dementia and their carers. It can also help to overcome problems with communication.
51. The Trust did not hold an introductory meeting or ask the family to complete a This is Me’ document. This is not in line with the NMC guidance above, and we consider this is a failing.
52. It is clear from the guidance that an introductory meeting is a mutually beneficial support tool for patients and clinicians, centred on patients’ needs. As such, we consider that by failing to complete this, the Trust missed an opportunity to better support and communicate with Mrs G and her family during this admission. We recognise the distress this would have caused Mrs G and her family.
53. In its complaint response, the Trust apologised that staff did not introduce themselves when Mrs G was transferred between wards as important personal details should be listed and information should be confirmed with patients and families. The Trust has acknowledged that relatives of people with dementia should be asked to complete a ‘This is me’ document or bring a previously completed one in with them.
54. It also explained that it will aim to ensure ward teams receive regular training on how to support person-centred care for people living with dementia while in hospital and that it had commenced walk-round handovers at each shift change which would give staff the opportunity to introduce themselves to patients and their relatives.
55. Our NHS Complaint Standards say that Organisations should openly identify instances when things have gone wrong and take responsibility for these. They should make sure staff look at what action will be taken to learn from the experience to continuously improve services and help support staff.
56. We consider, that in line with Our NHS Complaint Standards, the Trust did identify where things went wrong and take learning from this to improve its service. However, we would like the Trust to explain how these improvements are working in practice and how they are ensuring that the failings we have found are not being repeated.
Fluid intake in July 2023
57. Mr G complains the Trust did not ensure his mother had adequate fluids after she was transferred to another ward on 5 July 2023. He says she was in negative fluid balance for most of her admission as she had lost more fluids than she had taken in.
58. The Royal College of Nursing (RCN) and National Patient Safety Agency (NPSA) guidance says there is no agreed daily intake level for water in the UK. However, it says conservative estimates for older people are that the daily intake should not be less than 1.6L.
59. The records show the fluid balance details for Mrs G’s admission. Fluid balance is the clinical practice of tracking all fluids entering (oral intake) and leaving (output) a patient’s body over a set time to assess their hydration status. We can see that from admission to the ward on 5 July 2023 up until Mrs G was discharged on 24 July, Mrs G had a calculated volume for oral intake of 1000mls each day or less.
60. The NMC ‘Standards of proficiency for registered nurses’ says nurses should, ‘record fluid intake and output and identify, respond to and manage dehydration’.
61. In its complaint response, the Trust attributed Mrs G’s low hydration levels to the diuretic (type of drug that causes the kidneys to make more urine and helps the body to get rid of excess salt and water) she was prescribed on 7 July due to her history of heart failure. It said it subsequently discontinued the diuretic medication based on Mrs G’s low fluid intake.
62. The Trust concluded that Mrs G was not dehydrated throughout her stay and noted that her average fluid intake was 758 ml. While the notes demonstrate that nursing staff were advised to encourage Mrs G with her oral intake, the Trust acknowledged that it had not documented whether the issue of Mrs G’s hydration levels had been escalated, given her low fluid intake.
63. As Mrs G’s intake was a lot lower than the daily recommended intake, we consider the Trust did not act in line with the NMC standards of proficiently and did not respond to and manage Mrs G’s dehydration.
64. Our adviser said Mrs G’s hydration levels placed her at risk of dehydration which could have exacerbated her dementia and cognition. Our adviser also said dehydration will contribute to dry skin integrity which, in Mrs G’s case, could cause skin tears due to the frailty of the skin and can contribute to delayed wound healing.
65. Therefore, we consider this failing increased Mrs G’s risk of exacerbating her dementia and contributing to her issues with pressure ulcers. It also caused Mr G distress at witnessing his mother’s low fluid intake and made him question the care that the Trust was providing to his mother.
Catheter management
66. Mr G says the Trust did not reassess his mother’s catheter in line with the removal date of 7 July 2023. He says the catheter caused Mrs G discomfort as she tugged on it and eventually removed it herself.
67. The records show Mrs G had a catheter inserted on 30 June 2023, prior to her arrival on the ward, because she was not passing urine. We can see the expected removal date recorded as 7 July 2023. The Trust explained that it had expected to remove Mrs G’s catheter on 7 July 2023, however, following a review, it decided to keep it in place due to retention and skin integrity risks.
68. The Royal College of Nursing (RCN) standard for Fundamentals of Catheter Care provides guidance on catheter care and refers to the NHS England Urinary Catheter Tools which states that clinicians should assess the need for the catheter daily for inpatients and to document this.
69. The records show Mrs G’s urinary catheter was assessed and monitored at least once to twice each day with reasons provided alongside the assessment dates for why the catheter was still in place. On 7 July (the expected removal date) the reasons given for keeping the catheter in place were ‘retention and skin integrity’, and on 8 July ‘monitoring urine output’. The records also show that the catheter was removed by Mrs G on 15 July 2023.
70. Our adviser said the Trust’s management of Mrs G’s catheter was appropriate and the reasons provided for leaving the catheter in place were reasonable. We are satisfied that in line with the above RCN guidance, regular catheter assessments and monitoring took place and the Trust’s rationale for keeping the catheter in place past the removal date is supported by the notes.
71. We understand how distressing it would have been for Mr G to have witnessed his mother in discomfort because of the catheter, further worsened when she removed it herself.
72. We consider the care and treatment provided by the Trust in relation to the catheter was in line with the above RCN guidance, as such we have not found a failing for this part of the complaint. We hope this has provided some reassurance to Mr G that the decision to keep his mother’s catheter in past the expected removal date was made in line with guidance and in her best interests.
Side room
73. Mr G complains his mother was placed in a side room during her admission. He says this was not appropriate and meant she was not monitored closely enough.
74. The Royal College of Physician’s NEWS2 is a measurement tool designed to monitor and identify acutely ill patients. The test measures the degree of the patient’s illness, by examining six physiological measures, with low-risk patients at one end of the scale (patients who score between 0-4 and require monitoring every 4 to 6 hours) and high-risk patients at the other end (with a score of 7 or more, requiring continuous monitoring).
75. The records show Mrs G scored mostly between 0 to 3 during her admission. With her NEWS2 scores largely 3 and below, Mrs G required monitoring every four hours to six hours. The records indicate that Mrs G was mostly monitored in line with the NEWS2 guidance, however we also note that 30 out of 118 observation entries were marked as ‘overdue’. This suggests that Mrs G’s observations, at times, fell below the required standard set out in the NEWS 2 guidance.
76. The purpose of monitoring a patient is to pick up on any deterioration, and to ensure that their needs are being met. Mrs G did not clinically deteriorate during this period and did not suffer any falls. As such, we have seen no evidence in the records that the delays in the monitoring had any impact on Mrs G. As Mrs G’s NEWS2 score remained low (less than 4), this would not have led to any different treatment being provided if the delays had not occurred.
77. Also, whilst Mr G says that his mother was in a side room, we have seen evidence in the records that she was still within the nurse’s line of sight.
78. As such, whilst it seems that there were occasions that Mrs G was not monitored in line with the NEWS2 guidance, we have not seen any evidence that this had any impact on Mrs G or the care she received. We have also not seen any evidence to suggest that the location of Mrs G’s room had an adverse impact on the care she received.
Record keeping
79. Mr G complains the Trust’s record keeping was poor and this impacted on its ability to thoroughly investigate the care provided to his mother.
80. Our Principles of Good Administration state, ‘public bodies should create and maintain reliable and usable records as evidence of their activities. They should manage records in line with recognised standards to ensure that they can be retrieved and that they are kept for as long as there is a statutory duty or business need.’ As above, the NMC code also emphasises the importance of clear and accurate record keeping.
81. We have found failings above with the Trust’s record keeping in relation to the pressure ulcer care and fluid intake.
82. As explained above, due to the poor record keeping, we cannot come to a view of whether Mrs G was repositioned appropriately and whether her risk of developing pressure ulcers was appropriately managed, or her exact presentation when she was discharged from hospital.
83. We also could not determine Mrs G’s actual fluid intake as the Trust explained that the information it had recorded was not always accurate. It acknowledged its record keeping was not up to the required standard.
84. We note the Trust has apologised in its complaint response for its overall record keeping and acknowledged that documentation was an issue throughout Mrs G’s hospital stay.
85. As above, we consider this would have adversely impacted on Mr G’s experience with the Trust as he was left without information on exactly how his mother was cared for. This has caused significant distress.
Complaint handling
86. Mr G complains the Trust did not fully investigate his concerns regarding his mother’s care and treatment and it did not provide open and honest responses.
87. Our NHS complaint standards say organisations should take a thorough, proportionate, and balanced look into the issues raised in a complaint, give people fair and open answers to their questions based on the facts, and take full accountability for mistakes identified.
88. Mr G complained to the Trust in August 2023 expressing his dissatisfaction with his mother’s care and treatment. The Trust investigated his complaint and responded on 17 November 2023 addressing each point raised. 36 points in total were addressed by the Trust.
89. We can see that the Trust acknowledged its poor record keeping and accepted and apologised when this did not allow for a thorough response to a complaint issue. The Trust took accountability by identifying behaviour that was not acceptable, and it apologised that the care it provided fell below the standard it aspires to provide patients.
90. On 29 November 2023 Mr G contacted the Trust explaining that its initial response did not address all of his concerns about his mother’s care and treatment. On 9 May 2024 the Trust provided its final complaint response, cross referencing its response with Mr G’s complaint to ensure all issues raised were covered.
91. We can see the Trust provided a more detailed response to the additional questions posed by Mr G and its response covered a total of 48 issues. In its response, the Trust acknowledged its poor recording keeping and identified that improved written and verbal communication would have improved the care provided to Mrs G.
92. We understand how frustrating it would have been for Mr G and his family to receive a response with some unanswered questions and consider that this was due to the Trust’s poor record keeping resulting in a lack of information, rather than its refusal to respond to complaint issues.
93. We consider the Trust did fully answer Mr G’s complaint and gave him fair and open answers to his questions based on the information it had. It also took accountability for mistakes identified. As such, we are satisfied that Mr G was provided with a full response to the complaint issues he had raised, in line with Our NHS Complaint Standards and we have not found a failing with the Trust’s complaints handling.