Eating, drinking and taking medication
22. Mr O says after his father’s admittance to hospital, the family told the consultant they were concerned he was not eating and drinking enough. He says the Trust did not address this.
23. He explained clinicians said a dietician would see his father and staff would complete food charts. He says staff did not fill in the food charts and family found food untouched along with untouched fortified drinks. In addition, they found medication on the floor on several occasions.
24. In its responses, the Trust acknowledges staff did not complete food charts consistently and explains the pressures of the ward prevented this. It goes on to say that the dietician did review and plan for Mr O’s father but there was a delay in the plan’s review.
25. The Trust says staff are unable to force patients to take medication but finding tablets on the floor was not acceptable and it has learned from this. It says it has put in place a vigorous training plan for staff to prevent this.
26. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
27. In reaching this decision, we have considered guidance in respect of the issues complained about.
28. The NMC Code section 13.2 says nurses should ‘make a timely referral; to another practitioner when any action, care or treatment is required’.
29. The NMC Future nurse proficiencies sections 5.1 to 5.3 say nurses should:
‘5.1 observe, assess and optimise nutrition and hydration status and determine the need for intervention and support
30. use contemporary nutritional assessment tools
5.3 assist with feeding and drinking and use appropriate feeding and drinking aids’.
31. NICE nutrition guidance, section 1.3.1, says, ‘nutritional support should be considered for people 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’.
32. The RPS guidance, paragraph 17, says ‘When a medication is not administered or refused, details of the reason why (if known) are included in the record and, where appropriate, the prescriber multidisciplinary team is notified in accordance with the organisational policies and procedures. Appropriate action is taken as necessary’.
33. The CQC guidance, paragraph 2, says:
‘Covert administration is only likely to be necessary or appropriate where: a person actively refuses their medicine and that person is assessed not to have the capacity to understand the consequences of their refusal. Such capacity is determined by the Mental Capacity Act 2005, and the medicine is deemed essential to the person’s health and wellbeing’.
34. The medical records show when transferred from the ED to a ward, Mr M was ‘eating and drinking well’. They also show he had taken his medication.
35. Staff did not note any concerns about Mr M’s eating and drinking until a few days later when it says he vomited after breakfast. Staff gave him anti-nausea medication, and the medical records say he did not want lunch.
36. In the days that followed the medical records do not show any concern about Mr M’s eating, drinking and taking medication. Notes in mid-July refer to there being no concerns about him and that he had taken his medication.
37. A dietician held a telephone review of Mr M mid-July and asked that snacks and Complan (a fortified nutritional supplement and meal replacement shake) should be available to him between meals. The medical records show the dietician was unclear as to why the consultant had referred Mr M as he was eating and drinking at this point.
38. Later in July the medical notes show a clinician to have raised a new concern about Mr M, noting him to have ‘poor swallow’ and that staff should not crush medication for him. As this meant he was unable to take one of the medications prescribed, staff escalated this to the pharmacy.
39. At this time, the clinician referred Mr M back to the dietician for review. They also noted a lack of completed food charts.
40. Later notes show staff were helping Mr M to eat but he would refuse meals. They also say he needed supervision when taking medication and he was starting to refuse medication.
41. As Mr M continued to refuse food and found it difficult to swallow medication, the consultant and his family agreed he would have a nasogastric tube (NGT) fitted in early August. This meant he would receive liquid food and medication through the tube.
42. From this point forwards, the medical records say Mr M received regular food and drink through the tube and all medication was intravenous (given through a tube into a vein).
43. We asked our nursing adviser whether the care given to Mr M in respect of his eating, drinking and taking medication was in line with the guidance and standards.
44. They said the medial records show Mr M was eating and drinking independently at the start of his time on the ward and he was taking his medication. They said the records include malnutrition universal screening tool (MUST) tests, with Mr M having a rating of zero (no concerns) when he was admitted to hospital.
45. They felt this shows treatment was in line with NMC guidance as staff were using tools to help determine Mr M’s needs.
46. When Mr M started to refuse food and drink, our nursing adviser said the medical notes show staff tried to feed him and monitored his medication taking. They also said the records confirmed Mr M had been unable to swallow his chemotherapy medication from mid-July and staff correctly raised this with the pharmacy on the same day.
47. Again, this is in line with NMC guidance as this requires staff to assist with feeding and drinking where needed. Also, RPS guidance says where a patient is not taking a prescribed medication for any reason, staff should let the pharmacy know. The medical records show staff did this.
48. As Mr M’s ability to eat, drink and take medication reduced, our nursing adviser confirmed staff took the correct action. They said staff were correct to arrange for an NGT at the beginning of August as Mr M had become too drowsy to eat or he refused food and drink when offered. He also refused medication.
49. This shows the Trust to have met the requirements of NICE nutrition guidance which says staff should assist patients when they have not been able to eat for five days or more and where this is likely to continue to be the case.
50. It also met the NMC Code as it referred Mr M to a dietician within two days of admittance and then again when he started to refuse to eat.
51. In respect of medication, CQC guidance says when a patient refuses to take medication, staff should not give it without their knowledge unless they do not have capacity to make decisions (for instance, putting the medication in food).
52. The medical records show the Trust put in a place a Deprivation of Liberty Safeguards (DoLS) order giving it the ability to make the decision to give Mr M his medication intravenously. Our nursing adviser explained this is in line with the CQC guidance.
53. From this, we have not seen indications of failings as medical records show staff did act to help Mr M with his eating, drinking and taking medication. We can see staff did not complete the food charts consistently and we consider this is shortcoming. This is because it does not fall so far below the requirements of guidance to be considered a failing as there is a record of has been eaten and drank despite it not being put on a separate form. This is also the case in respect of family finding medication on the floor.
54. The medical records show Mr M had eaten on most days. These also show towards the end of July into August, staff were helping Mr M to eat and to take his medication.
55. When it became more difficult for Mr M to take food, drink and medication orally, the Trust fitted an NGT for feeding and hydration along with giving medication intravenously.
56. The medical records show when Mr M was unable to take one of his medications orally, the Trust acted in line with guidance.
57. The Trust has apologised for not completing the food charts. It has also apologised if Mr O found medication on the floor near his father, explaining it has put in place additional training to prevent this happening again.
58. This is what we are likely to have required it do had we seen indication of failings. As we have not seen indication of a failing, we will not be considering this further.
59. We realise it will have been very distressing for Mr M’s family to see him deteriorate at this time.
Wounds from falls not dressed
60. Mr O says in mid to late July, his father had an open wound on his elbow. He says it left blood on his bed sheets because staff had not dressed the wound. He says he asked the consultant whether his father had fallen again, and the consultant said they would find out and have the wound dressed.
61. Mr O says when he visited the following day, there was no dressing on the wound.
62. In its responses to Mr O, the Trust says there is no record of Mr M falling on the date referred to but that there was a wound to his elbow. It says staff dressed the wound once Mr O made a consultant aware of it being there and that the dressing may have come off.
63. In addition, the Trust explains it shared information about the elbow and its treatment with staff on the ward.
64. We have considered the medical records and were unable to find any information about a fall other than of a fall the week previously where Mr M did not sustain any injury. There is no reference to a wound or dressing in the medical notes, only in its response to Mr O’s complaint.
65. We asked our nursing adviser about this, and they too confirmed there is nothing in the medical records.
66. In some instances, it is not possible to reach a view on an issue raised as part of a complaint. This may be due to lack of information, conflicting evidence, or a difference of opinion. When this happens, it is not proportionate to progress the issue to investigation as it is unlikely we will reach a satisfactory conclusion. That is the case in this instance.
67. In view of this, it is not proportionate to look at this issue further as we are unlikely to be able to reach a view. This is because there are no records to enable us to compare what did happen with what should have happened, with only the views of Mr O and the Trust to refer to.
68. This does not mean we do not consider there to have been an open wound on Mr M’s elbow as both parties agree this was there. However, there is a difference in opinion as to what happened next, which will likely prevent our reaching a decision in this part of the complaint.
69. We understand it will have been upsetting to find Mr M with a wound that was open and without a dressing.
Diagnosis, treatment changes and communication
70. Mr O says the Trust changed his father’s diagnosis on more than one occasion. He says it would give medication in line with the diagnosis then stop this within a couple of days in line with the change of diagnosis.
71. He says the Trust said his father’s cancer had not spread but later said it had spread. He also explained the Trust did not tell him his father had had previous strokes and he found this out from the pharmacist.
72. In its responses, the Trust explained that potential diagnoses evolve as tests rule conditions out. It says it tried to update family members as Mr M’s diagnoses evolved and has apologised if this was not clear.
73. It goes on to say scans found ‘old’ strokes (where there is an interruption to the blood flow in the brain), but not one recent enough to have caused Mr M’s symptoms, along with chronic small vessel disease (furred arteries) which is associated with age.
74. The Trust explains the magnetic resonance imaging (MRI) scan did not find any new stroke or new cancer in the brain. It did find lesions (damage through injury or disease) in the bones of the skull consistent with cancer.
75. The Trust says treatment for meningitis (an infection of the protective membranes surrounding the brain and spinal cord) started after Mr M moved wards. This was because he continued to decline and showed signs of a brain infection. A lumbar puncture (collection of spinal fluid for diagnostic testing) did not show any evidence of infection, and treatment for this stopped.
76. GMC’s Good medical practice, point 16 b expects clinicians to ‘provide effective treatments based on the best available evidence’. Point 33 says ‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
77. Looking through the medical records, these show the Trust shared several potential diagnoses with Mr O and his family. These include:
• ataxia (poor muscle coordination) • MRI scan results showing old strokes • low potassium levels • dementia • explaining the need for a lumbar puncture to rule out meningitis • potential brain metastasis (secondary cancer).
78. On each occasion, the medical records show clinicians told the family they thought this this may be the diagnosis, and what further testing they would carry out to confirm this.
79. We asked our acute and general medicine adviser about the MRI scan results and whether these showed signs of new cancer.
80. They advised the MRI scan showed several known issues such as evidence of prostate cancer in the bone marrow of the skull. They also said there were issues expected in an older person such as chronic small vessel disease and old strokes. They said the scan did not show any new issue or issues that were not age related.
81. In respect of the old strokes, our acute and general medicine adviser explained there is no specific guidance for treatment as guidance relates to recent stokes. They said plans should be specific to the individual and should consider any other medication the patient is taking.
82. They said that clopidogrel (antiplatelet medication used to reduce the risk of heart attack and stroke), the treatment prescribed for Mr M, was appropriate as the alternative was statins (used to reduce cholesterol levels in the blood). Statins can interfere with liver function and Mr M had experienced issues with his cancer medication affecting his liver.
83. This is in line with GMC guidance of providing treatment based on the evidence, in this case symptoms shown by Mr M, and tests results.
84. From this we cannot see any indication of the Trust making firm diagnoses, then changing these. It shared details of potential causes of Mr M’s symptoms and of the tests needed to make a diagnosis.
85. Nor can we see any indication it did not tell the family of the old strokes.
86. In respect of the spread of cancer, Mr M was already being known to have stage 4 metastatic prostate cancer before his stay in hospital. This means the family were aware of its spread from the prostate.
87. Similarly, we have not found any indication that the Trust did not communicate properly with the family. This is because there are at least 18 notes of conversations with family members and of family meetings where the Trust shared information and discussed next steps for Mr M’s treatment.
88. The medical records show the conversations to have included information of potential diagnoses, treatment plans and next steps.
89. The records also show conversations about the results of CT scans, MRI scans and lumbar punctures. In addition, there are details of the family’s concerns about Mr M’s eating and drinking and his deterioration as well as what the Trust was doing to address the concerns.
90. The medical records show clinicians followed guidance for treatment of old strokes and that it acted on Mr M’s symptoms.
91. These also show the Trust met GMC guidance in respect of communication as it provided updates throughout Mr M’s stay in hospital.
92. In addition, the medical records show conversations took place about end-of-life care, as clinicians introduced this slowly over a period of a few days. The notes show the Trust considered the family’s wishes as it delayed removal of the NGT, something that needed to take place before transfer to a hospice.
93. As there are no indications of the Trust doing anything wrong in respect of communication and treatment of Mr M’s symptoms, we will not be looking at this issue further.
94. We realise this is not Mr O’s recollection of events and that it will have been distressing to see his father’s deterioration.
The discharge process took too long
95. Mr O complains the discharge process took too long with it taking more than a week for this to happen. He says after securing a place in the hospice, the Trust delayed transfer for three days because of issues with medication and it lost the place, then delayed the discharge further when another place was given.
96. On the day of transfer, Mr O says they waited seven hours for this to happen.
97. In its responses to Mr O’s complaint, the Trust says after discussing options for Mr M’s discharge with family a week before his discharge, the family said they would prefer for him to go to a hospice.
98. It says it worked with the continuing health care (CHC) team at the local authority who looked for a nursing home for Mr M to provide other options should a hospice place not be available.
99. The Trust says the family’s preferred hospice declined its first request for a bed as Mr M did not present as agitated and he did not need pain management. At this time, the local authority also advised of being unable to find a bed for him in a nursing home.
100. It went on to say the family later said they only wanted a hospice place or to take Mr M home and would not consider a nursing home. The Trust approached the hospice again and it accepted Mr M. The transfer took place the next day.
101. We have considered the NICE end of life guidance in deciding whether there are indications of failings in this part of the complaint. This says in section 1.8, Communicating and sharing information between services:
‘Adults approaching the end of their life should have care that is coordinated between health and social care practitioners within and across different services and organisations, to ensure good communication and a shared understanding of the person's needs and care.’
102. It goes on to say in section 10 that staff should ‘ensure that regular discussions and reviews of care, holistic needs and advance care plans are offered’.
103. It explains:
‘Shared decision making is when health and social care professionals and patients work together. This puts people at the centre of decisions about their own treatment and care. During shared decision making, it's important that • care or treatment options are fully explored, along with their risks and benefits • different choices available to the patient are discussed • a decision is reached together with a health and social care professional.’
104. The medical notes refer to conversations held with the family across the week before Mr M’s transfer from hospital to the hospice.
105. These show that initially the family considered both hospice care and moving to a nursing home for Mr M. The Trust spoke with CHC who started the process of sourcing a nursing home, whilst the family looked for a hospice.
106. This appears in line with the GMC guidance as the Trust considered the views of the family and demonstrates different agencies were working together to meet their requirements.
107. The nurse in charge of Mr M’s discharge contacted the hospice preferred by the family. The hospice initially said it would not take Mr M as he was asymptomatic (have a disease or infection but are not showing symptoms) and it did not accept patients at this stage.
108. The medical records also say the CHC had not been able to find a nursing home to take him.
109. A few days later, the medical records say the family decided they still wanted Mr M to go to a hospice but had decided against a nursing home, asking that if a hospice place could not be found, he return home.
110. After this, the Trust called the family’s preferred hospice again and asked it to reconsider accepting Mr M.
111. The hospice came back to offer a place shortly afterwards. The medical records show this conversation took place at 1.58pm, and the cut off for the hospice to take Mr M that day was 3.00pm. This did not give the Trust the time to ready Mr M for transfer the same day.
112. The hospice would not accept Mr M whilst he still had the NGT in place (the records show the family had not wanted this removed until the time of transfer to the hospice).
113. The hospice also did not support intravenous medication and needed a syringe driver (a small pump which delivers medication through a tube into the skin) fitting before it would take him. This needed to be put in before transfer could take place.
114. The next day, the medical records show the Trust discussed with the hospice whether it would give Mr M’s medication by subcutaneous injection (an injection given below the fatty tissue) rather than a syringe driver. The hospice agreed to this.
115. The consultant raised the prescriptions for subcutaneous injection medication at 9.30am. The pharmacist verified these at 10.30am but the medication was not ready for collection until late afternoon.
116. The transfer from the Trust to the hospice took place at 1.56pm without the medication.
117. We asked our nursing adviser what should happen when a patient needs to be transferred to a nursing home or hospice for end-of-life care.
118. They said there is no standard process for movement of a patient in these circumstances with this differing between local authorities and trusts. In addition, hospices are independent health care providers and work outside of a Trust’s policies and procedures.
119. Our nursing adviser went on to say that there were opportunities to have discussed discharge planning earlier in Mr M’s stay in hospital. They also said that whilst this was the case, the palliative team had given Mr M a short prognosis and, given the hospice declining to take him when first approached, the window of opportunity for the transfer to take place was small.
120. They said discussions with the family had taken place, but it did not appear all parties involved in the transfer process were involved in the conversations. They said had all parties been included, it may have given the family more clarity as to the full extent of the transfer process.
121. They said it appeared there was a delay of three days between the hospice declining to take Mr M and this being acted on and it is unclear what, if any, discussions were held with other parties during this time.
122. From the notes and our nursing adviser’s comments, we consider while there appear to have been shortcomings in way it managed the transfer process, the Trust did not delay the process unnecessarily.
123. The main reason for the delay in Mr M being transferred was because the hospice declined to take him when first approached. This was due to his needs not being severe enough to meet its criteria. This is not something the Trust can be held responsible for as hospices lie outside of the Trust’s area of control, and it has no input into acceptance criteria.
124. Our nursing adviser said there appeared to have been a delay between the hospice declining to take Mr M and the next contact to address this. From the medical notes, we can see that across that time, the local authority advised of not being able to find Mr M a place at a nursing home. Also, the family decided that they did not want to consider a nursing home, with a hospice or Mr M returning home being their preferred option.
125. In respect of delays when the hospice agreed to take Mr M and him being transferred, we cannot see any indication of the Trust having delayed this process for three days, but that the hospice declined to take Mr M on the first approach.
126. The hospice agreed to take Mr M at 1.58pm when it did accept him, but said he needed to be with them by 3pm. It is not realistic to have expected the Trust to be able to meet this timescale as Mr M still had a NGT and needed a syringe driver (or an alternative) fitting before the hospice would take him.
127. The medical notes show the Trust contacted the hospice the following morning to agree an alternative to fitting a syringe driver. Once agreed, it placed a prescription for the medication. This was not provided to the ward in a timely manner, with the transfer taking place without the medication.
128. We consider this indicates the Trust acted to ensure the transfer was not delayed on this day as Mr M was transferred before the hospice's cut off time of 3pm.
129. We can see the Trust did not meet the requirements of NICE guidance as it did not start its discussions about discharge planning when Mr M was first admitted. Once it had been decided he needed end of life care, it did start discussions with Mr M’s family and the other organisations involved in the transfer from hospital to a more appropriate setting.
130. Again, these discussions were not in line with NICE guidance as not all parties were involved only the Trust and family, so they may not have been aware of the complexity of the discharge process where end of life care is needed.
131. Despite this, discussions did take place, and it is evident the Trust worked with the family to provide transfer to a hospice, the family’s preferred option. The medical records show it did meet some of the requirements of the guidance.
132. We do not consider there is any indication these shortcomings caused the impact Mr O has advised of. These did not delay the discharge process, with this being the result of the hospice not accepting Mr M in the first instance and, when it did accept him, there was too little time to be able to transfer him that day.
133. We cannot see any indication of unnecessary delays on the day of the transfer, particularly as patient transport it not provided by the Trust, but by another NHS organisation.
134. In view of this, we will not be looking further at this part of the complaint.
135. We recognise how frustrating and annoying this will have been for Mr O and his family. They will have wanted to see Mr M settled in the hospice and receiving end of life care in this more comfortable environment as soon as possible.