Visiting
18. Miss A said her mother was very vulnerable as she did not speak English, and she was also hard of hearing. Miss A said her mother had also experienced a stroke and she usually stayed with her mother all day to help her. Miss A said the Trust allowed her to visit on one occasion throughout Ms U’s admittance and she was only allowed to stay for 30 minutes.
19. The Trust said Ms U was able to make staff aware of her basic needs and there was no requirement for her daughter to attend to act as an interpreter. The Trust said Ms U had been allowed one visit as a gesture of goodwill as it felt her family was clearly worried about her. The Trust said Ms U did not meet the criteria to allow a visitor.
20. The Trust’s COVID-19 visiting policy says patients may be accompanied where appropriate and necessary to assist with the patient’s communication needs.
21. From the records we can see on the day of Ms U’s admission, the Trust noted she spoke Arabic, and she was unable to speak much English. We can see Miss A was present with Ms U and the Trust asked Miss A for her mother’s medical history as it noted ‘patient cannot communicate well’.
22. The following day we can see at 10.23am the Trust noted Ms U spoke limited English but was able to speak in full sentences. At 11.12am we can see Miss A contacted the Trust and requested to visit her mother. We can see the Trust advised there was no visiting allowed at that time and she could contact the ward for updates.
23. We can see the call was passed to a second nurse and Miss A advised that her mother did not speak English well and she would like to interpret for her. The nurse documented Miss A could visit as a one-off.
24. The next day we can see Miss A requested to visit her mother and was advised Ms U did not meet the criteria for visitors. We can see Miss A explained her mother did not speak English very well. The Trust explained Ms U had been communicating with staff with no concerns and she was able to express her needs.
25. On the fourth day of Ms U’s admission, we can see she informed staff she was not happy in hospital and wanted to go home. We can also see she told staff she had not been receiving her medication, and she hadn’t received a wash yet. We can see Miss A contacted the Trust and requested to visit, and the Trust informed her Ms U did not meet the criteria for visiting.
26. Later that day we can see the doctor contacted Miss A as Ms U was not able to understand what was being told to her. We can see the doctor asked Miss A to translate, which she did. Ms U was discharged the following day.
27. We think the difficulty here is we have received conflicting accounts regarding Ms U’s ability to communicate with staff. We can see there are entries within the medical records which state Ms U has limited English but that she was able to communicate her needs to staff with no concerns. We can also see information that was provided by Ms U to the Trust which would indicate she was able to express her needs.
28. Miss U has told us her mother spoke very little English, and she would not have understood what was being told to her. We would like to make it clear, we do not doubt what Miss A has told us. We can see two doctors noted Ms U was not able to understand and on each occasion it asked Miss A to act as an interpreter which she did. We think this supports what Miss A has told us.
29. We need to consider, whether Ms U’s communication and understanding should have met the criteria for visiting in line with the Trust’s COVID-19 visiting guidance.
30. From the evidence we have seen so far, we think the Trust has acted in line with its COVID-19 visiting policy. We can see the Trust documented Ms U was able to communicate with staff and there is evidence that would indicate this, such as her telling staff she had not had her inhaler or tablets. As Ms U was able to communicate effectively, we do not think she met the criteria for visiting as she did not require a family member present with her to be able to communicate her needs to staff.
31. We can see on the occasions where the Trust noted Ms U was not able to understand due to English not being her first language, it asked Miss A to interpret which she did. Our adviser said Ms U’s communication was reasonable and she would not have met the criteria within the visiting policy.
32. We understand Miss A will be upset by our decision, especially as she has told us not being able to visit her mother was really hard for her as Ms U was calling her distressed. We recognise this was a difficult time for Miss A and we hope our decision does not cause her any further distress.
Catheterisation
33. Miss A said her mother called her from the Trust crying because she had been held down by multiple staff members and she said something had been pushed inside of her. Miss A explained her mother didn’t understand what had happened, what had been inserted or why, and she never consented to the procedure. Miss A said her mother had very little grasp of the English language and would not have understood.
34. The Trust said due to Ms U’s fluid retention in her legs she was unable to insert the catheter herself. The Trust said it gained Ms U’s informed consent, and two staff members held Ms U’s legs whilst a third inserted the catheter. The Trust also said a fourth staff member assisted with the catheterisation. The Trust said it spoke with the nurse in charge who confirmed Ms U had understood what was explained to her and consented to the catheter insertion.
35. NMC the Code says nurses must make sure they get properly informed consent and document it before carrying out any action.
36. From the records, we can see the on the second day of Ms U’s admission, at 2.59pm the Trust noted ‘patient catheterised as on IV furosemide and requested by the doctor’. There are no further records relating to Ms U’s catheterisation and the Trust have been unable to locate a consent form for catheterisation.
37. From the evidence we have seen, we do not think the Trust has acted in line with NMC the Code. We have not seen any documentation that shows the Trust clearly explained to Ms U the reasons for her catheterisation, that she understood the explanation given, and that she consented to the procedure. This is not in line with NMC the Code which says nurses must make sure they get properly informed consent and document it before carrying out any action.
38. Our senior nurse adviser said trying to explain catheterisation to someone with limited English would be very difficult and it would be unlikely you could be certain their consent was informed. Our senior nurse adviser said the Trust could have used an interpreter, or her daughter in this case, to explain the procedure to ensure it had gained her informed consent.
39. We have considered the impact this had on Miss A. Miss A has told us the Trust catheterising her mother without gaining informed consent was extremely traumatic for her mother which caused her a great deal of distress. We recognise it would have been distressing for Miss A to learn her mother had been catheterised especially as she has told us her mother rang her crying and upset due to the catheterisation that had taken place.
40. We contacted the Trust about this. The Trust has agreed to apologise to Miss A and acknowledge the impact of the indication of a failing we have seen. Miss A has also told us she was seeking service improvements, and the Trust has agreed to provide Miss A with evidence of what it has implemented relating to gaining consent for catheterisation.
41. We think this resolution will put right the impact that appears to have been caused by the indication of a failing we have seen. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services. We think it gives Miss A an appropriate and proportionate remedy for the indication of a failing we have seen, and the injustice that arose from this.
Inhaler
42. Miss A said her mother had asthma and she was prescribed an inhaler which was to be taken twice daily. Miss A said the Trust did not provide her mother with her inhaler on two days of her admission. Miss A said on the second date her mother had contacted her as she was breathless and distressed due to not being given her inhaler.
43. The Trust said Ms U was transferred to the ward, from the emergency department, and the inhaler was not in stock. The Trust said it was ordered and administered later that day. The Trust said on the next occasion there had been a medical emergency which had delayed the morning medication rounds.
44. NMC the Code says nurses must provide medication to the patient in line with appropriate guidelines. The BNF says Fostair should be taken twice daily, which was the dosage Ms U was prescribed, and our senior nurse adviser told us Fostair does not need to be given at set times. Fostair is a medication used to treat moderate to severe asthma and provides long-lasting relief to the symptoms of asthma.
45. The RPS administering medicine guidance says when a medication is not administered details of the reason why must be included in the records.
46. From the records we can see on the day of Ms U’s admission to the Trust, she reported she had been breathless for two days. We can see the Trust did not administer Ms U’s inhaler on this date and it recorded this was because Fostair was out of stock.
47. The following day we can see Fostair was still out of stock in the morning but was administered later that day at approximately 5.46pm. The next day we can see Miss A contacted the Trust at 12.31pm to advise staff her mother’s inhaler was in her bag, and she had not been given this. We can see the Trust administered Ms U’s inhaler at 8.16am and 5.51pm on this date.
48. The next day at 10.20am Ms U complained to staff that she was not being provided her medication. We can see Miss A contacted the Trust at approximately 10.34am to advise her mother had not had her inhaler. We can see the Trust advised there had been a medical emergency which had delayed the medication round and this was provided at 10.51am and 5.15pm. We can see Ms U was discharged the next afternoon.
49. From the evidence we have seen we think the Trust has acted in line with NMC the Code. We can see Ms U was provided her inhaler twice daily on each day of her admission. This is in line with NMC the Code which says medications should be given in line with guidance. In this case we can see Ms U’s prescription, and the BNF, says it should be given twice daily, which we can see the Trust did.
50. The exception to this is the day of Ms U’s admission, where she was not provided her inhaler, and the following day where it was only administered once. We can see the reason for this was recorded as the item being out of stock. We understand this would have been frustrating and upsetting to Miss A as she was worried about her mother. We think the Trust has acted in line with RPS guidance which says if a medication is not administered the reason why must be recorded.
51. We can see on Ms U’s admission the Trust prescribed Salbutamol which is a fast-acting drug used to relieve breathlessness, wheezing and a tight chest for people with asthma. We can see this had been prescribed to be given to Ms U as required.
52. Our senior nurse adviser told us if Ms U had been experiencing any symptoms of breathlessness, the Trust could have provided Salbutamol. We have not seen any indication within the records that Ms U experienced any breathlessness or side effects due to not being given Fostair on the day of her admission or the following morning.
53. We hope our decision provides reassurance to Miss A that the Trust was administering Ms U’s inhaler on each day of her admission in line with guidance and that Ms U had a second inhaler that could be given at any time if she required it. We think the Trust has acted in line with NMC the Code and RPS administering medication guidance in its actions relating to Ms U’s inhaler.
Marks and Bruising
54. Miss A said her mother was covered in large black bruises on her arrival home following her discharge from the Trust. Miss A said her mother also had an open wound on her bottom that the Trust had not informed her of, and no explanation was provided for how her mother sustained this.
55. The Trust said Ms U was transferred in and out of bed safely and Ms U was on blood thinning medication which can cause patients to bruise more easily. The Trust apologised if Miss A felt the marks were due to staff roughly handling her mother.
56. NMC standards for nurses says nurses must observe, assess and optimise skin and hygiene status and use appropriate products to prevent or manage skin breakdown.
57. From the records we can see the Trust completed a pressure ulcer risk assessment on Ms U’s admission and noted her skin was oedematous (swelling caused by fluid retention) and discoloured.
58. We can see during the night at 1.32am the Trust documented Ms U’s elbows, bottom, coccyx (tailbone), sacrum (bone at the base of the spine), genital area, knees and heels were red and blanched. The Trust noted it would use a barrier cream to treat this, and our senior nurse adviser has told us this was the appropriate treatment.
59. On the third day of Ms U’s admission the Trust documented her genital area and knees were intact and no longer red and blanching. We can see the Trust checked Ms U’s skin each day and documented its condition. On the morning of Ms U’s discharge at 11.18am the Trust noted Ms U’s bottom, coccyx and sacrum were red and blanched and the other areas had been resolved.
60. Miss A has provided us with photos that were taken the day after Ms U’s discharge. These photos are timestamped and we are satisfied they were taken on this date. The images show a dark purple bruise on what looks like Ms U’s arm and redness and marking to her bottom.
61. We can see on the day of Ms U’s discharge she accidentally pulled her cannula out. Our senior nurse adviser explained the bruising to Ms U’s arm may have come from this.
62. The Medical News article on bruising explains that a bruise will appear purple or black in colour one to two days after the injury occurred. As the photo was taken the day after Ms U’s admittance, the bruise to her arm could have been made by taking her cannula out on the previous day. We understand this may leave Miss A with uncertainty regarding how her mother sustained the bruising to her arm.
63. Our adviser said the photos that show Ms U’s bottom, show marks where she has been sat and her clothing has creased and made indentations on her skin. We can see the Trust also documented this area was red and blanching on her discharge and had been present since her admission.
64. From the evidence we have seen we think the Trust has acted in line with NMC the Code. We can see the Trust assessed Ms U’s skin each day and applied a barrier cream. This is in line with NMC the Code which says nurses must assess a patient’s skin and use appropriate products to prevent or manage skin breakdown. It is important to note Ms U was admitted to the Trust for a matter of days which is a short amount of time.
65. We can see Ms U was admitted to the Trust with redness and blanching to her bottom and the Trust treated this with barrier cream. We would not be able to say there was an indication of a failing in the Trust discharging Ms U with redness to her bottom as this was present on her admission and therefore not caused by the actions of the Trust.
66. We understand this area did not resolve with the barrier cream and Ms U being discharged in this way has caused Miss A a great deal of distress. Our senior nurse adviser told us barrier cream was an appropriate treatment, and we think the Trust acted in line with NMC standards for nurses which says nurses should use appropriate products to prevent or manage skin breakdown.
67. We understand our decision is not the one Miss A was hoping for. We understand Miss A has been through a difficult time and we do not want our decision to detract from that. We think the Trust has acted in line with guidance in its assessment and management of the condition of Ms U’s skin.