Cornwall Partnership NHS Foundation Trust
Disclosure of heart failure
23. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event 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 this matter.
24. Mr S complains the Trust did not disclose that Ms R had heart failure. He said when he did learn of this it caused him significant shock and upset. She was diagnosed with heart failure on 4 August 2024.
25. The Trust final response states it is truly sorry that Mr S did not receive regular updates on Ms R’s progress from the nursing or medical staff, and that the seriousness of her condition came as such as shock. The Trust response states this has been fed back to the elder care department at the governance meeting, to highlight the important of regular and frank but compassionate communication.
26. The response goes on to state the eldercare consultant doctor sincerely apologises for the lack of communication with Mr S regarding Ms R’s condition, and the impact this had upon him and Ms R’s family.
27. The Trust has accepted it did not give Mr S regular updates about her progress or condition. We consider this is an indication of a failing. The Trust has set out that this has been fed back to the relevant staff to improve communication.
28. NHS Complaint Standards set out an organisation should be accountable, acknowledge mistakes and put service improvements in place where appropriate. Mr S is seeking service improvements and improved communications between NHS organisations and between the NHS and its users. We consider the Trust has taken sufficient action to put this right in line with NHS Complaint Standards. We therefore will take no further action on the complaint.
Disclosure of DNACPR
29. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong in relation to this point.
30. Mr S complains the Trust did not tell him that Ms R had a DNACPR in place. He said when he did learn of this it caused him significant shock and upset.
31. We cannot see the Trust has specifically responded to this point in the complaint responses.
32. In order to consider this point, we have reviewed the records. The records state that the DNACPR was put in place and the patient had mental capacity to be involved with these decisions. The Trust has completed the document ‘Mental Capacity Assessment relating to the CPR decision documented in this Treatment Escalation Plan’. This form sets out the decision has been discussed with patient and relatives, and it is written ‘discussed with patient and her husband.’
33. Treatment and care towards the end of life: good practice in decision making’ guidelines state, ‘As with other treatments, decisions made in advance about whether CPR should be attempted must be based on the circumstances of the individual patient and take into account their wishes and preferences. It should also involve discussions with members of the healthcare team as well as (with the patient’s agreement) those close to the patient.’
34. We understand Mr S says the DNACPR was not disclosed with him. We do not dispute his recollection of events. We understand this would have been a very stressful and upsetting time. We cannot say that this was not discussed with him, as the records show a conversation did take place which would be in line with Treatment and care towards the end of life: good practice in decision making’ guidelines. There are two clear different views of the events that took place. As we were not present at the time of the event, we cannot say the conversation as recorded in the records did not take place. We therefore will not consider this further.
Explanations of medications
35. Mr S complains he was not told how to administer the medication prescribed by the other Trust, and he was unsure what the medications were for.
36. The Trust final response states Ms R did not start on any new medications whilst on the ward, and she was transferred from the other Trust with several medications including a recent prescription for new medication to treat heart failure.
37. Our adviser explained it is the responsibility of the prescribing organisation to explain medications prescribed. As part of the medication reconciliation process, it is the hospitals responsibility to provide a supply of medications on discharge and explain what has been prescribed to the patient and their GP.
38. We have seen from the records the medications prescribed on discharge were all oral medications, with no complexity in administration and were clearly explained. The medications would have had clear instructions on the label from the pharmacy. We do not consider the actions fell below what we would expect to be considered an indication of a failing. We therefore will take no further action.
Treatment Escalation Plan
39. Mr S complains he was not informed of Ms R’s Treatment Escalation Plan.
40. Ms R was discharged home on 17 September via hospital transport. The records state all belongings, TEP, discharge letter and prescription, and medications were with the patient on transfer.
41. We have reviewed the correspondence and it does not appear this was addressed by the Trust.
42. The medical records state on 18 September 2024, the nursing community matron discussed the Treatment Escalation Plan with Mr S and Ms R. The records state ‘NOT for CPR- but FOR ADMISSION- I explained this to Mr and Mrs Burk [sic].’ The records state Ms R told the community matron she does not want to be admitted.
43. We understand it would be distressing to see a Treatment Escalation Plan and not have gone through this sooner with the medical staff. We recognise this would have been difficult. We consider this distress would have been resolved when he discussed this with the community matron the following day.
44. We recognise this was difficult for Mr S. We have seen the Plan was discussed the day after discharge. We consider any distress was short lasting. When we consider complaints, we must focus on the most serious matters complainants bring us. This is because we are a publicly funded body, so we must work in a proportionate way and focus our attention on the matters that have had the most significant impact. The severity and length of Mr S’s injustice would not meet the threshold for us to consider this aspect of the complaint any further.
Medication on portable devices
45. Mr R complains the carers were unable to give Mr R her medication until they had received notification of this on their portable devices. He states she returned home with approximately ten medications, and he was only aware of three of them. He explained to us that she returned home on 17 September 2024 and the medications only appeared on the carers’ portable devices the following day. He states he is unsure whether all her medications appeared, he does not know which medications she was prescribed, and he does not know whether this impacted her clinically.
46. We understand how important it is that someone has the medications they need. Mr S has not been able to give us sufficient information about this point for us to consider this matter. We have not seen evidence in the records that Ms R was without treatment or experienced distress due to a lack of medication. We therefore cannot consider this further.
Hospital bed
47. Mr S complains the Trust did not direct how to use the hospital bed or what requirements she needed, and this caused him distress and confusion.
48. The Trust final response, dated 10 January 2025, explains that the Trust’s occupational therapy team undertake a home visit to assess the environment, and recommend any adaptations or equipment which may be needed and offer guidance for its use. If equipment is needed, an order is placed via Cornwall Council who commission an external agency to deliver the equipment. All equipment should come with written instructions, and the external agency should set up the equipment and give instructions on its use.
49. The Trust carried out a home visit on 2 September 2024, and the provision of a hospital bed was agreed. The Trust said there is no documentation regarding any specific guidance by the occupational therapist and the use of the bed.
50. The delivery of equipment and provision of instruction in its use is the responsibility of the provider of the equipment, which is Cornwall Council. The Trust said it will raise the concern with Cornwall Council Loans department via an incident report.
51. Our adviser confirmed the occupational therapist assesses the needs of the patient and organises the appropriate equipment to be delivered to their home.
52. The ‘Transfer of Care Referral- hospital discharge’ records state ‘hospital bed will be set up for downstairs living on discharge.’ Our adviser explained the occupational therapist would not be present when the bed is delivered, and it would therefore be the responsibility of the delivering agency to demonstrate the use of the bed.
53. We recognise it was frustrating not to have all the instructions he needed for the bed. The responsibility for delivery of the bed fell to Cornwall Council the Trust has informed the council of the concern. We would not expect the Trust to do anything else as it was not responsible for this action.
Royal Cornwall Hospitals NHS Trust
Treatment Escalation Plan
54. Mr S complains the Royal Trust did not explain Treatment Escalation Plan (TEP) before Ms R was discharged to his care. The Royal Trust completed a TEP for Ms R on 3 August 2024.
55. The Royal Trust said the form was discussed and agreed by Ms R, who was felt to have capacity to make her own decisions. It explains whilst the Do Not Resuscitate decision is made legally on medical grounds, the decision should be discussed with both the patient and next of kin wherever possible. The Royal Trust said the consultant profusely apologised for the failure in communication with Mr S and for the distress this caused.
56. We understand this was very difficult time for Mr S and we recognise it caused him distress to see the TEP when he had not been informed about this. The Trust has accepted this and has apologised for the distress it caused.
57. NHS Complaint Standards set out an organisation should acknowledge when something goes wrong and apologise for it. We have seen the Trust has taken action by way of an apology in writing. This is the correct action to put this right. We therefore will take no further action on this matter.
58. We understand this has been an extremely difficult experience for Mr S during an already very challenging time. We thank him for bringing his concerns to our attention.