Dementia care
18. Ms W complains while her father was on the emergency orthopaedic unit (EOU), staff did not consider his known dementia in his care. As a result of this, Ms W says his dementia worsened.
19. She says he was treated as a patient with capacity to make decisions in that:
• staff expected him to use a call bell if he needed anything • staff did not recognise that he would say ‘yes’ or ‘no’ in answer to questions without understanding what he had been asked • staff made no attempt to provide stimuli, even though she provided resources • she needed to ask Admiral nurses to arrange for her to have extended visits.
20. In its first response to Ms W’s complaint, the Trust assured Ms W its nurses had experience in working with patients with dementia and Admiral nurses (nurses who specialise in dementia care) assisted them. It also referred to a symbol used on the patient board to show they have dementia.
21. In its second response, the Trust said it had since introduced a booklet where family could note important information about a dementia patients' needs and it had put up dementia clocks (a clock with larger dials and figures on that also include the date and year to assist in a patient knowing the date and time) in the EOU.
22. The Trust did not directly respond to Ms W’s concerns about needing to involve Admiral nurses to get extended visiting. It said it was pleased the visiting was sorted out for her and it now has a new process in place for visiting patients with dementia.
23. We have considered the NICE dementia guidance which says the principles of looking after someone with dementia should be ‘person-centred’ and consider the individual.
24. It goes on to say care should ‘offer a range of activities to promote wellbeing...tailored to the person’s preferences’, ‘care coordination’ and that they should ‘develop a care and support plan’.
25. The NMC Code says nurses, including when treating patients with dementia, should:
• ‘1.1 treat people with kindness, respect and compassion • 1.2 make sure you deliver the fundamentals of care effectively • 2.1 work in partnership with people to make sure you deliver care effectively • 2.2 recognise and respect the contribution that people can make to their own health and wellbeing • 2.3 encourage and empower people to share in decisions about their treatment and care • 2.4 respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing and care • 3.1 pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages’.
26. The NMC Code says nurses should:
• 10.1 complete records at the time or as soon as possible after an event, recording if the notes are written sometime after the event • 10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
27. Our Principles, section three, says:
‘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’
28. From the medical records we can see the Trust documented Mr O to have vascular dementia when first admitted to the EOU and on many other occasions. It also noted Mr O was able to use the call bell and that he could make his needs known.
29. In addition, the Trust recognised Mr O did not have capacity to make decisions when planning his hip hemiarthroplasty at the end of September 2021, asking Ms W to consent to this.
30. In another instance, just after his admittance, the medical records say he is ‘unable to understand or make decisions, unable to retain information’.
31. When completing the discharge documents in mid-October, it says ‘lacking capacity’, but staff did not complete the dementia elements of the form.
32. Across his stay on the EOU, the medical records give conflicting information about Mr O’s capacity. On some days he it says he is ‘pleasantly confused’ and early in his stay on the ward the physiotherapist noted ‘patient cannot use call bell’. On other occasions the records say, ‘patient can make needs known’, ‘call bell within reach’.
33. These differing responses were recorded on more than one occasion both before and after the physiotherapist said Mr O could not use the call bell.
34. The medical records also show several occasions where Mr O give ‘yes’ or ‘no’ answers when asked questions. For instance, when asked whether he was experiencing pain, Mr O regular answered ‘no’ then later there is note of him getting upset because of the pain.
35. In respect of Admiral nurses, when admitted to hospital, Mr O was not assigned one, something the Admiral nurse service would normally accommodate.
36. There is nothing in the medical notes in respect of Admiral nurse intervention or support in arranging more visiting hours for Ms W. There is reference to intervention in respect of arranging a swallowing assessment when Mr O found eating difficult later in his stay in hospital.
37. The Trust’s website says extending visiting is encouraged for carers of patients with reduced capacity. Whilst there is nothing in the medical records to support Ms W needed to speak with an Admiral nurse outside of the Trust to ask they get her more visiting access, the Trust’s response to her complaint says it was pleased this was arranged for her. We consider this means she had previously had restricted visits to her father.
38. The medical records do not make any reference to provision of stimuli for Mr O during his time on the EOU. There is reference to Ms W asking about the lack of TV provision. Ms W says she brought in books and memorabilia to entertain her father.
39. The Trust acknowledges this in its response to her complaint, saying it was in the process of putting in new televisions, but that these were not available during Mr O’s stay in hospital.
40. We asked our nurse adviser what provisions staff should make for a patient with dementia, particularly in respect of the call bell.
41. Our nurse adviser says staff should not assume a patient can use a call bell and the patient should be placed close to the nursing station and monitoring should be carried out more regularly than for a patient with capacity.
42. They also said an assessment of needs as well as consideration of normal abilities should have taken place, and this should have been done with the carer (Ms W) and a designated dementia nurse.
43. Mr O’s medical records include dementia risk assessments, but these are blank and without a risk score.
44. This does not appear to be in line with either NICE Dementia or NMC Code guidance. These both refer to the need to cater for the individual and the NMC Code says there should be an initial assessment of the patients' needs along with a care and support plan. There is nothing within the medical records to show this was done.
45. Similarly, the NICE Dementia guidance says patients with dementia should have stimuli. The Trust did not provide this, admitting televisions were not available during Mr O’s stay and Ms W provided activities and stimuli for her father. Ms W says she often found these left out of her father’s reach.
46. The GMC guidance, NMC Code and our service’s guidance say accurate records should be kept. From the medical records, this does not appear to have been done.
47. The Trust says the nurses looking after Mr O had experience of treating patients with dementia. This is not evident in the medical records with conflicting assessments of Mr O’s cognitive ability. Despite a physiotherapist saying he did not have capacity to use the call bell to make his needs known early in his stay in hospital, the medical records show this was not acted on, with many references to him being left with the call bell.
48. Our nurse adviser says where a patient lacks capacity, then other methods of monitoring should be used, such as placing the patient near the nursing station and hourly checks being made. The Trust says Mr O was placed within sight of the nursing station, but the medical notes do not reflect hourly checks being made on him.
49. From this, we have found the Trust failed to take Mr O’s dementia into account when planning his care. There is no evidence to show he was assessed properly or that a care plan was put in place to cater for his individual needs. The forms needed to make an accurate assessment of Mr O’s needs have not been completed and there are instances where notes have been made in retrospect. This is not in line with guidance.
50. We realise it will have been distressing and upsetting for Ms W to see her father’s dementia and lack of capacity not being recognised by those looking after him.
Moving and handling
51. Ms W says staff used inappropriate methods to move her father that did not consider his osteoarthritis (OA), dislocated shoulder and hip hemiarthroplasty (hip replacement surgery).
52. She explains she made sure staff were aware of his shoulder dislocation and used an Ambi turn (a sit to stand transfer aid requiring input from the patient) to move him, despite him screaming with pain and a physiotherapist recommending full hoist transfer.
53. She says other patients commented that the same thing happened when she was not there. We recognise the distress Ms W experienced seeing and hearing her father was in pain.
54. In its first response to Ms W, the Trust says an outpatient's appointment had confirmed he did not have a dislocated shoulder, but that he had a torn rotator cuff (a group of four muscles and tendons in the shoulder), which is an age-related condition.
55. In its second response, it explains the use of a hoist may cause hip dislocation so it agreed Mr O should use an Ambi turn instead, with this being confirmed by the physiotherapy team who had initially decided a full hoist was needed.
56. We have considered the CSP Quality Assurance Standards which says,
• ‘8.3 Appropriate information relating to the service user and the presenting problem is collected • 8.4 Analysis is undertaken following information gathering and assessment in order to formulate a treatment plan, based on the best available evidence • 8.5 Appropriate treatment options are identified based on the best available evidence, in order to deliver effective care • 8.6 The plan for intervention is constantly evaluated to ensure that it is effective and relevant to the service user’s changing circumstances and health status’
57. The NMC Code says,
• ‘2.1 work in partnership with people to make sure you deliver care effectively • 8.5 work with colleagues to preserve the safety of those receiving care • 8.6 share information to identify and reduce risk’.
58. The NMC Code and Our Principles set out what patients can expect to be included in medical records, as explained in paragraphs 28 and 29.
59. In the medical records provided by the Trust, there is a copy of a letter from Mr O’s GP referring him to orthopaedics with ‘slight subluxation in keeping with rotator cuff laxity’ (partial dislocation of the shoulder possibly caused by deterioration of the rotator cuff).
60. On Mr O’s medical admission form it lists him as having OA in multiple joints. This is also recorded in the transfer documents completed when he moved from the emergency department (ED) to the EOU. There is no reference to the orthopaedic referral for potential shoulder injury.
61. Following the move to the EOU, Mr O had a physiotherapy assessment which noted an Ambi turn had been put next to his bed. The medical records then say he was moved using a Sara steady (another stand to sit aid requiring input from the patient) on 3 October, two days after the physiotherapy assessment.
62. Two days later, following a further physiotherapy assessment, the medical records say Mr O should be moved using a full hoist. A moving and handling assessment carried out a few days later says Mr O needed two people to move him using a hoist.
63. A further assessment took place almost three weeks later which says, ‘unpredictable re movement, use Ambi turn, if not suitable, then Sara stedy or full hoist’.
64. Mr O attended the orthopaedic outpatient's clinic whilst an inpatient in the EOU.
65. The medical records say a previous X-ray appeared to show a dislocation of the shoulder but that a more recent X-ray did not. This indicated an anterior superior escape secondary to a chronic cuff deficiency, and he had significant wasting of the cuff (the shoulder bone was escaping the top of the shoulder socket because of age related deterioration of the rotator cuff).
66. To help us reach our decision, we spoke with both our physiotherapist adviser and our nurse adviser.
67. We asked our physiotherapist adviser to explain the difference between the Sara stedy, Ambi turn and full hoist. They said the Sara stedy and Ambi turn require the patient to be able to weight bear and work with staff and the equipment to facilitate moving.
68. They said a full hoist is used where a patient cannot mobilise at all or where a patient does not have capacity to understand instruction.
69. They said in this instance a full hoist was appropriate considering Mr O’s known OA and recent surgery, combined with his dementia. They referred to Mr O having fallen prior to admission and this again made the physiotherapist’s recommendation of using a full hoist appropriate.
70. They went on to say that a patient should be encouraged to try to assist in their own mobilisation by using Sara stedy or Ambi turn but reiterated the recommendation to use the full hoist had been correct based on his presentation.
71. Our physiotherapist adviser says there are no additional measures where a patient has OA as a physiotherapy assessment will consider a patient's presentation at the time as well as any pre-diagnosed conditions.
72. They explained the same was the case with the suspected dislocated shoulder and pointed out notes of the outpatient appointment said the shoulder was not dislocated but the pain was caused by the chronic cuff deficiency which is age related and not an injury.
73. We asked our nurse adviser about the movement of Mr O and whether it had been appropriate to use a Sara stedy and Ambi turn despite the recommendation of full hoist transfer.
74. They said Mr O’s medical records show the recommendation of which equipment to use and the number of staff needed to help move him, but the records do not show consistent documentation of how he was moved.
75. There is only one moving and handling assessment in the medical records, and this was carried out early in Mr O’s stay in hospital. Our nurse adviser said they would have expected a further assessment would be carried out at least one week into his stay.
76. The medical records and the advice we have received indicate the Trust followed the CSP guidance or the NMC guidance.
77. The records show Mr O had at least three physiotherapist assessments across his stay and that early into his admittance the physiotherapist recommended use of a full hoist for transfer from bed to chair. At this point, he had recently undergone hip surgery, and his mobility would have been more restricted. Our physiotherapist adviser confirmed the recommendation to have been appropriate. Our view is this reflects the Trust having analysed Mr O’s condition based on his presentation after the operation.
78. Several weeks into his stay in hospital, the recommendation changed with the medical records showing the recommendation movement by Ambi turn then ‘if not, Sara steady or full hoist’.
79. Again, our physiotherapist adviser says it was appropriate to encourage Mr O to move himself. This is reflected in the CSP guidance which says the plan should be changed to reflect the patients' changing needs in line with their ‘health status’.
80. The NMC Code requires nurses to work with others to ensure delivery of care is done ‘effectively’. The medical records do not show this to have been the case as there are instances where staff moved Mr O by Ambi turn and Sara stedy after the physiotherapist’s initial recommendation to use a full hoist.
81. In addition, there are few medical records about moving Mr O considering the length of his stay on the EOU and there is only one moving and handling assessment in the records.
82. Our nurse adviser refers to the lack of consistent records and that the nursing team needed to have worked with the physiotherapy team to support moving Mr O appropriately.
83. We have found that despite the recommendations of the physiotherapist, staff moved Mr O using equipment which was unsuitable for him, requiring him to weight bear. In addition, record keeping is not consistent and there are instances where moving has not been noted at all. We consider this is a failing on the part of the Trust.
84. We can understand how upsetting it will have been for Ms W to see her father moved inappropriately and to witness and know this caused him pain.
Eating and drinking
85. Ms W complains the Trust did not ensure her father ate and drank enough whilst on the EOU. She says he lost weight in less than two weeks and needed encouraging to eat and drink. She says that whilst referred to a dietician, this was not done soon enough. Because of this, she says her father lost weight and caught infections.
86. In its first response, the Trust says it assessed Mr O using the malnutrition universal screening tool (MUST) as having a score of zero. This score indicated he was not at risk of losing weight. Staff referred him to a dietician mid-October, and the Trust acknowledged this ought to have happened sooner as he had a low body mass index and his food intake varied.
87. To reach a view, we considered NICE CG32 which says all patients who are at risk of malnutrition should have a comprehensive nutritional assessment that considers the risk of refeeding syndrome.
88. NICE CG32 also says,
‘1.1.2 Healthcare professionals should ensure that care provides: • food and fluid of adequate quantity and quality in an environment conducive to eating • appropriate support, for example, modified eating aids, for people who can potentially chew and swallow but are unable to feed themselves.
1.1.8 The specialist nutrition support nurse should work alongside nursing staff, as well as dietitians and other experts in nutrition support, to...ensure adherence to nutrition support protocols’.
89. The NMC Code and Our Principles set out what to expect to see in medical records, as referenced in paragraphs 28 and 29.
90. We also considered the BAPEN tool (MUST), which provides the formula for calculation of BMI, explains how to calculate the risk of malnutrition score (MUST score) and when to act on this.
91. The BDA model sets out six stages that should be followed when assessing a patient and advises ‘comprehensive assessment covering anthropometry (measurement of the physical properties of the human body, such as height, weight), biochemistry (study of chemical processes in the body), clinical, dietary, environmental/economic/educational factors. Dieticians should formulate a diagnosis and intervention plan’.
92. From the medical records, we can see the admission form refers to Ms W having told the Trust her father had lost a considerable amount of weight over a period of three to four months and that he had lost his appetite. A few days later, the medical records ask staff ‘encourage oral and fluid intake’.
93. The Trust’s letter to Mr O’s GP following his admittance to hospital says his oral intake had reduced prior to him being admitted.
94. Within the first few days of admittance, the medical records say Mr O was eating and drinking ‘adequate amounts’ and ‘normal diet and fluids tolerated’.
95. The first MUST score is noted more than a week after Mr O admittance. This does not state a score but says Mr O had not lost weight recently.
96. In the days after this, the medical records show Mr O’s intake of food and fluid's reduced to a poor level.
97. Further checks were made weekly with Mr O scoring as ‘low risk’.
98. The MUST form says where a patient has a score of one or higher without improvement over three days then a food record chart should be used and a dietician referral raised. It also says the patient should be offered build up shakes (in this case Forti sip) and the patient should be encouraged and assisted to eat.
99. In mid-October, a dietician saw Mr O. They said he had initially had a good appetite and managed most meals, but his daily intake left him in calorie deficit. They recorded his weight and noted this had reduced by 13.2% in two weeks. They prescribed six bottles of Forti sip per day, asked staff keep food and drink charts and arranged to see him the following week.
100. Ms W does not agree this was the case and says her father did not eat properly at all whilst in hospital.
101. After the dietician saw Mr O, staff completed the food and fluid chart that day and noted him having Forti sip as well as managing all meals and drinks.
102. The following week, the dietician visited Mr O and noted a 6% increase in Mr O’s weight since the previous week. They also noted the staff had not kept food and fluid charts since the day of their previous visit, so they could not assess actual intake, asking the EOU keep records to enable a proper assessment.
103. The following week, the dietician visited again. This time the medical records show Mr O was refusing meals and preferred sweet rather than savoury options. The dietician prescribed a different type of Forti sip, a more protein enriched version to provide more sustenance.
104. A further dietician visit took place a few days later, recording the same plan should carry on. This was the case again the following week as Mr O had another slight increase in weight.
105. Following Mr O’s transfer to another ward, the medical records say his dietary information did not move with him and staff raised a new referral for a dietician to attend. They did so a few days later, noting a further slight improvement in weight and instructed staff restart the Forti sip as it had stopped when he moved wards.
106. Mr O was referred to the speech and language therapy team (SALT) at the end of November, several weeks into his stay, as Ms W had raised concerns about his ability to swallow. The referral said he was experiencing issues swallowing and he was losing weight again.
107. We asked our dietician adviser about the management of Mr O’s food and fluid intake whilst in hospital. They said the Trust used an adapted version of the MUST assessment, not the generic version. They said the Trust assessed Mr O as having a score of MUST 0 on admission, using its version of the assessment. Had the generic version been used, he would have scored MUST 2.
108. This would have required immediate referral to a dietician, whereas the Trust’s version does not require referral unless the patient has a score of three or where the patients eating and drinking does not improve over several days. This resulted in a delay in Mr O’s referral.
109. They went on to say where the score is two or greater, the dietician should provide a comprehensive assessment including an intervention and monitoring plan along with dietic diagnosis. They said this needs to be done within 24 hours of admission.
110. Our dietician adviser says Mr O’s GP had prescribed six bottles of Forti sip per day prior to admission. When he was on the EOU, only three per day were given. Even after dietician increased this to six again, the medical records do not show staff increased from giving him three per day.
111. They explained it would have been reasonable for the Trust to have maintained the Forti sip level prescribed by Mr O’s GP. They said not doing so is likely to have contributed to his weight loss.
112. Our dietician adviser says the assessments that were done do not include all of the information with only anthropometry being recorded, and that Mr O was at risk of refeeding syndrome (potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients when they recommence eating larger amounts of food) due to how quickly he had lost weight.
113. Our dietician adviser says supplements were not necessarily appropriate for Mr O because of this. In addition, there was no indication that staff considered his dementia in his plan.
114. The medical records do not show staff to have assessed Mr O on admittance, something our dietician adviser says should have happened. This means staff did not refer him to a dietician referral in a timely manner, with it being more than two weeks into his stay before the MUST assessment took place.
115. We have found failings as the Trust did not act in line with the BDA model and NICE CG32 guidance. These both require a patient have a comprehensive assessment on admittance. This should include anthropometry, biochemistry, clinical, dietary, and external factors where a patient is at risk of malnutrition. This enables the dietician to make a diagnosis and plan for the patient.
116. The medical records show staff reviewed Mr O’s anthropometry and they recorded his body mass index (a measurement of weight compared to height) and weight loss. Our dietician adviser says there is no record of the other and, as refeeding was a risk factor for Mr O, supplements were not necessarily the correct way forwards.
117. The Trust used an adapted MUST assessment. This meant Mr O did not meet the criteria for referral to a dietitian at the point recommended by the BAPEN model. We consider this is a failing as it led to a delay in referral and seeing a dietician and, across the wait for this to happen, he was not given the Forti sip prescribed by his GP at the prescribed frequency of six bottles per day.
118. The medical records show staff restarted this once he had seen the dietician, but this was not at the six bottles daily as prescribed, with the medical records showing him being given just three bottles per day.
119. The medical records do not show the Trust to have kept accurate records of Mr O’s eating and drinking. This meant the dietician was unable to accurately assess his intake between visits.
120. This is not in line with the NMC Code which require accurate records are maintained to ensure all medical staff are able to assess a patient properly.
121. Similarly, the medical records do not show staff helped Mr O to eat and drink, something that a patient with dementia may have needed and something the NICE CG32 guidance advises may be necessary. As such, we consider this a failing.
122. We realise this will have caused Ms W a great deal of distress across the period of her father's stay in hospital.
Personal care and medication
123. Ms W complains the Trust did not meet her father’s personal hygiene and care needs whilst he was on the EOU. She says she found him with dried faeces on his person, and he would slip into uncomfortable positions on the bed, without anyone noticing or moving him.
124. In addition, she says she frequently found his medication in a pot untouched and in his pockets as staff did not help him take this.
125. In its responses to the complaint, the Trust agreed it was unacceptable to find Mr O in a soiled condition, but that he had been given laxatives and that he may have relieved himself in between checks. It said it had told all staff of the importance of making regular checks.
126. Regarding assisting Mr O to take medication, the Trust said staff advised there had not been any issues in his taking medication. It also referred to Ms W’s concerns that her father’s medicine cupboard was left unlocked. It said this had been addressed with staff and this issue had been used as a training opportunity.
127. For this part of the complaint, we have considered the NMC Code which says ‘1.2 make sure you deliver the fundamentals of care effectively’.
128. The RCN guidance section seven says:
‘Registered healthcare professionals who administer medicines, or when appropriate delegate the administration of medicines, are accountable for their actions, non-actions and omissions, and exercise professionalism and professional judgement at all times’.
129. As in paragraphs 28 and 29, both the NMC Code and our Principles say records should be updated at the time and should be reliable and useable.
130. The medical records show regular notes saying staff had met Mr O’s personal needs and medication given. There is a note at the start of his admittance that he ‘takes own medication’. Further notes early in his admittance to the EOU say, ‘assisted with hygiene needs’, ‘all regular medication given’ and ‘medication taken willingly’.
131. Later in his admittance, the medical records refer to an incident when Ms W visited and found her father to have a black tongue. After initial concerns about a fungal infection, the Trust found Mr O had chewed iron tablets rather than swallowing them. There is no reference to him not having taken the tablets properly in the records, only of the investigation once found with a black tongue.
132. As the stay in hospital extended, there are more references to Ms W being concerned about the support offered to her father in respect of personal hygiene and taking medication.
133. The medical records say Ms W spoke with Admiral nurses, in their capacity to support those with dementia and their carers, to raise concerns about her father’s personal care. She was concerned about his teeth as they were not being brushed, and he was not able to swallow medication. The notes say she had found his medication in front of him several times, meaning staff were not assisting him to take this.
134. Further notes in the medical records say when the Admiral nurse raised Ms W’s concern, staff said Mr O was not always compliant when they attempted to clean his teeth.
135. We spoke with our nurse adviser and asked whether Mr O’s personal care needs and taking of medication had been supported properly.
136. They said it is fundamental practice to help a patient with their personal hygiene needs whilst in hospital. Where the patient is vulnerable (as Mr O was), comfort rounding (a structured process whereby regular checks are made, also known as intentional rounding) may be used to ensure observation and key care components such as personal hygiene and bed positioning take place regularly. The medical notes show this happening.
137. In respect of taking medication, our nurse adviser says this is another fundamental component of practice. The medical records indicate Mr O to have taken medication but there are also notes of Ms W’s concerns that this was not the case.
138. Our nurse adviser went on to say that while the medical records indicate personal hygiene care needs were met and medication was administered, there is a lack of nursing assessments and care planning. They also referred to the lack of referral to a dementia specialist to help plan care which would be best practice.
139. We have decided is there is evidence to show the Trust met Mr O’s basic personal needs. Whilst this may not have been of the standard of care Ms W wanted for her father and will not have been of the standard of care she had provided to him, it did meet the basic requirements of national guidance.
140. This is not the case in respect of administration as there is a lack of planning of care or consideration of his dementia. In addition, there is evidence to show Mr O being given medication, but not that staff assisted him to take this. This does not show the Trust acted in line with the NMC Code.
141. The medical records show staff attended to Mr O’s needs on a regular basis with there being notes of washing, changing clothes and of giving Mr O medication across each day. These also show Mr O to have been observed regularly, in line with the NMC Code.
142. There are instances where Ms W found her father in a poor state with dried faeces, which the Trust has agreed is not acceptable, and she raised concerns about him not having his teeth brushed.
143. The medical records show these concerns were raised at the time and the Trust has explained why this may have been the case and it has used these instances as a learning tool.
144. It is evident care the Trust provided to Mr O was not always in line with the guidance of the NMC Code, but it was addressed when raised. The Code requires care provision to be ‘effective’, and the medical records support the personal care provided was, overall, effective.
145. Our nurse adviser says there is nothing to show Mr O’s dementia was considered and there is no evidence of a nursing assessment taking place or of a care plan being put in place. This is something the NMC Code requires and this has been addressed earlier in this report.
146. In respect of ensuring medication was taken, we can see from the medical records this was given to Mr O regularly. We cannot see staff ensured this was taken or there was an expectation that assistance may be needed. This is not in line with the NMC Code or Our Principles.
147. The early comment in the medical notes ‘takes own medication’ implies Mr O could take medication without assistance. We have already decided Mr O could not take responsibility for his own care because of his dementia.
148. There are many instances with the medical records where it is clear Mr O was given his medication to take, but only one specific instance where it is recorded that he took this. This note says, ‘medications taken willingly’.
149. Both Ms W and the Trust refer to an incident where Ms W found her father to have a black tongue, and it was established this was due to him chewing a tablet rather than swallowing it. We consider this is likely due to staff not ensuring he took his medication.
150. This does not appear to meet the requirements of RCN guidance as, whilst providing the medication, there is nothing to show anyone took responsibility for ensuring Mr O took this.
151. We have not found failings in the way in which the Trust provided support with personal needs.
152. We have found failings in the Trust ensuring medication was taken and failings in administration and record keeping.
153. This will have been very distressing for Ms W to witness.
Pain management
154. Ms W says her father suffered a great deal of pain whilst on the EOU. She says he suffered pain when being moved and, as he had pressure sores, was in constant pain because of these.
155. She says this was not managed by staff on the ward who accepted Mr O saying he was fine when asked about pain. She said this was a typical response as he did not want to make a fuss but staff, as trained professionals, ought to have seen through this.
156. In the Trust’s first response to this it recognised Mr O will have suffered pain, and he was regularly provided medication to address this. It explained he was not given stronger medication as this would likely have increased his confusion.
157. In the second response, the Trust admitted Mr O should have been referred to the pain team who, with the input of an Admiral nurse, may have been able to better address his pain. It said it had learned from this and more attention to the management of pain in a patient with dementia would be given ongoing.
158. We have considered the FPM Core standards which say:
‘1. All nurses must be able to assess pain and deliver evidenced, informed pain management appropriate to their level of their knowledge and skill and the setting in which they work.
2. Nurses must be familiar with comprehensive and consistent pain assessment using valid and reliable assessment tools. A good quality assessment will involve people with pain, their family members and carers’.
159. The PAINAD scale explains the signs to look for to determine the pain level of a patient with dementia. This includes observing the patients breathing, negative vocalisation, facial expression, body language, and consolability.
160. The BPA guidelines refer to the Abbey pain scale where appendix four explains this is ‘an instrument designed to assist in the assessment of pain in residents who are unable to clearly articulate their needs’.
161. From the medical records we can see prior to Mr O being admitted to hospital and before any surgery took place, he had a buprenorphine patch (medicine to treat moderate to severe pain) every seven days, 30mg of nefopam (a painkiller) three times a day and a total of 4g of paracetamol (two 500mg tablets, four times a day) to manage his pain. This was prior to his fall or surgery.
162. On the day he was admitted to hospital, he was assessed as having a pain scale score of one. It is unclear as to how this score was reached.
163. Further references to pain vary with the medical records saying Mr O ‘denies pain’, ‘no pain’, ‘regular pain relief given’ and ‘analgesia given as prescribed’. We have already reached a view staff did not ensure medication was taken.
164. Towards the end of his stay on the EOU, there are lists to show the medication provided to Mr O. These say he was prescribed the buprenorphine patch and paracetamol with 1g (two 500mg tablets) to be taken four times a day.
165. Following Mr O losing weight, medical records show Ms W queried why staff had reduced her father's paracetamol because of the weight loss but did not replace this with another pain killer. There is nothing within the medial records to show the dosage had reduced.
166. After this the notes say the paracetamol was put back to the previous dose of 1g four times daily as Mr O was in pain. As such, there is nothing to show how much the paracetamol had been reduced by or for how long.
167. In helping us consider whether Mr O’s pain had been managed properly, our nurse adviser says they could not see any evidence of staff assessing his pain using either of the tools recommended for patients with dementia.
168. Our nurse adviser says Mr O’s pain was not assessed using either the Abbey scale or the PAINAD scale, despite the Trust’s pain assessment forms recommending use of the Abbey scale for a patient with dementia.
169. From this, we have found failings that Mr O’s pain was not managed in line with guidance.
170. From the medical records, it is clear Mr O was taking pain relief medication before he had the hip hemiarthroplasty. This prescription was not increased following the surgery, with him continuing the same pain management routine.
171. An assessment of the amount of pain Mr O experienced was carried out but no tool was referenced, just the score of one. Specific pain measurement tools are recommended for patients with dementia as they may not vocalise when in pain, but behaviours may indicate they are in pain.
172. Our nurse adviser says staff did not measure Mr O’s pain level properly because the correct tools for measurement (the PAINAD and Abbey scale) were not used, with assessments using tools for patients with capacity.
173. The Trust has recognised it did not manage Mr O’s pain properly, acknowledging he needed to have been referred to the pain team, and an Admiral nurse was needed to help with the assessment. The Trust has recognised it did not take Mr O’s dementia into account when assessing his pain levels. It has not said how it will prevent this from happening again.
174. It will have distressed Ms W to know her father was in pain without this being addressed.
Pressure care
175. Ms W complains her father's pressure sores were not cared for properly whilst he was in the EOU. She says she often found him ‘in a mess’, and he was constantly in pain because of these.
176. The Trust explained in its response to Ms W’s complaint Mr O had a grade two pressure sore when he was admitted to the EOU and the tissue viability team (TVN) saw him two days later. After this his mattress was changed to support the pressure ulcer.
177. We have considered the requirement of NICE guidance on the prevention and management of pressure sores which says,
• ‘1.1.3 Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk assessment scale) when assessing pressure ulcer risk.
• 1.1.4 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).
• 1.3.1 Develop and document an individualised care plan...and adults who have been assessed as being at high risk of developing a pressure ulcer, taking into account: • the outcome of risk and skin assessment • the need for additional pressure relief at specific at-risk sites • their mobility and ability to reposition themselves • other comorbidities • patient preference.’
178. Mr O had three Waterlow assessments across his stay on the EOU. The first was carried out on the date of his admission where he had a score of 14. This means he was at risk of pressure sores.
179. A further assessment took place 11 days after his operation and showed him to have a score of 17, meaning he had a high risk of developing pressure ulcers. A third Waterlow assessment took place almost two weeks later and Mr O’s score had increased to 31.
180. At the beginning of October, the medical records refer to a TVN plan, but there is nothing to show Mr O had been referred to the TVN team or that an assessment had taken place.
181. The plan says ‘Cat 2 natal cleft/sacrum, cat 2 blister buttock, mature lesion. Slough, granulation, moist, clean surrounding skin with warm water and pat dry, apply carvilon cream, change dressing 3/7’. This refers to the actual sore and its care, with a double barrier cream needing to be applied and a new dressing every third day.
182. In mid-October the Trust created a body map for Mr O which showed a grade two pressure ulcer on his sacrum (base of the spine, top of the pelvis).
183. Throughout the medical records there is reference to the pressure sore and the care being provided. The care reflected the plan put in place at the beginning of October. This was updated mid-October when it was noted the sore was improving.
184. There had been improvements and, to aid healing, the TVN plan changed saying dressings should be changed on every bowel movement. It was also noted that a medic review was needed.
185. We asked our nurse adviser about the care provided in respect of the pressure sores and what level of care had been needed. They said the Trust had acted correctly in providing an air loss mattress for Mr O as it managed the risk of pressure ulceration.
186. There is evidence in the medical records of Mr O being repositioned regularly, but our nurse adviser says the Trust did not assess him regularly enough to prevent further deterioration.
187. Mr O was assessed on admission to the EOU, in accordance with NICE guidance on pressure sores. There is nothing in the medical records to show he was assessed again after his operation with the next assessment being carried out eleven days after this. The guidance requires an assessment take place after every clinical change, for example, after an operation.
188. When Mr O was reassessed eleven days post operation, his Waterlow score had increased but the medical records do not show his plan was reviewed. This is something the NICE guidance requires take place after every clinical change.
189. We note Ms W says she could be sat with her father for three or more hours without him being repositioned. The NICE guidance recommends repositioning at least once every four hours. It is unclear from the medical records whether this happened. Also, after the third Waterlow assessment the TVN asked for Mr O to be monitored every two hours. There is nothing in the medical records to show this was done consistently and we cannot say with certainty he was moved in line with guidance.
190. From the above, considering the requirements of the NICE guidance on pressure sores and we have decided the Trust failed to provide the correct level of care.
191. We recognise how distressing it will have been for Ms W to witness this deterioration of her father sores and the pain this caused him.
Impact
192. Ms W says the lack of care provided by the Trust resulted in her father being in unnecessary pain and discomfort during his stay in hospital. She said she often found him crying in his chair due to the pain. She also said this was exacerbated by staff ignoring his dementia.
193. We think this caused Ms W a significant amount of upset and distress and, as the medical records show, it is clear she raised concerns with the staff on the ward on more than occasion but did not see any improvement.
194. We have decided the failings in care led to Mr O being in more pain and discomfort than ought to have be the case. In addition, the standard of record keeping was not of the required level, and our view is this also affected his care. This is because the Trust did not meet the requirements of guidance in its care provision.
195. Within the medical records it shows staff made incorrect assumptions of Mr O’s capacity, assuming he was able to make his needs known. Because of this, we have found this impacted the level of care provided to him as him not making his needs known is likely to have led to his needs being missed.
196. In respect of moving Mr O, our view is the failing will have led to him being moved using equipment that was unsuitable, causing unnecessary pain. The lack of assessments will have impacted his care further. In addition, Mr O being unable to make is needs known, left him in positions that were uncomfortable and causing pain for extended periods.
197. When considering the impact of the failure to make sure Mr O ate and drank enough, we cannot say with certainty that this was the only cause of his weight loss, the impact Ms W says was due of failings of the Trust.
198. From the medical records, it is clear Mr O’s weight loss had started prior to his admission in hospital and that he had been prescribed six cartons of Forti sip per day to help correct this.
199. Our dietician adviser explained it is common for elderly patients to lose weight in a hospital setting and it is likely this had some impact on Mr O’s eating and drinking. They went on to say the failure to refer Mr O to a dietician earlier is likely to have contributed to his weight loss and frailty, along with an increased nutrition need due to his skin integrity and fracture of his hip.
200. When Mr O was admitted to hospital he had with issues around his weight and unintentional weight loss. Being in hospital compounded this, as is common in patients who are admitted to hospital. We consider this was worsened by the Trust not replicating Mr O's prescription of six Forti sips per day along with it not making a timely referral to a dietician.
201. In respect of not attending to Mr O's personal needs and ensuring he took medication, we cannot see significant failings in the personal care provided with issues raised by Ms W being resolved at the time. We consider Mr O will have been affected by not being assisted in taking medication as the medical records show this was the case.
202. We cannot determine which medications were taken and when from the medical records, meaning we cannot say what the impact of not taking medication properly was. We have found this led to pain relief medication not being taken regularly, contributing to Mr O’s pain not being managed properly.
203. Regarding the management of pressure sores, these likely impacted Mr O as they caused him pain. We have found these were not managed properly and, as we have found regular and appropriate assessment of the sores was not provided.
204. A theme running through each of the issues raised by Ms W in that the Trust did not maintain medical records in line with guidance.
205. We have decided this impacted all aspects of care provided to Mr O as the purpose of accurate record keeping and form completion is to ensure all staff involved with care have correct understanding of a patient's needs. Mr O's medical records do not show this to have been the case.
206. Ms W has told us that witnessing the poor level of care provided to her father has had a lasting impact on her and she has been diagnosed with significant emotional distress. She has counselling for this but is still traumatised by recollections of the suffering her father endured. She says this has also impacted her son and grandson.
207. We have found that witnessing her father’s pain and distress can be linked to the impact Ms W has described and, as she had been his carer prior to this, she understood his needs and how to best manage his dementia.
208. She clearly had concerns about his dementia and pre-existing conditions (like weight loss) and felt these were not being considered and staff were not listening to her.
209. This will have increased her concerns about her father’s care and her distress at witnessing him in pain and being upset because of his needs were not met. We can see this has had a lasting impact on her as she needed counselling because of this.
210. As her father’s carer, she likely felt frustrated as she did not think her concerns were acted on which would add to her upset.