United Lincolnshire Teaching Hospitals NHS Trust

4. Miss B complains about the following aspects of the care and treatment United Lincolnshire Hospitals NHS Trust gave her father, Mr J.

• It discharged Mr J on 30 January 2023 after he had a stroke and before he was well enough.

• It left Mr J in discomfort on a trolley in its emergency department (ED) for 24 hours on 13 February. It has not clearly explained what it did for him during this time.

• It did not care for him on a specialist stroke ward or provide the close observation and specialist stroke treatment he needed between 14 and 17 February.

• It did not do an MRI scan quickly enough after 3 March or tell the family what it was doing about this.

• Aspects of its nursing care did not support Mr J’s recuperation, specifically it left drinks where he could not reach them, did not always give him access to food and often did not clean his dentures despite the family asking about this.

• The Trust discharged him to a care home on 11 May without telling the community stroke team or giving it and his family adequate information about his needs. Miss B thinks he should have gone to a rehabilitation unit.

5. Mr J had further strokes and Miss B says this might not have happened if the Trust had given him better care between January and March 2023. She says the Trust’s actions caused Mr J to deteriorate more rapidly than he should have done and possibly lessened the extent of his recovery, which the family now has to live with. The family felt they had to see him suffer more than he should because of the quality of treatment and nursing care he received. This made them lose faith in the NHS. The family say they dreaded going to see Mr J in hospital because of this.

6. She would like the Trust to provide a meaningful written apology and evidence of service improvements so that other families will not have the same experience.

7. On 20 January 2023 Mr J was admitted to hospital following a stroke. The Trust discharged him on 25 January. He was 70 years old.

8. On the night of 11 February Mr J’s family called out paramedics because he was exhibiting symptoms which they thought looked like another stroke. The paramedics did not take him to hospital but the family called them out again on 12 February. The Trust readmitted Mr J into its ED.

9. Mr J stayed in the medical emergency assessment unit (MEAU) until 17 February when he was moved to the stroke department. He had a further seizure on 3 March. The Trust called Mrs J on 5 March to discuss whether he should have a DNACPR (do not attempt cardiopulmonary resuscitation) order.

10. The Trust attempted an MRI scan on 15 March but had to postpone this until 21 March due to Mr J’s agitation and confusion. The scans revealed Mr J had had two strokes whilst an inpatient at the Trust.

11. On 23 April the Trust moved Mr J to a different ward.

12. The Trust discharged Mr J on 11 May. His family complained about aspects of his care and treatment, including nursing care and his discharges in February and May. They were not satisfied with the outcome of local resolution meetings they had with the Trust in 2023 and complained to us in January 2024.

The Trust wrongly discharged Mr J on 30 January

16. Miss B says the Trust should not have discharged her father so quickly after his stroke in January 2023, as he went on to have another stroke and needed to be readmitted to hospital shortly afterwards.

17. The Trust says it had investigated him through a variety of relevant methods and procedures, such as doing a CT scan (a medical imaging technique). It says he was sufficiently well enough to be discharged on 30 January and it provided a plan to follow up on his recovery within six to eight weeks later.

18. The relevant standards are NICE NG128 and the ‘National clinical guideline for stroke for the United Kingdom and Ireland’.

19. NG128 says clinicians should use appropriate imaging techniques as soon as possible when a person is admitted with a possible stroke. This is also confirmed by the national clinical guideline. If possible, they should consider thrombolysis and thrombectomy early after admission, if the patient meets the necessary criteria. Thrombolysis and thrombectomy are medication to dissolve and surgery to remove a blood clot from an artery or vein respectively.

20. NICE CG162 says organisations should make sure they have good discharge plans and offer this to people as early as possible where this is appropriate.

21. We asked our physician adviser about this. They said they although the Trust could have documented its care of Mr J a little more clearly, its actions were in line with the relevant standards.

22. We can see from the records Mr J arrived at the Trust six hours after his first event. This means it could not offer him thrombolysis because the window for this is four and a half hours after a stroke. It gave him a CT scan shortly after his arrival, which was in line with NG128 and the national clinical guideline.

23. Our physician adviser said the CT scan showed Mr J had likely had an ischaemic stroke. This is a sudden blockage that kills brain cells. They said the Trust managed this with antiplatelet drugs (which prevent clots) and organised further tests. This is also in line with NG128 which says to use anti-blood clotting drugs in such circumstances. The tests do not seem to have indicated a thrombectomy (surgery) was necessary. The records could be clearer as to how far the Trust considered this option, but there is no indication this would have made any significant difference to what it did.

24. Our physician adviser said the Trust made sure Mr J was seen by a stroke specialist when he arrived at the hospital. It later screened him for diabetes and organised a diabetes liaison nurse review. It discussed with him important lifestyle factors and driving. This shows it had a plan for his recovery and for what he would do on discharge.

25. It did an MRI scan as the standards suggest and arranged monitors and tests for him when clinical evidence showed Mr J had dead tissue in different parts of his vascular system. Our adviser said there are no set guidelines on where or how this should be done. But we can see the Trust had a plan for his ongoing care in line with NICE CG162.

26. We understand why Mr J’s family was concerned about the care he received in January 2023, when he had to be readmitted to hospital again soon afterwards. This was a very worrying and upsetting time for them. When we weigh up the evidence, we think the Trust acted in line with the relevant standards here. We have not found a failing in the Trust’s decision to discharge him on 30 January.

The Trust left Mr J in discomfort on a trolley on 13 February and did not explain its actions on that day

27. Miss B says the Trust left her father on a trolley rather than in a hospital bed throughout the day. She says this caused him discomfort and the Trust did not update his family about what was happening.

28. The Trust says there is no evidence Mr J spent the entire day on a trolley. It says it transferred him to a bed shortly after his arrival and took him for a number of tests and assessments during the day. But it says it also cannot see in its documentation anything which suggests it kept his family updated about this at the time. It apologised for this.

29. Our ED adviser said there is no information in the medical records to clarify whether Mr J was left on a trolley or in a bed. But they also said there are no national guidelines as to whether someone should be put in a bed or on a trolley when in an ED. We can see from the records the Trust took Mr J for various tests and assessments that day. This indicates he was not simply left on a trolley. There is not enough evidence for us to say the Trust got something wrong here.

30. But the GMC’s ‘Good medical practice’ stresses the need for notes to be clear, accurate, legible and to detail actions agreed and taken. Mr J’s notes do not do this as we would expect. It is not clear if, how and when it explained to his family what it was doing and why.

31. We have found the Trust got something wrong here. We can see this upset his family and the time and has caused them concern about how well he was being treated since then.

The Trust did not care for Mr J on a specialist stroke ward or give him specialist stroke treatment between 14 and 17 February

32. Miss B says the Trust cared for her father in its ED during this period. She says the Trust did not give him the close and specialist observations he needed.

33. The Trust says its stroke team assessed Mr J throughout this period. This included its stroke consultant assessing Mr J on 13, 14, 15 and 16 February. It also says its speech and language therapy (SALT) team assessed him on 14 February and it checked his NEWS (a measure of how serious a patient’s condition is) several times on each day between 14 and 17 February. It says these scores show he did not go above the score necessary for more urgent treatment.

34. It also says a bed in the stroke unit was not available until before 16 February. Because of this it says it made sure its acute medical and nursing team followed a specific care plan which it had made for Mr J.

35. We asked our ED adviser about this. The ED team triaged Mr J eight minutes after his arrival there. Our adviser said this is within the national guidance timeframe as given in the Royal College of Medicine’s guidance ‘Initial assessment of emergency department patients’.

36. The records show Mr J was assessed by a stroke advanced care practitioner 15 minutes after he arrived at the ED. A stroke consultant then reviewed him and transferred him to the medical emergency assessment unit (MEAU). Our adviser said no ED clinician assessed him, only experts in stroke care. He was not cared for at this time by the ED team.

37. We also asked our physician adviser about this. They said ideally the Trust should have admitted Mr J to an acute stroke unit within four hours of his admission to hospital. But this was not possible on this occasion due to capacity issues. Our adviser said the Trust did then give him the best alternative possible, which was care from the stroke team in the MEAU.

38. The relevant standards are those we described above in paragraphs 19 to 21.

39. Our adviser said Mr J was again outside of the time window for thrombolysis. They said it is not entirely clear from the records exactly when the Trust gave him a CT angiogram, but it did do so. This combines a CT scan with a test to check the blood vessels and tissues. Our adviser says clinicians should do this as quickly as possible. They say it did give him this as it should have done.

40. The records we have seen so far do not say the Trust considered if it needed to do a thrombectomy. It was not sure if this was a new stroke or not. Its initial CT scan indicated this was not a new stroke. But a magnetic resonance imaging (MRI) on 16 February indicated this was a new event (an extension of the previous stroke). This test detects lesions in the brain.

41. The records show the Trust put a plan in place for his care. This is in line with the relevant guidance.

42. We understand the family’s concern that the Trust was not treating Mr J in its stroke unit at the time. This was a worrying time for them, which that concern made worse. When we weigh up the records, we can see the Trust was not able to immediately transfer Mr J to the stroke unit but did so as soon as it could. The records show he was treated by stroke specialists throughout who acted in line with the relevant guidance.

43. There are some things the Trust could have done better. It is not clear how quickly it did the CT angiogram and the records do not indicate whether it considered a thrombectomy. It does not appear to have realised this was a new stroke until it had been caring for Mr J for several days. But we have not seen any indication these things had a negative impact on Mr J’s care or recovery at this stage in his admission.

44. When we weigh up the evidence and take an overall view on how the Trust cared for Mr J during this time, we think it did what it should have. We can see the Trust assessed him regularly and reviewed his needs based on those tests. We do not think his care fell so far below the relevant standard that any shortfall amounts to a failing.

The Trust did not do an MRI scan quickly enough after 3 March or tell the family what it was doing about this

45. Miss B says the Trust did not do an MRI scan on her father quickly enough from 3 March. It rescheduled MRIs on a number of occasions. She says it did not properly let the family know what was happening. Miss B says the Trust’s failure to organise an MRI in a timely fashion was a factor in Mr J suffering further strokes whilst he was in hospital.

46. The ‘National clinical guideline for stroke for the United Kingdom and Ireland’ says MRI imaging should be considered in patients with suspected acute stroke when there is diagnostic uncertainty. It says it should be the principal brain imaging used for detecting what is wrong with a person who has had a stroke. It also says non-invasive methods such as a CT scan or MRI should be used before considering invasive methods of scanning and testing a patient (such as CT angiography).

47. The records show the Trust had given Mr J an MRI scan on 25 January, the previous time he had been admitted. He also had an MRI on 16 February. The Trust did not give him a further MRI scan on his new admission until 21 March. This was partly because he had been due to have one on 15 March, but was not able to tolerate this due to his agitation.

48. We asked our physician adviser about this. They said the records suggest Mr J deteriorated on 2 March. The Trust did a CT scan of his brain on 8 March, but this did not indicate any real change. He also had a CT angiogram, which suggested he needed medical management only for the thickening of blood vessels in his brain. The Trust gave him an echocardiogram on 10 March which again did not suggest any significant issues which would change its care plans.

49. On 20 March the records show the Trust did not find anything on its cardiac monitor. So it planned to implant a loop recorder to get better results. On 21 March it did another MRI scan. Our physician adviser said all of these were appropriate steps for the Trust to have taken in managing Mr J’s care and treatment. But our physician adviser agreed the Trust should have done another MRI scan sooner.

50. MRI is the principal investigation for managing a person who has had a stroke. But it was 13 days after Mr J’s deterioration on 2 March that the Trust first attempted the scan and 19 days before it did it. We recognise the Trust monitored Mr J in other ways, but it should have done an MRI sooner. In correspondence with us the Trust has acknowledged this.

51. It should also have talked to him and his family about this. Our ‘Principles of Good Administration’ (‘Being customer focused’) say organisations should be flexible in their communication with service users. They should communicate with people in a way which is appropriate to their needs and circumstances. The records show us the Trust discussed its management plan for Mr J with his family on 3 March. And it tried to speak to his wife on 5 March about the DNACPR order. But we cannot see that the Trust explained its thinking about an MRI scan with his family. Again, in correspondence with us, the Trust has acknowledged it should have spoken with the family about this.

52. We looked at what difference an earlier scan might have made. Our physician adviser told us there is no indication not doing an MRI scan more quickly caused Mr J harm. They said the Trust did not need to change its plans based on the result of the 21 March MRI scan. So we do not think an earlier scan would have made any difference clinically.

53. But Mr J’s family knew he had had MRIs before and were not sure why the Trust did not arrange another one sooner. This caused them concern about his treatment and what was happening to him. With the benefit of hindsight, the earlier scan would not have changed the treatment plan. But his family were clearly very worried and unsure about what the Trust was doing. The Trust could have alleviated some of this if it had done the scan sooner or at least spoken to the family about the plans for the scan.

The Trust’s nursing care did not support Mr J’s recuperation

54. Miss B says the quality of the Trust’s nursing care was poor. She says this meant her father did not recover as quickly and as well as he should have done. She also says it was difficult to find anyone to discuss her father’s condition with her. She says this caused the family’s faith in the Trust to decrease and they were concerned about seeing him.

55. She says the Trust often did not clean Mr J’s dentures regularly. She also says these did not fit as well as they should because he lost weight in hospital, but the Trust did not seem to recognise this or do anything about it. So he struggled to eat and drink. She also says the Trust’s nurses did not help provide her with relevant information or contacts to discuss her father’s condition and progress as they should, despite regular requests from his family.

56. The Trust has acknowledged some aspects of its nursing care could have been better and that it would be happy to apologise for this.

57. The relevant standards are NICE guidance 128 (see above), NICE clinical guideline 32 (CG32), the NMC’s ‘Future nurse: standards of proficiency for registered nurses’ and ‘The Code’.

Mr J’s oral care, eating and drinking

58. ‘Future nurse: standards of proficiency for registered nurses’ says nurses should demonstrate knowledge, skills and ability to deal with a number of areas of nursing care including oral care. NG128 says medical professionals should be aware of risks associated with malnutrition and oral care as the risk of malnutrition, and that dysphagia, poor oral health and reduced ability to self-feed will affect nutrition in people with stroke.

59. We can see from the records Mr J needed support when using his toothbrush throughout his stay at the Trust, although this did ease a little as his recovery progressed.

60. We asked our nursing adviser about this. They said Mr J’s dentures were not always cleaned and on one occasion they were found in his bedside drawer. They said the Trust did have an oral documentation chart for him, but there was only one entry on this and very little reference to Mr J’s oral hygiene in his charts.

61. CG32 says appropriate support should be given to help people who have difficulties with chewing and they should be given adequate quantities of food and drink. ‘Future nurse: standards of proficiency for registered nurses’ says nurses must observe and optimise someone’s nutrition and hydration and assess their capacity to support themselves.

62. We can see from the records the Trust referred Mr J to the SALT team (which supports people who have had a stroke and may be struggling to communicate or swallow) and dieticians. We can see it weighed him on numerous occasions between March and May 2023. Our nursing adviser said his weight loss was mainly due to the effects of his strokes. The Trust did maintain food charts and assisted with his mealtimes. It administered intravenous (IV) fluids when he was not drinking enough. These actions appear to have been in line with the relevant standards, as the Trust checked his nutritional needs and assisted with his eating and drinking.

63. But the records do indicate the Trust sometimes left his drinks on Mr J’s lefthand side where he could not reach them. Our nursing adviser said his fluid balance charts were poorly completed.

64. When we weigh up the evidence, we have found failings in some, but not all aspects of Mr J’s nursing care. It should have made sure Mr J’s dentures were kept clean throughout his admission. His weight loss was unfortunately due to his strokes, and there is evidence ward staff did help him to eat when he was struggling. But staff did not make sure he had drinks accessible at all times.

65. We can understand why Miss B feels the Trust did not give her father the best chance of recovering from him strokes. He was very unwell and there are so many factors that contributed to the pace of his recovery. It is not possible to say if or how much the poor aspects of care we have found contributed to this. But we can see it caused Mr J and his family more distress and to lose faith in the care he was receiving from the Trust.

Communication with the family

66. Miss B says the Trust’s nurses did not help provide her with relevant information or contacts to discuss her father’s condition and progress as they should, despite regular requests from his family.

67. NMC’s ‘The Code’ says nurses should share with people and their families the information they need or want about their health, care and ongoing treatment in a way they understand. Its ‘Future Nurse’ guidance says nurses should respond to questions in the same way.

68. We asked our nursing adviser about this. They said there are events which can happen during a patient’s stay in hospital when family should be informed, specifically when the patient is unable to update family independently. Our adviser said this applied in Mr J’s case when he changed wards in April 2023.

69. We can see from the records Mr J’s family arrived to visit him but the Trust had not told them his new ward was closed to visitors due to Covid-19. We can see this was upsetting and frustrating for them.

70. The records show the Trust did hold meetings with his family in April and May. But our nurse adviser said over a three month admission such as this they would have expected more communication from the nurses to the family, especially when wards were closed to visitors and Mr J had got Covid-19 himself.

71. The combination of Miss B’s account and our nursing advice suggests the Trust did not make sure its communication with his family was in line with the NMC Code. In correspondence with us, the Trust has also told us it acknowledges there were problems with some of the communication from nursing staff. So when we weigh up the evidence, we have found failings in the Trust’s communication.

72. This meant Mr J and his family were at times left unsure about what was going on. They were understandably very worried about his overall care and recovery, and this made an already difficult time worse.

Discharge on 11 May

73. Miss B says the Trust discharged her father inappropriately. She says it says it gave neither the community stroke team nor his family sufficient information about his needs. She says the Trust should have discharged him to a rehabilitation unit. She thinks the Trust’s actions stopped her father from recovering as well as he should have done.

74. The relevant standard is the ‘National clinical guideline for stroke for the United Kingdom and Ireland’. This says families of people who have had strokes should be involved in hospital discharge planning, as should members of the community stroke rehabilitation services.

75. We asked our adviser about this. We can see the Trust documented many therapy assessments for Mr J. Our adviser said he appeared to have very little tolerance for rehabilitation sessions and did not appear to be benefitting greatly from them. Our adviser said they did not think the Trust giving him more therapy sessions would have changed his outcome. They said Mr J had a serious brain injury which stopped him recovering more quickly. So we do not think there is strong evidence that the Trust should have arranged to discharge Mr J to a rehabilitation centre.

76. But we have seen no evidence the Trust explained to Mr J or his family why discharging him to a rehabilitation unit was not beneficial. It is not clear what information the Trust passed on to the community stroke team. This is not in line with the national guidelines. We have found a failing here.

77. Our physician adviser said Mr J had a series of severe strokes which left him very unwell. We can see the Trust did investigate and manage this as we would expect. His brain was too severely affected to be able to make a prompt recovery. The Trust could not have changed the outcome in terms of his strokes. But again this poor communication added to the family’s concerns, worries and frustration at a very difficult time.

What the Trust has already done to put things right

78. We can see the Trust investigated Miss B’s complaints, held two resolution meetings with the family and sent her a written response. It discussed what happened with the family in some detail. It explained some of its decisions and apologised for things it said it had got wrong, and for the impact on the family.

79. When we proposed to do this detailed investigation, we recognised what the Trust had already done. We did not include the issues those actions related to in the scope of the detailed investigation. We agreed to look at further issues where the Trust had not accepted errors in its actions. So the Trust has not yet acknowledged what we have found here that it got wrong or the impact those things had on Mr J and his family. We have made recommendations for further actions to put things right.

1. We have found the Trust got something wrong in how it communicated with the family about Mr J’s care while he was waiting to be admitted on 13 February 2023. We think it should have done an MRI sooner and communicated better with the family about this in March. We think the Trust did not provide aspects of his nursing between March and May as it should have. And we think it should have communicated better with the family and community services when it discharged him in May 2023.

2. We have found the ICB did not get anything wrong when it treated and discharged Mr J in January 2023. We can also see it provided care by a stroke specialist in February 2023 while he was waiting to be moved to a stroke unit.

3. We partly uphold this complaint. We recommend the Trust apologises to Miss B for the impact of what we have identified it got wrong and provide evidence of service improvements to stop those things happening again.