Epsom and St Helier University Hospitals NHS Trust

7. Miss X complains about the care Epsom and St Helier University Hospitals NHS Trust (the Trust) provided to her grandmother, Mrs P between 14 February 2023 to 8 April 2023. She says:

• the Trust failed to give Mrs P insulin for 2 days after admitting her to Ward J on 15 February 2023 • the Trust failed to properly monitor Mrs P’s blood sugar level • the Trust failed to provide proper nursing care/hygiene • despite the Trust identifying Mrs P as a fall risk, it issued her beds without side rails • the Trust failed to move Mrs P’s medication with her belongings when moving her to a different ward on 24 March 2023 • the Trust failed to communicate Mrs P’s care plan with her family.

8. Miss X says the Trust’s failings led to Mrs P having a UTI on 17 February 2023 and her kidney deteriorating. She says the lack of side rails on the bed led to Mrs P falling out of her bed and she had to be readmitted to the hospital. She says the missing medication is GDPR breach as Mrs P’s information was on the labels. She says the poor communication caused the family to worry every time they left Mrs P at the hospital.

9. She says due to the poor care Mrs P received, Mrs P was terrified of nurses and people in uniforms, and it affected caring for her. This greatly affected Miss X’s mom; Mrs P’s daughter, who was her full-time carer. It was upsetting to see Mrs P experience such treatment and it caused the family great worry every time they left her at the hospital. The stress of the events witnessed led to Miss X and her mother, Mrs P’s daughter, being diagnosed with fibromyalgia which was determined to have been stress induced. Mrs P’s daughter is also currently on anti-depressants.

10. As a result of her complaint Miss X would like the Trust to take accountability and to get a proper apology from those involved. She also wants service improvements, as she does not want other people to experience similar. She also seeks a financial remedy of £5000.

11. Mrs P has a history of dementia and diabetes. Following a fall in her home on 14 February 2023 an ambulance team rushed Mrs P to the A&E department at the Trust. An X-ray revealed she had one broken and one dislocated shoulder.

12. On 15 February 2023 she was admitted to the Orthopaedics Team and the Trust carried out a procedure to fix her shoulder. The issues complained about occurred during her admission after this procedure.

13. On 21 March 2023 the Trust discharged Mrs P home.

14. On 23 March 2023 Mrs P was readmitted to the Orthopaedics Team after she fell out of bed at home.

15. At 1.30am on 25 March 2023 the Trust transferred Mrs P from Ward K to Ward L as she had Covid.

16. On 8 April 2023 the Trust discharged Mrs P home.

Insulin

20. Miss X says the Trust failed to administer Mrs P insulin for two days. She told us the Trust had put Mrs P’s insulin on hold in the event surgery would be needed. She said the surgery took place on 15 February 2023, however, after the surgery, the Trust did not administer Mrs P insulin until the afternoon of 17 February 2023.

21. She also said a pharmacist had called Mrs P’s daughter on the morning of 16 February 2023 to confirm what medicine Mrs P took. However, this information did not reach the doctor, and the insulin was not administered.

22. Medical records show Mrs P was triaged in the Emergency Department (ED) at 5:41pm on 14 February 2023. On 15 February 2023 she was admitted to the Orthopaedics Team. Her medical records show she was prescribed insulin to be administered once a day at lunchtime. She was given insulin at 12.45pm on 15 February.

23. Later on 15 February the Trust suspended all Mrs P’s medication as it planned to perform her surgery. The surgery took place at 5.10pm the same day. The next time she was due for her insulin was at lunchtime 16 February 2023.

24. On 16 February the ward Pharmacist reviewed Mrs P’s medication history and transcribed the details into the Trust’s electronic prescribing administration system (ePMA). The Pharmacist transcribed all Mrs P’s medications, and they were all administered, except her insulin.

25. In its complaint response the Trust stated its review was unable to determine the reason Mrs P was not prescribed insulin.

26. PGAM guidance states medication can only be administered in line with a prescription. Schedule 17 states records should be kept of all administered or withheld medications. These records should be completed at the time of the administration or as soon as possible thereafter. It further states where a medicine in not administered, the prescribing multidisciplinary team should be notified and appropriate action taken.

27. NICE MO guidance describes how clinicians should identify an accurate list of a person's current medicines and compare them with the current list in use, recognising any discrepancies, and documenting any changes to get a complete, accurate list of medicines. It states this process of reconciliation should be done within 24 hours of a person moving from one care setting to another, or sooner. It explains the process should be repeated at every transition in the hospital.

28. We can see the Trust prescribed and administered Mrs P’s insulin on 14 and 15 February. We can see when the ward Pharmacist reviewed Mrs P’s medications on 16 February there was an error resulting in her insulin not being added to the ePMA. This error resulted in Mrs P not being administered her insulin on 16 February.

29. We have seen, once this issue was identified, the Trust took timely action in line with MO 2025 guidance to resolve the issue resulting in Mrs P receiving her insulin on 17 February. We have seen an indication of a failing in the Trust not prescribing and administering insulin to Mrs P for 24 hours.

Impact 30. Our adviser explained that though Mrs P’s insulin prescription was delayed and caused her not to be administered on 16 February, this had no clinical impact on Mrs P as her medical records shows her blood glucose levels were in the normal range (7.9 and 13.5 post food).

31. As the indicated failing did not have an impact on Mrs P, we will not be taking any further action on this part of the complaint.

32. We hope Miss X is reassured by our adviser’s information that Mrs P was not adversely impacted by the missed insulin dose on 16 February.

Blood sugar level

33. Miss X informed us when Mrs P had hypoglycaemia and fell into a coma years ago a doctor informed the family her blood sugar rating should be between 10 and 12.

34. Miss X states on different occasions, the Trust failed to properly monitor Mrs P’s blood sugar levels which led to Mrs P experiencing multiple episodes of hypoglycaemia. The family believe the repeated hypos, along with her urinary tract infections, contributed to the deterioration of her kidney function on 24 February 2023.

35. Medical records show Mrs P’s blood glucose levels (BGL) were checked multiple times daily and the results were documented. Her target blood glucose levels were also stated in her records as 6 – 12 mmol/L.

36. At times, Mrs P’s blood glucose levels were fairly stable, while on other occasions they were elevated. Mrs P’s glucose readings from her admission date up till the date her kidney function deteriorated were:

• 15 February 2023 – 10.9 (12:42pm), 9.2 (5:19pm), 9.4 (9:28pm) • 16 February 2023 – 7.9 (5:55am), 8.7 (11:47am), 13.5 (5:58am), 13.2 (10:00pm) • 17 February 2023 – 9.2 (6:40am), 12.0 (12:16pm), 11.6(5:14pm). 6.7(9:15pm) • 18 February 2023 – 4.6 (7:04am), 8.9 (11:30am), 6.9 (5:21pm), 4.8 (9:16pm) • 19 February 2023 - 4.1 (6:17am), 8.2 (11:38am), 3.8 (5:23pm), 8.3 (6:41pm, 6.6 (10:17pm) • 20 February 2023 – 4.9 (7:00am), 6.3 (12:20pm), 2.8 (7:54pm), 4.1 (9:01pm), 3.3 (10:32pm), 3.8 (10:36pm), 8.9 (11:43pm) • 21 February 2023 – 6.7 (2:54am). 6.8 (6:17am), 8.8 (10:14am), 6.6 (5:20pm), 6.7 (11:05pm) • 22 February 2023 – 6.0 (7:46am), 7.4 (12:03pm), 6.8 (5:19pm), 6.7 (9:40pm) • 23 February 2023 – 5.4 (7:29am), 5.6 (11:34am), 6.1 (5:08pm), 5.1 (9.05pm) • 24 February 2023 – 4.1 (6:58am), 4.9 (12:17pm), 5.1 (1:01pm), 5.4 (4:56pm), 7.4 (6:37pm), 6.4 (9:33pm)

37. On 20 February 2023, Mrs P’s BGL was lower than her target BGL level. Nurses consulted doctors and a diabetes specialist nurse (DSN). The DSN recommended reducing Mrs P’s insulin from 12 units to 4. The Trust steadily reduced the dosage down to 4 units by 24 February 2023.

38. Our adviser explained kidney deterioration would be attributed to high, rather than low blood sugar levels. They also explained a treated UTI would also be unlikely to damage the kidneys.

39. The NMC Code states nurses should, ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’ and ‘make a timely referral to another practitioner when any action, care or treatment is required’. They should ‘ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’.

40. NICE Diabetes guidance explains adults with diabetes, and the staff caring for them, should receive ongoing support and advice from a trained diabetes specialist team). In addition, it states if hypoglycaemia becomes more frequent, the possible causes must be reviewed, including reassessing the patient’s insulin dose.

41. The Trust acted in line with the NMC Code by regularly observing and monitoring Mrs P’s BGL at different times daily. They ensured her BGL levels remained within the required target (6 – 12 mmol/L) and when the readings were more frequently below or above the required target level, she was referred to doctors and the DSN. Our adviser said their action to reduce Mrs P’s insulin over time was clinically appropriate and in line with NICE diabetes guidance. We have seen no failings on the part of the Trust.

Poor nursing care

42. Miss X says on 16 February 2023, the Trust transferred Mrs P to a new ward. She says her mum visited Mrs P at lunchtime on 17 February 2023 to feed her. She found her in a whole day’s worth of urine. The family believe this led to Mrs P having a urinary tract infection (UTI).

43. Medical records show Mrs P had episodes of incontinence (loss of bladder/bowel control) and the nurses managed that with bedpans and continence pads. Records show nursing staff attended to Mrs P’s care at 3:20pm on 16 February 2023 prior to her transfer to a new ward. Though the records noted she was wet with urine at 7:10pm, it also shows nurses attended to her care needs during that time.

44. The medical records show on 17 February two nurses attended to Mrs P care needs at various times.

45. The NMC Code states ‘nurses should observe, assess and optimise skin and hygiene status and determine the need for support and intervention’. It states nurses should, ‘assess needs for and provide appropriate assistance with washing, bathing, shaving and dressing’.

46. Though there were episodes of incontinence, the records show the Trust acted in line with guidance by regularly attended to Mrs P’s continence needs. This regular care shows the Trust did not leave her in ‘days’ worth of urine’, especially on the days complained about.

47. We see no indications of failings and so will not be taking any further action on this part of the complaint.

Communication

48. Miss X states on several occasions the Trust did not keep Mrs P’s family informed about her care. In particular, she says the Trust did not tell the family when Mrs P’s blood sugar levels dropped, and that despite requesting to be updated when Mrs P’s COVID‑19 test results were available, this information was not passed on to the family.

49. The medical records show on 20 February the Trust and Mrs P’s family discussed Mrs P’s insulin. At this discussion the doctor noted Mrs P’s daughter administers her insulin at home. Mrs P’s daughter also asked the ward staff to update her if they make any changes to her mum’s treatment plan, especially if she needs catheterization. On 16 February the Trust informed Mrs P’s family about her transfer to a new ward.

50. On 16 March the Trust discussed Mrs P’s physiotherapy with her family. On 21 March it discussed with her family her overall care, specifically her eyes, weight and catheter. On 21 March 2023, the Trust updated Mrs P’s family about her discharge and on 25 March 2023 it explained to Mrs P’s family she had been moved to a new ward because she had contracted COVID.

51. The NMC Code states nurses owe a duty of confidentiality to all those who are receiving care. This includes making sure they are informed about their care and that information about them is shared appropriately. The Code goes on to say to achieve this, ‘they must share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’.

52. Miss X makes specific references to the Trust not informing Mrs P’s family of changes to her blood sugar levels and COVID results. We have seen evidence from Mrs P’s medical records the Trust informed the family Mrs P was COVID positive and had been transferred to a new ward. We can also see the Trust discussed her insulin with her family on 20 February 2023.

53. While the updates may not always have been provided as quickly as her family had desired, her care plan was communicated to them. We have seen the Trust acted in line with guidance by engaging with Mrs P’s family throughout her hospital admission. For this reason, we will be taking no further action on this part of the complaint.

Incomplete equipment supplied

54. Miss X complains the Trust issued Mrs P beds without siderails and this caused her to fall out of bed on 23 March 2023 and had to be rushed to the hospital where she was readmitted.

55. Days before Mrs P’s planned discharge on 21 March 2023, the Trust arranged for her home stay equipment to be delivered. Her family realised the bed issued did not have side rails. Mrs P’s family raised concerns to the Trust stating her mom was a fall risk and was originally admitted due to a fall. She says the Trust informed her that they had assessed Mrs P and found she did not need them.

56. Mrs P’s medical records show during her admission, nursing staff completed daily falls risk assessments. On every occasion, she was identified as being at risk of falling. Records do not show a bed rails assessment was completed before the discharge equipment was prescribed and issued.

57. In its response dated 7 March 2024, the Trust states it held a multidisciplinary team meeting where Mrs P was assessed as not needing side rails. It explained this was based on nursing staff reporting she was not considered a falls risk on the ward and therefore would not require rails at home. We were unable to find evidence of this in the records.

58. In a further response dated 28 March 2025, the Trust acknowledged they could not locate the details of the meeting referred to in their earlier letter. It also explained at the time of Mrs P’s first discharge, bed‑rail risk assessments were not part of its discharge process. The Trust have since introduced this assessment and now complete it before discharge.

59. Records show the Trust performed a bed rails assessment on 3 April 2023, prior to Mrs P’s second discharge on 8 April 2023. She was assessed as a fall risk, therefore needing bedrails.

60. Although there is no specific national guidance stating when bed rails should be prescribed, HCPC guidance states requires OTs to make reasoned decisions about initiating, continuing, modifying or ending treatment or interventions, and to record their decisions and rationale appropriately. It also requires OTs to carry out appropriate assessments or monitoring procedures safely and effectively.

61. Given that Mrs P was consistently identified as a falls risk during her inpatient stay, the Trust should have considered her ongoing needs and potential fall risk at home before discharge.

62. In determining whether to prescribe bed rails, MHRA guidance states when medical devices are prescribed or issued, risks must be balanced against anticipated benefits through a documented risk assessment. It also emphasises that because beds, mattresses, bed rails and patients vary, each situation requires its own careful assessment before bed rails are first prescribed, and assessments should be reviewed and recorded following any significant change in the patient’s condition.

63. Our clinical adviser clarified that although Mrs P had been identified as a falls risk during her hospital admission, that assessment was not the same as the specific risk assessment required for the use of bed rails. The standard in-hospital falls risk assessment could not, on its own, determine whether bed rails were appropriate or necessary in a home environment. As such, the Trust should have undertaken a dedicated bed‑rail risk assessment at the point of prescribing and arranging her bed for home use.

64. We can see the Trust assessed Mrs P’s fall risk during her admission. We found the Trust did not carry out a risk assessment for Mrs P’s need for bed rails at home but made a decision not to prescribe her bed rails. We have seen an indication of a failing as the Trust did not follow guidance in considering her falls risk and performing a risk assessment to determine if she needed bed rails before reaching a decision that she did not.

Impact

65. Our clinical adviser explained that in community settings, bed rails are not routinely provided because they carry significant risks. They must be specifically prescribed following a formal risk assessment. As no assessment was completed, it is not possible to determine what the outcome would have been. Bed rails might have prevented Mrs P from falling out of bed, but they also could have posed serious risks, such as entrapment or suffocation, particularly given her dementia.

66. Had an assessment been completed, Mrs P might have been assessed as needing bed rails, not needing them, or requiring an alternative such as a crash mat.

67. As the required assessment was not carried out, it is not possible for us to determine the impact on Mrs P.

68. Since Mrs P’s complaint, the Trust have introduced bed-rail assessments as part of their discharge process. We hope Miss X feels reassured by the improvements the Trust has made.

69. We can see the Trust completed a bed-rail assessment during Mrs P’s second discharge, showing the Trust has learned from the earlier missed opportunity. We thank Miss X for raising her concern.

Missing medication

70. Miss X complains that on 24 March 2023, after the Trust moved Mrs P to a different ward, she discovered that Mrs P’s medication was missing from her belongings. She says she went to the previous ward to ask about it, but staff there were unable to locate the medication. Miss X believes this amounted to a GDPR breach because the medicines had dispensing labels containing personal information.

71. Medical records show Mrs P was transferred from the Ward K to Ward L at 1.30am on 25 March 2023.

72. During a medication round later that day, Mrs P’s family asked a nurse why her medication was not in her bag. The nurse contacted the Ward K, which stated Mrs P’s medication had been sent with her to the new ward. The nurse then contacted the night staff on Ward L, who confirmed they had not received any medication from Ward K at the time of transfer.

73. Mrs P’s prescription chart and medication administration shows Ward L requested medication for her at two points on 25 March; 12.16pm and 20.07pm. Records also show these medicines were subsequently prescribed and administered at the required times. The records show Mrs P received all her due medication for the day.

74. In its response to Miss X’ complaint, the Trust state the records show all Mrs P’s medication was handed over to the Ward L’s nurse at the time of her transfer, but it’s clear there was a breakdown in the usual ward transfer process. It apologised for this and assured Miss X any medication left behind for any reason is stored in a Pharmacy Returns Box in a locked clinical room. The Pharmacy Team picks this up and discards any medication found in it.

75. We can see there is a contradiction in both wards’ accounts. While Ward K claim to have sent the medication, Ward L claimed they did not receive it. We reviewed the records to determine whether Mrs P’s medication was handed over to Ward L, but we found no evidence confirming this.

76. We have seen evidence Ward L ordered additional medication for Mrs P, indicating it did not have Mrs P’s medication from Ward K.

77. On the balance of probabilities, we think it is more likely than not Mrs P’s medications were not transferred correctly. However, we cannot determine whether this amounted to a data breach as we cannot establish what happened to the medication after the transfer.

78. The medication was either misplaced temporarily or left behind and subsequently destroyed in line with Trust policy, but there is insufficient evidence to conclude Mrs P’s personal data was accessed by anyone unauthorised.

79. We understand Miss X felt worried and concerned as an impact. We believe this impact sits at level 1 of our Severity of Injustice Scale.

80. A case is considered to be level 1 when the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact.

81. We will usually consider an apology to be an appropriate remedy for these cases. The Trust have apologised for the breakdown in the transfer process in line with the remedy we would expect in such cases. We are also reassured by the Trust’s policy any medication left behind would likely be destroyed.

82. We consider the Trust have done enough to resolve this part of Mrs P’s complaint. We will therefore not be taking any further action on it.

1. We have carefully considered Miss X’s complaint about Epsom and St Helier University Hospitals NHS Trust’s (the Trust) actions towards her grandmother Mrs P.

2. We have seen no indications of failings regarding Miss X complaint about the Trust’s monitoring of Mrs P’s blood sugar levels, the standard of nursing care, and poor communication.

3. Regarding the complaint about the Trust not giving Mrs P insulin, we have decided that we cannot link the events to the impact Miss X has described.

4. With respect to the missing medication, we consider the Trust has already taken reasonable steps to address the effect this had on Mrs P.

5. As for the concerns about incomplete equipment, we are unable to reach a firm decision, but we have noted the Trust has since made improvements to reduce the chance of this happening again.

6. We will explain our reasons for our decision in this statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Miss X for sharing her grandmother’s experience with us. It is also important to acknowledge that finding no indications of service failure or no unremedied injustice does not detract from Mrs P and her family’s experience, or the upset and worry these events caused.