Medway NHS Foundation Trust

7. Miss N complains about aspects of care and treatment her mother, Mrs N, received from Medway NHS Foundation Trust (the Trust) in 2024. Specifically, Miss N said the Trust: • did not update Mrs N’s next of kin details between 21 May and 3 June 2024 • incorrectly recorded Mrs N had Methicillin-resistant Staphylococcus aureus (MRSA) • left Mrs N in a holding bay, without observations on 31 May 2024 • left Mrs N in extreme pain between 31 May 2024 and 25 June 2024 • caused Mrs N to fracture her back, while under the care of the Trust.

8. Miss N said as a result of the lack of observations, Trust staff found Mrs N unresponsive, in the holding bay on 31 May 2025.

9. Miss N told us she felt if Mrs N had not received the incorrect MRSA test, the Trust would have transferred Mrs N to a different hospital where she believed the care would be better. MRSA is a bacterium that can cause a serious infection if it gets inside the body.

10. Miss N said she had to chase the Trust to update the next of kin details multiple times which caused further stress when dealing with her mother’s declining health.

11. Miss N told us she was left deeply upset by the death of Mrs N and seeing her mother in substantial pain. Miss N said the actions of the Trust left her experiencing stress and upset.

12. As an outcome to the complaint, Miss N seeks an explanation from the Trust for Mrs N’s rapid deterioration and a sincere apology.

13. This brief background is only intended to place the key factual events related to this complaint in context, not to provide a full account of everything that happened.

14. Mrs N was taken to hospital by ambulance 20 May 2024 due to a leg wound and raised temperature. The Trust diagnosed Mrs N with bilateral cellulitis and treated her with antibiotics. Bacterial cellulitis is a serious infection in the deeper layers of the skin, in both legs.

15. On 30 May, the Trust recorded Mrs N had contracted MRSA.

16. On 31 May, the Trust recorded the initial MRSA swab was inconclusive. It re-swabbed Mrs N and identified that MRSA was not present.

17. On the same day, the Trust planned to transfer Mrs N to a different hospital within the same Trust. Mrs N’s transfer did not go ahead. The Trust did not complete the transfer arrangements in time.

18. On 31 May, the Trust placed Mrs N in a holding bay waiting for a ward transfer. At approximately 10.00pm, Trust nurses found Mrs N unresponsive. The Trust treated Mrs N with antibiotics, fluids and oxygen. The Trust transferred Mrs N back to a ward.

19. On 7 June, the Trust carried out a lumbar spinal X-ray.

20. On 25 June, the Trust discharged Mrs N to a local hospice.

21. On 27 June, sadly, Mrs N died.

the Trust did not update Mrs N’s next of kin details between 21 May and 3 June 2024 and incorrectly recorded Mrs N contracted MRSA

25. We have decided to consider these parts of the complaint together, as our analysis for both components is similar.

26. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. We have carefully considered this element of Miss N’s complaint. We have decided the Trust has already done enough to put right the impact of these events.

27. Miss N said while her mother was in hospital, Trust staff did not update her mother’s next of kin information in a timely manner. She said Trust staff repeatedly tried to contact her using her late father’s telephone number instead of hers.

28. She said she had to ask the Trust to update this information seven or eight times.

29. Miss N told us this caused her upset and frustration as she felt the Trust delayed updating her about her mother’s condition. In addition, Miss N said during an already stressful time this caused her further worry and wasted time.

30. We can see from Mrs N’s medical records the Trust had Miss N documented as Mrs N’s next of kin on 28 May.

31. Additionally, Mrs N’s medical records show on 3 June, the Trust documented Miss N asked the Trust to remove a specific telephone number from her mother’s next of kin contact profile.

32. On 10 June, Mrs N’s medical records also document Miss N was upset as the Trust had only recently updated her mother’s next of kin information.

33. Mrs N’s medical records show the Trust regularly updated Miss N on her mother’s condition between 21 May and 24 June. The Trust updated Miss N in person and by telephone.

34. In its response dated 25 September, the Trust acknowledged the issue with the contact telephone numbers caused Miss N concern and distress. It apologised for the delay in updating the telephone information.

35. The Trust said it had highlighted next of kin information in the Trust’s weekly communication for learning and improvements amongst staff, because of Miss N’s complaint.

36. We will now look at Miss N’s concerns that the Trust incorrectly recorded Mrs N contracted MRSA on 30 May.

37. Miss N told us the Trust recorded her mother had MRSA on 30 May. She said the Trust later realised it had recorded the information incorrectly.

38. Miss N said the Trust arranged to transfer her mother to a different hospital (within the same Trust) on 31 May. She told us because of the incorrect recording of an MRSA diagnosis, her mother’s transfer could not happen.

39. Miss N said she believes her mother’s life could have been saved if the transfer had happened. She said she also believed the care her mother received could have been better at a different hospital.

40. The Trust said it did not transfer Mrs N to a different hospital as planned on 31 May. It said once it had the transfer arrangements in place, the ward at the new hospital had closed for new admissions that day. It said it planned to transfer Mrs N the following day.

41. The Trust apologised in its complaint response for the incorrect MRSA diagnosis it issued to Mrs N.

42. Looking at Mrs N’s medical records, we can see Mrs N tested positive for MRSA, on 30 May.

43. On 31 May, Mrs N’s medical records show the Trust retested her for MRSA. This test was negative.

44. On 31 May, Mrs N’s medical records show the Trust missed the cut off for her discharge to the different hospital.

45. There is no indication this transfer did not happen due to the Trust incorrectly recording an MRSA diagnosis for Mrs N on 30 May.

46. We appreciate this was a difficult time for Miss N and understandably obtaining accurate updates on her mother would have been important to her and her mother.

47. We understand Miss N felt there was a missed opportunity for her mother on 31 May, and this understandably has caused her further distress.

48. We have identified these areas of Miss N’s complaint relate to accurate record keeping.

49. GMC Good medical practice says, ‘You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous and legible’.

50. We consider the Trust did not act in line with the GMC Good medical practice in this instance. This is because Mrs N’s medical records did not reflect the correct telephone number for her next of kin up to 3 June. It also incorrectly recorded Mrs N had MRSA on 30 May.

51. For this part of Miss N’s complaint, we have referred to our Severity of Injustice. We have also referred to our Principles of Remedy.

52. Our Severity of Injustice supports our investigations when considering the impact our complainants have experienced as a result of their complaints.

53. Level one injustice sets out the emotional distress complainants have experienced. It says, ‘These will usually be injustices such as annoyance, frustration, worry or inconvenience, for a period of up to two weeks. We would generally consider an apology to be an appropriate remedy for level one injustice’.

54. Our Principles of Remedy says, ‘Where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise’.

55. It further sets out, ‘There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service. Remedies may be financial or non-financial. An appropriate range of remedies will include: an apology, explanation, and acknowledgement of responsibility.

56. We can see the Trust updated Mrs N’s next of kin contact details within 14 days. The Trust updated Mrs N’s incorrect MRSA diagnosis within one day. This is within a period of two weeks.

57. While we understand the distress this caused Miss N, we can see the Trust regularly updated her by telephone and in person.

58. The Trust has apologised to Miss N for both errors. We are satisfied the Trust has done enough to put things right. We would not expect the Trust to take any further action.

59. We are sorry to learn that Miss N experienced additional worry at an undeniably stressful time for her

the Trust left Mrs N in a holding bay, without observations on 31 May

60. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something went wrong.

61. Miss N said the Trust moved Mrs N into a holding bay on 31 May, while she waited for a transfer to a different hospital.

62. She said her mother’s health deteriorated on this day and she never regained full consciousness after this. Miss N said her mother had been recovering well up until this date.

63. Miss N told us on this day, Trust staff resuscitated her mother following a deterioration in her health. She said she believes this was due to a period of neglect and lack of nursing care.

64. The Trust said in its complaint response, its staff observed Mrs N at approximately 10.00pm on 31 May. It said there was a dramatic change in Mrs N’s condition. It further it treated Mrs N with fluids, antibiotics, medication to reduce her heart rate and oxygen.

65. To understand this element of Miss N’s complaint, we have looked at Mrs N’s medical records. Specifically, we have reviewed the Trust’s observations of Mrs N for this day.

66. To support us with this, we have considered the RCP NEWS2. This guidance shows the level of observations patients need. RCP NEWS2 considers the following observations: • respiration rate (breaths per minute) • oxygen saturation (percentage of oxygen in the blood) • systolic blood pressure (the level your blood pressure reaches when it pumps blood around the body) • pulse rate • level of consciousness/onset of confusion • temperature.

67. Each observation is given a score, depending on whether the observation is normal.

68. The total NEWS2 score determines how often observations should be carried out. A NEWS2 score of 0 would suggest a patient’s observations are within normal ranges. Patients with a NEWS2 of 0 should be monitored every 12 hours, as a minimum.

69. From Mrs N’s medical records, we can see the Trust moved her to a holding bay on 31 May at 12.14am. At this time Mrs N’s NEWS2 score was 2. This NEWS score requires a minimum 4–6 hourly observations.

70. At 3.04am, 5.19am and 7.06am the Trust completed vital sign observations on Mrs N, and it recorded Mrs N had a NEWS2 score of 2. This NEWS2 score requires a minimum 4–6 hourly observations.

71. We can see from Mrs N’s medical records that she did not receive further vital sign observations until 5.54pm. This was ten hours after her previous vital sign observations. At this time, Miss G’s NEWS score was 0.

72. Mrs N’s medical records note at 11.00am and 2.32pm the Trust changed Mrs N’s incontinence pad.

73. At 9.49pm the Trust completed vital sign observations and identified Mrs N was not responding. This was four hours after her previous vital sign observations, when she had a NEWS2 of 0.

74. At this time Mrs N had a NEWS score of 9. RCP NEWS2 says patients with NEWS2 scores of 7 or over should be reported immediately to the medical team caring for the patient. Mrs N’s medical records note Trust staff escalated her care at 10.04pm.

75. To help us understand what should have happened, we asked our adviser to explain the appropriateness of the Trust’s observations, in line with guidance.

76. Our adviser said although Mrs N’s medical records show the Trust did not complete any specific vital sign observations between 7.06am and 5.54pm on 31 May 2024, there is evidence to show Trust nurses completed healthcare tasks. They further said it is clear from Mrs N’s NEWS2 score at 5:54pm, the lack of observations did not impact Mrs N’s health.

77. Our adviser told us, looking at Mrs N’s medical records, Trust staff found her to have a NEWS2 of 9 at 9.49pm. The Trust resuscitated Mrs N using antibiotics, medication, fluids and oxygen, following her deterioration.

78. They further said, it was clear from Mrs N’s records the Trust did not complete cardiopulmonary resuscitation (CPR). CPR is an emergency lifesaving procedure performed when someone’s heart stops beating.

79. We understand Mrs N’s sudden deterioration will have come as a shock to Miss N. We do not underestimate the impact this will have had on her.

80. Based on the evidence we have seen, we are satisfied Mrs N’s NEWS2 score of 0 at 5.54pm showed no concerns with Mrs N’s presentation at the time. This NEWS2 score required the Trust to complete 12 hourly observations of Mrs N.

81. Sadly, Mrs N deteriorated approximately four hours after this set of observations.

82. We have found no indications of failings in this element of Miss N’s complaint.

83. We were sorry to hear about Mrs N’s deterioration in her health. We recognise this was a worrying time for Miss N. We understand it will have been upsetting to see her mother this way.

the Trust caused Mrs Ingleton to fracture her back and left Mrs N in extreme pain between 31 May and 25 June

84. We have decided to consider these parts of the complaint together, as our analysis for both components is similar.

85. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something went wrong.

86. Miss N said after her mother’s deterioration on 31 May she noticed her mother was in extreme pain. She said she believes the Trust did not manage her mother’s pain levels appropriately.

87. Miss N said she believes the Trust injured her mother during resuscitation on 31 May. She said her mother had metal rods in her back and could not lay flat as a result without being in pain. Miss N said if Trust staff laid her mother flat to resuscitate, this could have caused her mother an injury.

88. Miss N told us her mother was not fully conscious after 31 May 2024. She said Mrs N could not communicate her pain levels.

89. The Trust said throughout Mrs N’s admission, Trust staff monitored her pain levels by checking her vital signs, behavioural changes and body language. It said it prescribed Mrs N regular paracetamol and oxycodone (a strong opioid medication used to treat severe, ongoing pain), when necessary.

90. Mrs N’s medical records have several entries showing she was comfortable, with a pain score of 0. The ward round entries do not mention Mrs N complained of pain, except for one instance during the ward round on 10 June 2024 when Mrs N said she has pain on her back.

91. NICE Analgesia guidance says when choosing an analgesic to prescribe for mild-to-moderate pain in adults and young people aged 16 and older, use clinical judgement, depending on: • the cause and type of pain • the severity and impact of the pain (for example, the impact on function, sleep, and mood) • the likely timescale for the pain to start to improve • the age and co-morbidities of the person, and concurrent medication • factors which might influence the risk of dependence, gastrointestinal side effects, cardiovascular events, renal deterioration, overdose or other potential complications of treatment.

92. It further says, you should begin with the safest medication that is likely to alleviate pain. In many cases, paracetamol would be the preferred first choice. It says opioids (strong pain medication) are usually reserved for moderate to severe pain, for pain that has not responded to paracetamol.

93. Additionally, the guidance says clinicians should use the lowest effective dose and stop treatment if there is minimal or no effect. Or if it is no longer needed.

94. Our adviser said Mrs N’s medication charts show the Trust prescribed paracetamol daily between 31 May and 25 June. On 6 June, Mrs N’s medical records note, on examination she had tenderness in the lumbosacral region (lower back) and the left hip. There is no reference to her being in pain.

95. Our adviser said during this ward round, Mrs N’s medical records show Miss N reported that her mother was experiencing ‘severe back pain now’. At this point, Trust staff explained to Miss N her mother had not undergone CPR. Following this discussion, the Trust examined Mrs N’s back and requested a spine X-ray.

96. Following a discussion with Miss N, Trust staff changed Mrs N’s paracetamol prescription from as required, to regular administration. Between 17 and 25 June the Trust also administered oxycodone to Mrs N.

97. Our adviser told us based on Mrs N’s medical records showing a regular 0 pain level score. They said she received the correct pain relief for her presenting pain levels.

98. They further said the radiology report in Mrs N’s medical records shows there was no new injury to her back but noted the presence of scoliosis of the back (curvature to the side), which had not been seen on previous X-rays from 2009. Our adviser told us, because of this finding and the tenderness of the spine, a Trust orthopaedic consultant recommended a computerised tomography (CT) scan. A CT scan is a test that takes detailed 3D images of inside your body.

99. The Trust carried out Mrs N’s CT scan on 9 June.

100. Mrs N’s medical records show the CT scan identified she had a spinal displacement of L2 vertebrae. This means the second bone of the lumbar spine had slipped to the right by 1.5cm. The lumbar spine is the lower back.

101. Our adviser said people in Mrs N’s age group often have fragile bones and are susceptible to compression and breaks. They further said, as the Trust did not carry out CPR on Mrs N, it is unlikely the displacement of the L2 vertebrae happened due to her being laid in in the incorrect position. They told us this kind of displacement would only happen through trauma. Based on this information, they believe the change in Mrs N’s spine happened sometime between 2009 and 2024.

102. Having considered this evidence, we have seen nothing to suggest the Trust failed to provide the correct pain relief or caused Mrs N to fracture her back. There is no evidence to show Mrs N had a back fracture. We understand Miss N identified her mother was in pain and this must have been distressing for her.

103. The evidence we have seen shows the Trust acted on Miss N’s concerns, when raised, despite regularly recording Mrs N pain levels as 0.

104. Based on the evidence we have seen, we are satisfied the Trust provided the correct pain medication in line with NICE Analgesia. We are further satisfied the Trust did not cause her to fracture her back.

Conclusion

105. Looking at the evidence, we have not seen any indications of failings with Mrs N’s care. We recognise Mrs N’s hospital admission caused Miss N a great deal of stress and worry.

106. We thank Miss N for bringing this her complaint to us. We hope this review of her complaint has provided reassurance in the Trust’s care for her mother.

1. We have carefully considered Miss N’s complaint about Medway NHS Foundation Trust (the Trust). We are sorry to hear how Miss N was affected by the concerns she has raised on behalf of her mother, Mrs N.

2. There are elements of Miss N’s complaint where we have not seen any indications that things went wrong. This means from the evidence we have considered, we are satisfied the Trust provided the appropriate care and treatment to Mrs N.

3. However, we have identified indications of service failure relating to some aspects of Miss N’s complaint. We have seen the service provided to Mrs N was not in line with the standard of service we would expect.

4. We have carefully considered the impact this had. We have also considered if there was more the Trust could have done to put things right.

5. Our view is that the Trust took proportionate action to remedy the concerns Miss N raised. We will explain the reasons for our decision in this statement.

6. Complaints give us valuable insight into the organisations we investigate. We would like to thank Miss N for sharing the experience she and her mother encountered. We acknowledge the distress this complaint has caused Miss N. We do not underestimate the impact this has had.