Blackpool Teaching Hospitals NHS Foundation Trust

4. Mr L complains about aspects of care and treatment his brother, Mr C, received from the Trust, and the Practice.

5. Specifically, Mr L complains the Trust did not treat Mr C’s mental health appropriately, despite concerns raised by staff, between 27 February and 29 April 2021.

6. Mr L also complains, following Mr C’s discharge from a Care Home on 27 May 2021, the Practice: • did not provide Mr C with appropriate mental health support • did not review or treat Mr C for two weeks • did not monitor Mr C’s blood pressure appropriately (from 27 May 2021 to September 2021) and did not provide appropriate appointment times (early morning only) given he was diabetic.

7. Mr L says his brother died as a result. He says his family’s confidence and pride in the NHS has been badly shaken by his brother’s treatment.

8. Mr L would like an apology and service improvements from the Trust and the Practice.

9. This background intended to place the key events related to the complaint in context, not to provide a detailed chronological account of everything that happened.

10. Mr C was over 60 years old at the time of events. He had diabetes and a history of depression.

11. In February 2021, the Trust admitted Mr C to hospital. During his admission, in March, Mr C experienced a stroke. Later in March the Trust transferred Mr C for rehabilitation.

12. During his admission the Trust deemed Mr C lacked capacity and placed him under deprivation of liberty safeguards (DOLs). DOLs is a legal process used to protect people who lack capacity to make decisions about their care or treatment.

13. On 29 April, the Trust discharged Mr C to the Care Home, as it had concerns about him living at home alone. The Trust discharged Mr C with the plan of him having follow up appointments with the stroke team, for a scan of his heart and blood vessels, and a cardiologist.

14. On 27 May, the Care Home discharged Mr C home.

15. On 14 June, Mr C had a telephone health check with the Practice. On 22 June, the Practice arranged a face-to-face diabetic review for Mr C, which he did not attend.

16. From July 2021 to March 2022, the Trust and the Practice attempted to contact Mr C about his health for follow up appointments. Mr C either cancelled or did not attend these appointments.

17. Sadly, Mr C died on 21 March 2022.

The Trust

22. Mr L complains the Trust did not treat Mr C’s mental health appropriately, despite concerns raised by staff, between 27 February and 29 April 2021.

23. Mr L says during Mr C’s time as an inpatient his poor mental health had become self-evident to the Trust’s staff. He considers the Trust should have done more to support his brother given his confusion and vulnerability throughout his admission.

24. In its complaint response, the Trust did not identify any concerns in the way it managed Mr C’s condition.

25. We reviewed the Mr C’s medical records with the help of our physician adviser. The records indicate Mr C’s main mental health condition throughout his admission was delirium.

26. NICE CG103 says delirium is a common clinical condition where a person suddenly becomes confused, struggles to think clearly, or misunderstand what is happening around them. It usually starts quickly, can come and go throughout the day, and may change in how severe it gets over time.

27. Our physician adviser explained Mr C’s delirium was likely due to his multiple underlying medical conditions including heart failure with atrial fibrillation (irregular heart rhythm), a blood clot in the heart, diabetes and electrolyte disturbances. Mr C also experienced a stroke during his admission.

28. SIGN 157 helps us understand what should happen to reduce risk of and manage patients experiencing delirium.

29. The first step in this guidance is to consider acute, life-threatening cause of delirium, including low oxygen level, low blood pressure, low glucose level and drug intoxication or withdrawal. These are issues which may be corrected with treatment or intervention.

30. The guidance also says to identify and treat potential causes (such as medications or acute illness), noting that multiple causes are common.

31. It says to optimise physical health, manage other conditions, environment (reduce noise), medications and natural sleep to promote brain recovery.

32. It also says to try and prevent complications of delirium such as immobility, falls, pressure sores, dehydration, malnourishment and isolation.

33. The guidance says medication (pharmacological treatment) should be reserved for severe agitation or distress which does not respond to non-pharmacological approaches.

34. Ultimately, the main aim is to ensure the patient is as healthy and comfortable as possible to reduce the risk of delirium or promote recovery if delirium does occur.

35. The records show the Trust followed several steps in line with SIGN 157 to manage Mr C’s delirium.

36. For example, the records show the Trust regularly assessed Mr C’s observations to help identify if there were any acute or life-threatening causes for his delirium.

37. The records evidence the Trust monitored Mr C’s food and fluid intake and bowel movements. The Trust provided Mr C with Movicol (a laxative) to help him pass stools when required. We understand from the physician advice this is an important preventative strategy as constipation can contribute to delirium.

38. On 23 March, the records indicate Mr C experienced a few episodes of confusion with agitation. Our physician adviser noted around this time the records suggest Mr C’s blood sugar was low, so it is possible this contributed to the delirium.

39. At this time, the records show staff offered Mr C tea and toast as well as other snacks to improve his blood sugar. The Trust also provided one to one security to ensure Mr C’s safety as well as of others.

40. The records also indicate the Trust assessed Mr C’s pain levels, which he regularly reported as zero (no pain). Our physician adviser explained pain can be a contributory factor to delirium.

41. The nurse intentional rounding charts demonstrate nurses regularly assessed Mr C to ensure he was comfortable.

42. The nursing notes also indicate on occasions when Mr C was confused or agitated, staff would provide reassurance and this often de-escalated his confusion quickly.

43. The above demonstrates the Trust took multiple measures, including regular monitoring, promotion of physical health and de-escalation of agitation using non-medication methods, in line with SIGN 157.

44. For the most part, the records indicate Mr C remained calm. Episodes where he experienced delirium were short lived and managed without medication. This indicates the Trust effectively managed Mr C’s episodes of delirium.

45. For this reason, we do not consider there is an indication something went wrong here and we will not consider this further. We recognise seeing a family member experience delirium can be distressing. We hope Mr L finds reassurances the Trust implemented multiple measures to support Mr C and manage his delirium.

The Practice

Mental health support

46. Mr L complains, following Mr C’s discharge from the Care Home on 27 May 2021, the Practice did not provide Mr C with appropriate mental health support.

47. Mr L says the Practice should have been aware of Mr C’s history of depression and should have taken this into account.

48. In its complaint response, the Practice said it offered Mr C appropriate appointments and reminded him of the importance of attending all his appointments with both the Practice and the Trust. It says Mr C did not present with any mental health conditions.

49. GMC ‘Good Medical Practice’ help us understand what should happen. This says when assessing, diagnosing or treating patients, doctors must adequately assess the patient’s conditions, taking into account their history, views and values. It also says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary.

50. For Mr C’s care, we understand this means doctors should have adequately assessed and treated any symptoms Mr C presented to the Practice with or follow up actions the Trust discharged Mr C with.

51. We reviewed Mr C’s records with the help of our GP adviser to help us understand if what did happen was in line with what should happen.

52. On 29 April 2021, the records show the Trust discharged Mr C to the Care Home. The discharge summary from the Trust did not include any information regarding Mr C’s mental health or set out any follow up actions the Practice needed to complete.

53. During Mr C’s stay at the Care Home, he registered with a different GP Practice.

54. The Care Home records indicate it discharged Mr C home on 27 May 2021. Mr C re-registered with the Practice before his discharge and the Practice asked him to make an appointment for a diabetic review on his return home.

55. The records indicate Mr C had contact with the Practice in June, September, October, November 2021 and in March 2022. Sadly, Mr C died on 21 March 2022.

56. On review of these records, we cannot see Mr C raised concerns about his mental health or requested support from the Practice for this. Therefore, the Practice could not provide any mental health support to Mr C as it was not aware he needed this.

57. The records indicate Mr C was able to attend appointments when we wanted, he was not housebound and was able to rearrange appointments himself. This is different to a patient who has severe mental health problems where they need help to engage with healthcare.

58. For this reason, we have not seen an indication the Practice failed to provide appropriate mental health support to Mr C following his discharge to the Care Home. Therefore, we will not consider this further.

Lack of review or treatment for two weeks

59. We recognise Mr L is concerned the Practice did not review or treat Mr C for two weeks following his return home on 27 May.

60. From the GP advice, we understand there are no specific guidelines which state how soon a GP should review patient following discharge home. Therefore, GMC guidelines referred to above remain relevant.

61. The Practice and Mr C’s telephone appointment, on 14 June, was just over two weeks after Mr C returned home.

62. Based on the evidence we have seen, we do not consider there was need for the Practice to review Mr C sooner than 14 June. This is because the Trust’s discharge summary did not request the Practice to complete any follow up actions, and he had follow up appointments in place with the Trust to manage his conditions.

63. Additionally, the records indicate Mr C was able to engage with healthcare providers, was not housebound and he did not raise any concerns to the Practice about his health on his return home.

64. Based on the above, we consider the Practice attempted to review Mr C on his return home, in line with GMC guidance which says doctors must adequately assess patients and provide appropriate advice promptly. For this reason, we have not seen an indication something went wrong here and will not consider it further.

Blood pressure monitoring

65. Mr L complains the Practice did not monitor Mr C’s blood pressure appropriately, from 27 May to September 2021.

66. Mr L also complains the Practice did not offer appropriate appointment times given Mr C was diabetic. Mr L said early appointment times for blood tests were a problem for Mr C as they required him to fast from the evening before, but he was afraid of experiencing hypoglycaemia (low blood sugar).

67. From the GP clinical advice we understand there are no specific guidelines which set out specific intervals of monitoring for a patient’s blood pressure when discharged home.

68. The records indicate the Trust discharged Mr C to the Care Home on 29 April. The discharge summary did not set out any follow up actions for the Practice.

69. On 5 May 2021, the records show the Practice phoned Mr C to ask him to contact reception to make a diabetic review appointment on his return home from the Care Home. The records show the Care Home discharged Mr C home on 27 May.

70. On 14 June, the records show the Practice had a telephone appointment with Mr C.

71. The notes indicate the Practice made a face-to-face appointment for Mr C for a diabetic review including blood tests, foot check, urine test and blood pressure. The Practice booked this appointment for 22 June, but Mr C did not attend.

72. The Practice could not monitor Mr C’s blood pressure if he did not attend for the appointments.

73. We discussed Mr L’s concerns about the early morning appointment times requiring Mr C to fast overnight with our GP adviser.

74. There is no guidance which states diabetic patients should be offered specific appointment times for blood tests.

75. Our GP adviser explained fasting blood tests are not always required for diabetic reviews.

76. The records on 23 February 2021 show Mr C raised concern to the Practice about fasting blood tests and requested a district nurse to visit his home.

77. The Practice explained the district nurses would not visit as he was not housebound. The Practice also explained it could do non-fasting blood tests, but Mr C was still not happy with this and declined an appointment. The Practice explained if he changed his mind to contact reception for an appointment.

78. The above demonstrates the Practice could do either fasting or non-fasting blood tests if Mr C preferred and he was aware of this. This is in line with GMC guidance referred to above which says doctors must take into account a patient’s views and values.

79. Therefore, we do not consider the early appointment times the Practice offered indicates a failing, as Mr C was aware the Practice could adapt the blood test to suit his needs.

80. We understand Mr L strongly feels the Practice should have done more to support Mr C following his discharge home. We hope Mr L finds reassurance in our consideration of his concerns. We thank him for bringing his complaint to us.

1. We have carefully considered Mr L’s complaint about the care and treatment his brother, Mr C, received from Blackpool Teaching Hospitals NHS Foundation Trust (the Trust) and a Practice in the Blackpool area (the Practice). We recognise this has been a difficult time for Mr L, given the sad loss of Mr C.

2. After careful consideration of the evidence, we have not seen any indication of failings in the complaints about either the Trust or the Practice.

3. As we have seen no indication of failings, we have decided not to investigate further. We recognise how important this complaint is to Mr L, and we hope he finds reassurance in how we have considered his concerns.