Harrogate and District NHS Foundation Trust

3. Miss A complains about the care and treatment the Trust provided to her mother, Mrs A, from May to June 2024.

4. She specifically complains the Trust: • should not have swapped her mother's rollator for a zimmer frame without a seat • should have involved the family about the decision to operate on her mother.

5. Miss A says having a zimmer frame led to her mother having a fall and breaking her hip. This ultimately led to her having surgery and her premature death. She says the family missed an opportunity to spend more time with her mother when she was conscious.

6. Miss A wants the Trust to acknowledge the failings and make improvements to ensure this does not happen again.

7. Mrs A was admitted to hospital on 29 May 2024 with a suspected stroke due to right sided weakness.

8. She had a history of COPD, asthma and a heart condition, plus a recent stroke which had affected her mobility.

9. The physiotherapist gave Mrs A a Zimmer frame on 30 May.

10. Mrs A fell in hospital in the early hours of 31 May and broke her hip.

11. She had hip replacement surgery the same day.

12. Mrs A sadly died on 4 June 2024.

Rollator 16. Mrs A says her mother had been using a rollator for more than 15 years and it should not have been replaced. She says if staff had not given her a zimmer frame, she would not have fallen.

17. When Mrs A complained, the Trust explained the Zimmer frame was more appropriate based on the assessments carried out and it was a more rigid frame given her needs at that time.

18. The Trust added that a rollator has brakes which can be difficult to use and has a tendency to ‘run away’ with patients on polished shiny floors in comparison to carpeted floors which she would have had at home.

19. The records show the OT saw Mrs A on 29 May 2024 and wanted to witness her using the rollator. It appears she was able to mobilise from her bed to the toilet but needed assistance to do so.

20. On 30 May 2024, staff assessed Mrs A again with the rollator and supported her to use it. The OT documented that she needed a lot of assistance and when she took a few steps, she became unsteady and was leaning backwards.

21. The OT visited Mrs A again later the same day and asked her to trial the Zimmer frame. The OT recorded that she needed assistance to get out of bed but once up, she needed less assistance. She was able to mobilise to the end of the bay and return to bed.

22. The OT took away the rollator and gave her the zimmer frame to use instead. This was documented at around 4pm.

23. The OT’s assessment included an evaluation of Mrs A’s mobility needs and the notes indicate they spoke with her daughter to understand the goals Mrs A wished to achieve during her rehabilitation in hospital.

24. NICE guidance for falls says NHS services must:

• individually assess mobility aids for suitability • consider strength, balance, endurance, and fatigue • select equipment that minimises fall risk.

25. The OT documented clear clinical reasoning for recommending a zimmer frame, noting that Mrs A appeared unsteady when using the rollator and that the zimmer frame offered greater stability on the ward flooring. In this context, the zimmer frame was considered the safer option.

26. We think this was in line with the Health and Social Care Act 2008 regulation 12 which requires NHS providers to ensure:

• Equipment is safe, suitable, and used correctly • Decisions are based on a comprehensive assessment • Steps are taken to prevent avoidable harm • Clinical reasoning is clearly recorded.

27. We understand it was very upsetting for Miss A to learn her mother had a fall in hospital after her rollator was changed and her concern that the use of the Zimmer might have been a factor.

28. After considering all the evidence, including the clinical advice we obtained, we think the Trust acted in line with NICE guidance by assessing Mrs A’s mobility and stability using the rollator. It changed her rollator to a zimmer frame which it considered the safer option, in line with the Health and Social Care Act. We have seen nothing to indicate the Trust ‘should not have swapped’ the rollator for a Zimmer.

29. Mrs A had a fall after being given the Zimmer frame but we cannot say this was because of the Trust’s decision to change her equipment.

Family 30. Miss A says the decision for hip surgery should have been made with the family. She says if the family had been involved in the discussions about surgery, they would have been able to spend more time with her mother before she went for surgery while she was conscious.

31. We understand Miss A’s concern about this and sympathise with her that she did not get to spend more time with her mother before her surgery. When she complained, the Trust said staff explained to Mrs A that it was high risk surgery and that it would be very painful to move if she did not have it. The main purpose of the operation was pain relief and to be able to get some movement back. The Trust said if the operation had not gone ahead, it was highly likely Mrs A would have died in pain.

32. The records show Mrs A agreed to surgery and signed a consent form after she had a detailed discussion with the clinician on 31 May 2024. There is also evidence in the notes indicating that Mrs A was in pain.

33. The records show one of the medical team rang Miss A to advise her Mrs A would be having surgery within 24 hours or so. There is a detailed record of the conversation in the morning where the clinician also offered to speak to Miss A on the ward round later that day.

34. There is also a note recorded around 2pm the same day that says when Mrs A was transferred to surgery she was accompanied by her daughter.

35. Mrs A had capacity to make her own decisions so there was no strict requirement for the Trust to discuss her care with anyone else. Our geriatrician adviser said there is no guidance to say family must be part of the decision making. They said it was good practice, however, to ensure the family were updated and aware of the plan and we have seen evidence to show that happened in this case.

36. Our Principles of Good Administration state organisations must act in accordance with recognised quality standards, established good practice or both when delivering clinical care. In this situation, we have relied on the professional judgement of our geriatrician adviser, based on their experience and knowledge of established good practice.

37. We considered whether the Trust, knowing the risks of surgery, should have factored in an opportunity for Miss A and family to spend more time with Mrs A beforehand.

38. Our geriatrician adviser said doing emergency surgery promptly is important for the best outcome and as a pain control measure.

39. This is supported by NICE guidance for hip fracture management which says:

‘1.2.1 Perform surgery on the day of, or the day after, admission.’

40. Our geriatrician adviser added that the mortality rate increases the longer someone waits for surgery and as Mrs A was at high risk of mortality, it was important to do it as soon as possible.

41. We agreed with our geriatrician adviser’s view that clinicians would need robust reasons to delay surgery in this instance and there were none present at the time of the decision making.

42. We recognise Miss A wishes to have spent more time with her mother before she went into surgery and we understand she feels she missed this opportunity.

43. We have seen no indications the Trust did anything wrong here. We consider the Trust kept Miss A informed of her mother’s planned surgery but did not need to involve her in the decision making. We think the Trust acted in line with NICE guidance by providing emergency surgery promptly and did not have sufficient reasons to delay the surgery.

1. We have carefully considered Miss A’s complaint about Harrogate and District NHS Foundation Trust (the Trust). We are very sorry to learn about the sad death of Mrs A, and we recognise the family are devastated by their loss and wish they could have spent more time with her before her surgery.

2. We have seen no indication that the Trust did anything wrong when it changed Mrs A’s rollator to a zimmer frame or when it made decisions around her surgery.