James Paget University Hospitals NHS Foundation Trust

3. Mrs E complains about aspects of the care and treatment of her late grandmother, Mrs H, by James Paget University Hospitals NHS Foundation Trust between September and October 2023. She specifically complains:

• Mrs H did not receive adequate 1:1 care despite her family’s concerns around her dementia diagnosis and risk of falls • there were delays in carrying out further investigations including CT scans after Mrs H fell on 2 September and 13 September • the Trust did not investigate Mrs H’s symptoms of discoloured hands on 5 October.

4. Mrs E says these events contributed to Mrs H’s deterioration and death. She says the lack of 1:1 care and failure to listen to the family’s concerns led to Mrs H falling, which resulted in a bleed on the brain and her deterioration. She says the delays in CT scans after the falls and lack of investigations into Mrs H’s symptoms on 5 October meant opportunities were missed to diagnose and treat her and potentially prevent her death.

5. Mrs E says the loss of her grandmother has caused great emotional and mental distress to herself and her family, and she can’t grieve properly until she has answers.

6. As an outcome to her complaint, Mrs E is seeking an acknowledgement from the Trust, service improvements and financial remedy.

7. Mrs H was 94 and had a history of dementia and Alzheimer’s. Her behaviour became violent in the two weeks leading up to her admission to the Trust. Mrs H was admitted to the Trust’s Emergency Department (ED) on 16 August 2023 following a fall, with a referral letter from her GP. The Trust carried out a CT scan which showed the usual signs of aging but nothing concerning, and blood tests ruled out infection. It transferred Mrs H to the Emergency Assessment and Discharge Unit (EADU) and then to a ward on 24 August. Mrs H was on anticoagulant (blood thinning) medication at the time of her admission.

8. The Trust called Mrs E on 2 September to say Mrs H had fallen and sustained a head injury. The next day the Trust carried out an ECG (a test that records the electrical activity of the heart) and a CT scan. On 4 September, it told Mrs E that Mrs H had sustained a brain bleed, and that anticoagulants had been removed from her daily medication.

9. Mrs H tested positive for covid and was moved to another ward on 9 September. Mrs H fell again on 13 September and told Mrs E she had hit her head. Mrs E requested a CT scan, but this was refused, and the Trust arranged an X-ray of the hip area. On 15 September, the Trust told Mrs E that Mrs H had sustained a small fracture of the hip area, and she had been fainting. Mrs E says she continued to request CT scans and Mrs H continued to become more agitated, tired and confused.

10. The Trust carried out a CT scan on 22 September which confirmed the brain bleed had worsened. The Trust said it would be monitored, and it would see how it progressed. It transferred Mrs H to another ward on 2 October, and she was discharged to a nursing home on 5 October.

11. Prior to discharge, Mrs E noticed Mrs H’s hands and fingernails were discoloured, but the doctor was not concerned.

12. Mrs H fell in the nursing home on 9 October and sustained a head injury. She was taken to hospital for treatment and returned to the nursing home the next day. Mrs H was found unresponsive at the nursing home on 27 October. She was taken to hospital and died later that day. A post-mortem found she died of a bilateral pulmonary thromboembolism (blood clots blocking arteries in both lungs).

16. 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 for each part of the complaint.

1:1 care

17. Mrs E says the Trust did not provide adequate 1:1 care from Mrs H’s admission onto the ward on 24 August 2024 despite this being a requirement due to her dementia diagnosis and risk of falls.

18. In its complaint response, the Trust apologised that it was not always able to provide Mrs H with 1:1 care due to staff shortages but explained this was escalated to the duty matron in line with usual practice.

19. NICE falls guidance recommends during a hospital stay, it should be ensured that any multifactorial intervention:

• promptly addresses the patient's identified individual risk factors for falling in hospital and • takes into account whether the risk factors can be treated, improved, or managed during the patient's expected stay.

20. We reviewed Mrs H’s records with the help of our nursing adviser. We can see the Trust completed a falls risk assessment on admission to ED which deemed Mrs H to be at high risk of falls. It also completed a bedrails assessment which deemed bedrails were not to be used.

21. The Trust assessed Mrs H as a purple enhanced patient, meaning she required 1:1 care for 24 hours per day. We can see the Trust completed enhanced supervision charts from 17 August onwards. Our adviser explained on review of the charts, Mrs H’s care is well documented and shows overall she was well supervised and receiving 1:1 care throughout her admission.

22. They told us the mobilisation charts show Mrs H was mobilising around the bay with the assistance of a frame and one member of staff, again highlighting the supervision provided.

23. The Trust completed an incident report following Mrs H’s fall on 2 September, which shows she was accompanied by a healthcare assistant at the time.

24. It also explained two members of staff were assisting Mrs H at the time of her fall on 13 September. It says they stayed with her but used a hands-off approach as Mrs H was agitated.

25. We have seen the Trust apologised it could not provide 1:1 care at all times due to staff shortages. We acknowledge there may have been times where 1:1 care was not possible because of this.

26. From the evidence we have seen, and the advice we received, we consider 1:1 care was provided to an acceptable level, and the falls were not as a result of Mrs H being unaccompanied.

27. Overall, we consider the Trust acted in line with the above guidance in its assessment of Mrs H’s condition, the measures it put in place to address her requirements, and the 1:1 care it provided throughout her admission.

Post-falls investigations

28. Mrs E says there were delays in carrying out further investigations including CT scans after Mrs H fell on 2 September and 13 September.

29. In its complaint response the Trust said Mrs H refused to have a CT scan on the night of the fall on 2 September, however by the next morning she was accepting of having the CT scan and this was performed at 1.44pm on 3 September.

30. Regarding the fall on 13 September, the Trust said it determined a CT scan was not required unless Mrs H’s consciousness reduced. It said observations to assess consciousness levels were all in normal range.

31. The Trust said continually repeating a CT scan would not have changed the outcome for Mrs H, as the initial CT scan had already established there was a bleed. It said regular scans would result in Mrs H being exposed to excess radiation, which poses its own risks.

32. NICE head injury guidance recommends for people who have sustained a head injury and have no other indications for a CT head scan, but are on anticoagulant treatment or antiplatelet treatment, consider doing a CT head scan within eight hours of the injury.

33. Mrs H was on anticoagulant medication at the time of her admission. She first fell in hospital on 2 September at approximately 6.30pm and sustained a head injury. The Trust carried out a CT scan at 1.44pm the next day, approximately 19 hours after the fall, which showed a small bleed on the brain.

34. From the records we can see the Trust recorded Mrs H refused a scan at 11.30pm on 2 September. This means the Trust acted in line with the above guidance by attempting to arrange a scan within five hours of the fall, however as Mrs H refused, this did not go ahead.

35. Our geriatrician adviser explained as the CT scan was not an essential emergency intervention, it could wait until the next day when Mrs H then agreed to the scan.

36. Mrs H fell again on 13 September. The Trust stopped Mrs H’s anticoagulation medication following her first fall on 2 September. Our adviser explained this means she no longer met the criteria for a scan within eight hours.

37. NICE head injury guidance relevant to those not on anticoagulant medication recommends for people who have sustained a head injury, a CT head scan should be carried out within one hour if any specifical risk factors are identified, including vomiting, post-traumatic seizure or signs of a skull fracture.

38. The Trust carried out an X-ray of Mrs H’s left hip and shoulder which showed a small fracture in her hip area, but no further CT scans were carried out. Our adviser explained there was no indication for a repeat CT scan following the fall on 13 September, as Mrs H did not present with any of the specific risk factors and was no longer on anticoagulation medication. We therefore consider the Trust acted in line with guidance by not carrying out a CT scan following the fall on 13 September.

39. On 22 September Mrs E told the Trust Mrs H was showing signs of deterioration. Our adviser explained it is important that Trust’s listen to families and take their opinion seriously as they are often best placed to recognise any changes in the patient’s condition and wellbeing. The Trust arranged a CT scan the same day which showed the bleed had worsened.

40. We can see the Trust sent the CT imaging to the neurosurgery team at another Trust for further advice. It explained there was no indication for surgical intervention and conservative management was most suitable.

41. We know Mrs H was an elderly lady with significant dementia and was at risk of bleeding. Our adviser explained due to her condition, they do not consider she would have been a candidate for surgery. This is in line with the advice from the second Trust.

42. Our adviser told us as intervention was not appropriate, there would be no change to Mrs H’s treatment if CT scans had been carried out earlier or more frequently. We consider the Trust acted appropriately in its assessment and treatment of Mrs H following her falls. We hope our explanations provide some reassurance to Mrs E and her family.

Symptoms on 5 October

43. Mrs E says on 5 October, she noticed Mrs H’s hands and fingernails were dark in colour with a purple tone. She says a healthcare assistant informed her they had noticed this two days prior. Mrs E says a doctor told her this was not a concern, and not something that would prevent Mrs H from being discharged.

44. Mrs H died of a bilateral pulmonary thromboembolism on 27 October. Mrs E is concerned the symptoms displayed on 5 October could have indicated a pulmonary embolism and considers the Trust should have investigated.

45. In its response the Trust explained there is no documentation to reflect these concerns were raised or investigated.

46. NICE PE guidance says signs and symptoms of pulmonary embolism are non-specific, but symptoms typically have a sudden onset, and include shortness of breath, chest pain and coughing up blood.

47. We reviewed the records with the help of our geriatrician adviser and have not seen evidence Mrs H presented with any of these symptoms prior to her discharge.

48. From the records, we can see on 5 October Mrs H had a respiratory rate of 18 and oxygen levels of 98% in room air.

49. Our adviser explained typically, the cause of discoloured hands as a symptom of a pulmonary embolism would be because of low oxygen levels. They explained Mrs H’s levels on 5 October are within normal range and do not indicate any breathlessness on the day of discharge. They told us they do not consider there is anything to suggest Mrs H’s hands were discoloured due to low oxygen levels.

50. Our adviser also explained based on the records, they consider Mrs H presented with symptoms of a pulmonary embolism when she was readmitted on 27 October, and not prior.

51. Based on the evidence we have seen, we do not consider Mrs H displayed symptoms of a pulmonary embolism on 5 October, in line with the above guidance. We think the Trust acted appropriately by not further investigating these symptoms.

52. We understand these symptoms caused concern for Mrs E. We appreciate how difficult it must have been for her to see her grandmother’s condition deteriorate and are very sorry for her loss. Overall, we consider the care and treatment provided by the Trust was in line with guidance. We therefore will not consider the complaint further.

1. We have carefully considered Mrs E’s complaint about James Paget University Hospitals NHS Foundation Trust (the Trust). We were very sorry to hear about the events which led her to complain to us and offer our sincere condolences on the death of her grandmother, Mrs H. We know this has been a very difficult time for Mrs E and her family.

2. We have seen no indication that anything went seriously wrong with the overall care or treatment of Mrs H. We explain the reasons for our decision below.