Calderdale and Huddersfield NHS Foundation Trust

5. Ms O complains about the following aspects of care the Trust provided to Mrs M between 23 July and 2 September 2024:

• between 23 July and 14 August, ward 6 staff did not always administer Mrs M’s medication as they should have • staff on ward 6 allowed Mrs M to develop a pressure sore and then did not adequately treat this, including not discharging Mrs M with any cream or dressings • staff on ward 6 prematurely discharged her mother on 14 August when she could not walk unaided and had severe delirium • staff started Mrs M on new heart failure medication prior to discharge and failed to keep her in hospital to monitor this • staff did not perform an echocardiogram (ECG) prior to discharge • staff failed to pick up on signs of Mrs M’s deterioration, malnourishment, and dehydration over the bank holiday weekend • on 25 August she requested a consultant and the Speech and Language Therapy Team (SALT) to review her mother, but they did not attend until 27 August • the Trust did not carry out a property disclaimer following admission resulting in one of her mother’s rings going missing.

6. Ms O says her mother died from the lack of care and treatment. She feels if staff had not prematurely discharged her and provided the correct care over the bank holiday weekend, she would not have aspirated and declined. She also says her mother’s pressure sores developed from grade 2 to 3 causing her pain and discomfort.

7. Ms O says she finds this mentally destroying and she still has nightmares and flashbacks to Mrs M’s poor care. She says she has suffered stress and anxiety. Ms O says seeing Mrs M in fear towards the end of her life was heartbreaking.

8. As an outcome to the complaint, Ms O would like an acknowledgement of failings, an apology, service improvements and a financial remedy. She would also like the Trust to reimburse her for Mrs M’s missing jewellery.

9. On 21 July, Mrs M presented to A&E with shortness of breath, a cough, swelling to her legs, and worsening confusion. The A&E team’s initial impression was she may have pneumonia (an infection of the lungs) and an acute kidney injury (AKI). An AKI is where the kidneys suddenly lose their ability to filter waste from the blood.

10. On 22 July, the Trust transferred Mrs M to ward 2 (an acute medical unit). On 23 July, it transferred her to ward 6.

11. The Trust discharged Mrs M home on 14 August, with a package of care including carers to attend three times a day.

12. On 17 August, Mrs M represented to A&E with increased shortness of breath, swelling to her legs, and increased confusion. The impression was that she had heart failure (where the heart is unable to pump enough blood to meet the body’s needs) and pleural effusion (the build-up of fluid between a lung and chest wall).

13. On 18 August the Trust admitted Mrs M to ward 2B (an acute medical unit). On 20 August, it moved her to ward 5C.

14. Mrs M died on 2 September. Her death certificate stated her primary cause of death was aspiration pneumonia (a lung infection which occurs when fluid, saliva, or vomit is inhaled into the lungs) and frailty of old age.

Medication

18. 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 has gone wrong regarding Mrs M’s medication.

19. Ms O complains that between 23 July and 14 August, staff on ward 6 did not always administer her mother’s medication which she feels may have had a detrimental impact. She told us that on several occasions she found tablets on the floor and had no way of knowing which day they were from. We understand why this would have caused Ms O such concern.

20. Ms O has not raised this issue with the Trust in her written complaints. Subsequently, the Trust has not responded to any concerns about nurses not administering Mrs M’s medication correctly in its responses to her complaint. However, we consider we can provide a view on this aspect of the complaint now and that it would be more customer focused to do so rather than asking Ms O to return to the Trust to raise this.

21. The medication administration guidance says the treating team should administer medicines in accordance with prescriptions. Our nurse adviser confirmed the medical charts in Mrs M’s records show nurses administered her medications in line with the prescriptions issued by the doctors.

22. However, the records also show that a lot of the time, Mrs M refused her medication. There are various confirmed instances of this in the records during Mrs M’s time on ward 6. There are also various recorded instances of staff encouraging her to take her medications.

23. The medications administration guidance also says staff can administer medicines to people covertly who actively refuse their medication and lack mental capacity to make decisions about their care. During her first hospital admission the records show the treating team felt Mrs M had capacity.

24. The records show Mrs M was intermittently confused following admission and not completely refusing her medication but that she required a lot of encouragement and persistence. Our nurse adviser did not think this would have warranted covert administration.

25. We acknowledge Ms O’s account that she found tablets on the floor and we have taken this into account. However, as the Trust has not had the opportunity to respond to this complaint, we do not have any statements or recollections from staff on this issue. It is unlikely that staff would have been able to recollect whether Mrs M’s tablets were on the floor, especially given the length of time that has now passed. Without further evidence, we are unable to comment on this further.

26. Based on the available evidence, we cannot see any indications of failings regarding the administration of Mrs M’s medications. The medication charts show nursing staff administered medications in line with prescriptions. At times, Mrs M refused them but there is evidence staff encouraged her. We are sorry we are unable to take this part of Ms O’s complaint further.

Pressure sore

27. Ms O says staff on ward 6 allowed Mrs M to develop a pressure sore and then did not adequately treat this, including not discharging her with cream or dressings. We were very sorry to hear Mrs M developed a pressure sore and of the pain and discomfort this caused.

28. In response to this concern, the Trust said that it understood staff were treating moisture associated skin damage to Mrs M’s groin and sacrum with barrier spray. It said the category 3 sore had a dressing applied and the category 2 sore had barrier spray applied.

29. The Trust said the records show evidence of nurse rounding and skin bundles completed between two to four hourly and documentation in the records confirmed that dressing checks and regular changes took place. The Trust apologised that staff had not provided barrier spray and the dressings upon discharge.

30. The Trust said the nursing records show there appears to be consistent documentation relating to skin inspections and assessments and that Mrs M was repositioned to reduce pressure damage and deterioration.

31. The NICE guidance for pressure ulcers recommends a risk assessment of pressure ulcer risk for adults admitted to hospital. We can see the records show the nursing team carried out a risk assessment for Mrs M following admission in line with this guidance which found she was not at risk.

32. However, despite nursing staff not considering Mrs M to be at risk of pressure sores, the records show staff still repositioned her every four hours. The rounding charts show there were some occasions where staff did not reposition Mrs M every four hours, but the records show she never went longer than six hours.

33. This is in line with the NICE guidance for pressure ulcers which says nursing staff should encourage adults who they have assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every six hours. It says if they are unable to reposition themselves, the nursing staff should offer help to do so, using appropriate equipment if needed.

34. Once Mrs M began to show signs of her skin becoming red early on during the admission, the nursing team acted in line with the national guidance by ensuring they were repositioning her every four hours and by applying barrier cream.

35. The records also show the nursing team carried out regular skin assessments which our nurse adviser said was good practice. They explained that overall, the nursing team did everything in line with guidance in terms of preventing the development of pressure sores.

36. Our nurse adviser said the only additional thing the nursing team could have considered was using an air mattress for Mrs M. However, they explained that this is down to professional judgement and not a requirement in the guidance.

37. Overall, we do not think there are indications that staff failed to take appropriate action whilst Mrs M was in hospital. We were sorry to hear that despite nurses acting in line with guidance during the admission, Mrs M still developed a pressure sore.

38. We have seen some issues relating to pressure sore care at the time of discharge though. Ms O also said staff did not discharge her mother with any cream or dressings and district nurses were unable to arrange this following discharge. The Trust acknowledged in its complaint response that it did not discharge Mrs M with the dressings and barrier cream.

39. Our nurse adviser said if Mrs M had dressing and barrier creams during the admission, the treating team should have discharged her with these also. They explained the records indicate Mrs M’s pressure sores got significantly worse during her time at home.

40. However, our nurse adviser explained this deterioration is more likely due to less frequent positioning whilst at home rather than due to not having the creams or dressing applied (although the cream may also have helped to reduce the level of deterioration also).

41. We note the Trust has acknowledged that it did not refer Mrs M to the district nursing team at discharge to continue to review and treat the pressure sores. There are therefore indications of failings in relation to this aspect of care at the time of discharge.

42. We recognise the Trust apologised that staff did not provide the cream and dressing at discharge and that they did not send a referral to the district nursing team. However, we cannot see it has apologised to Ms O that this may have contributed to the deterioration of Mrs M’s skin at home or for any subsequent impact this may have had on Ms O.

43. The Trust has also not explained what learning it has taken from this issue or what it will do differently going forward to prevent this happening again.

44. Because of this, we have asked the Trust if it would be willing to carry out further work on this part of the complaint to address this issue in line with the outcomes Ms O has asked for. The Trust has agreed to do this and so we are satisfied this further work will help resolve the issues Ms O has raised with us.

Discharge from hospital

45. Ms O says staff on ward 6 prematurely discharged Mrs M on 14 August when she could not walk unaided and had severe delirium. She says this resulted in Mrs M’s readmission to hospital on 17 August.

46. The DOH discharge guidance outlines criteria to reside in hospital. This says doctors should review every patient on a twice daily ward round to determine the following:

• requiring ITU or HDU care?

• requiring oxygen therapy/Non-Invasive Ventilation (NIV)?

• requiring intravenous fluids?

• NEWS2 greater than 3?

• diminished level of consciousness where recovery realistic?

• acute functional impairment in excess of home or community care provision?

• last hours of life?

• requiring intravenous medication (including analgesia)?

• undergone lower limb surgery within 48 hours?

• undergone thorax-abdominal/pelvic surgery within 72 hours?

• within 24 hours of an invasive procedure?

47. The guidance says if the answer to each question is ‘no’, consideration for discharge to a less acute setting must be made.

48. Our physician adviser said that, at the time of discharge, Mrs M was physiologically stable so from this perspective it was a reasonable decision to discharge her.

49. Mrs M had presented to hospital with heart failure, an AKI, and delirium. Our physician adviser said she also likely had a lower respiratory tract infection.

50. Our physician adviser said by the time of discharge Mrs M’s kidney function and creatine level had improved. Her clinical notes said she was alert and comfortable and her physiological observations were all within normal limits. Therefore, our physician adviser said from a medical perspective, Mrs M’s recent problems were resolving.

51. However, our physician adviser explained the notes also show Mrs M was still some way from her functional baseline. She had been mobile with a stick and living independently until a few weeks prior to this admission. At the point of discharge, she was mostly bedbound which our physician adviser said raises the question of how she would get around at home.

52. There was also evidence Mrs M had delirium on admission to hospital but there is no evidence the treating team assessed this again prior to discharge.

53. The hospital arranged for a care package for Mrs M at home however, she then returned to hospital within three days as she had deteriorated. We can she had not been eating or drinking sufficiently and was increasingly confused. On readmission, her kidney function had worsened significantly.

54. Overall, our physician adviser did not think we could say Mrs M should definitely have remained in hospital longer. We note the only criteria she may have met to continue to reside in hospital in line with the DOH discharge guidance was that her acute functional impairment may have been ‘in excess of home or community care provision’.

55. However, it is also clear staff felt Mrs M would be able to manage at home with a care package in place. As such, we cannot say Mrs M’s needs were in excess of home provision.

56. Taking into the evidence from our physician adviser that the discharge was within the limits of acceptable practice, we do not think we could go as far as to say there were failings here if we investigated this issue further. As such, we have decided not to take this forward.

57. We were very sorry to hear that Mrs M deteriorated at home and required readmission only a few days later. We are in no way underestimating how distressing this was for Mrs M and Ms O.

Heart failure medication

58. Ms O complains staff started her mother on new heart failure medication prior to discharge and should have kept her in hospital to monitor this. She feels this resulted in her mother deteriorating at home.

59. The Trust said it started Mrs M on three new medicines. These include bumetanide and spironolactone (medicines which helped the body get rid of excess water) and bisoprolol (a medication which lowers high blood pressure and treats heart related conditions).

60. The Trust said these medications do require monitoring, but that the patients GP or nursing teams can do this within the community. It said patients are not required to stay in hospital for these to be monitored. It said prior to discharge, the treating team referred Mrs M to the heart failure nurses and asked to arrange an appointment to see her. It also said the treating team informed her GP.

61. The NICE guidance for chronic heart failure for adults indicates no requirement for patients to remain in hospital for monitoring of heart failure medication. Our physician adviser said any of these medications can be started in an outpatient setting.

62. Taking this into account, we cannot conclude that Mrs M should have remained in hospital for monitoring of her new heart failure medication. We hope this provides some reassurance to Ms O on this matter.

ECG

63. Ms O complains staff did not perform an ECG prior to discharge as advised by a doctor. We understand why Ms O is so concerned if she believed Mrs M required an investigation prior to discharge which then did not occur.

64. The GMC guidance says doctors should:

• adequately assess a patient’s conditions, taking account of their history, including symptoms, relevant psychological, spiritual, social, economic, and cultural factors and the patient’s views, needs, and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigations or treatment.

65. Our physician adviser said Mrs M did not require an ECG prior to discharge as she was was physiologically stable at this time and there was nothing documented to say she was having a new cardiac event.

66. We therefore cannot say the Trust acted outside GMC guidance in relation to this issue and so we have seen no indications of failings here.

Bank holiday weekend care

67. Ms O told us she is concerned staff failed to pick up on signs of her mother’s deterioration over the bank holiday weekend (24 to 26 August) whilst on ward 5C. Ms O says her mother became malnourished and dehydrated during this time.

68. Ms O says staff should have been monitoring her mother’s food and drink from 22 August (as requested by SALT), but this did not happen. She also says that on 25 August she requested a consultant and SALT to review her mother, but they did not attend until after the bank holiday weekend.

69. We have considered whether there are indications the clinical team should have been monitoring Mrs M’s nutritional and fluid intake over this weekend, whether nursing staff should have escalated her care, and whether they should have taken any action to address poor nutrition.

70. Firstly, it is important to note we can see no documentation in the medical records of Mrs M’s family requesting a doctor review her over this weekend. Whilst we have no reason to dispute Ms O’s account, we have instead considered whether there are clinical indications Mrs M required a review over the bank holiday weekend.

71. The RCGP NEWS2 guidance recommends the use of NEWS2 for assessing patients at risk of deterioration. NEWS2 is a clinical tool doctors and nurses can use to detect early signs of a patient’s deterioration, and which guides them on whether to escalate a patient’s care.

72. We can see the nursing team used NEWS2 to assess Mrs M over the bank holiday weekend. Our nurse and physician adviser confirmed the NEWS2 charts do not show Mrs M was deteriorating. The nursing team recorded her observations as being 0 or 1 throughout this time and all her observations were within a normal range.

73. It was only after the bank holiday weekend on 27 August where there is documented evidence of deterioration on Mrs M’s NEWS2 charts. As such, from this perspective, Mrs M did not require escalation to the medical team over the bank holiday weekend in line with the RCGP NEWS2 guidance.

74. The NHS Seven Day Services Clinical Standards also says there should be consultant led board rounds on every acute inpatient ward every day. It says the consultant decides which, if any of the patients’ reviews that day they can delegate to another competent clinician, such as a specialist nurse or senior medical trainee.

75. This guidance also says clinicians should document decisions that the patient does not need a daily consultant review, along with how the patient will be reviewed each day by the multi-disciplinary team (MDT) to ensure staff act on any signs of clinical deterioration.

76. We can see no evidence of any medical review of Mrs M over the bank holiday weekend in line with this guidance. We also cannot see any evidence to suggest the consultant had delegated responsibility to a competent clinician at this time. This is an indicated failing.

77. BAPEN’s Malnutrition and Universal Screening Tool (MUST) is a five-step screening tool to identify adults who are at risk of malnutrition. This advises that if a patient scores 1 (medium risk), nurses should monitor and document their dietary intake for three days.

78. It advises that if the intake is adequate then to continue to repeat the screening weekly. If intake is inadequate then clinicians should take steps to increase overall nutritional intake, monitor the patient and review the care plan regularly.

79. Following admission, Mrs M had a MUST assessment and scored 1 meaning she was medium risk. We can see evidence the nursing team monitored her intake in the days following this as per BAPEN’s MUST.

80. The guidance recommends repeating MUST scores weekly and we can see that nursing staff did this on 26 August in line with this guidance. Again, Mrs M scored a 1 and nursing staff monitored her intake in the days following this.

81. During a review by SALT on 22 August, prior to the bank holiday weekend, we can see it recommend the medics should manage Mrs M’s nutrition and hydration and suggested potentially giving Mrs M a short-term nasogastric (NG) tube. This is a tube inserted through the nose into the stomach to provide nutrition and fluids.

82. Overall, the records show the nursing team consistently documented Mrs M’s food intake over her second hospital admission other than 24 and 25 August when there is no documentation. However, we can see written nursing notes documenting that Mrs M was eating very little apart from yoghurts.

83. As such, the nursing team were aware that Mrs M was eating very little at this time and so we consider food charts are unlikely to have made much difference to her management. We therefore can see no indication that not keeping food charts would have had any impact.

84. The NICE guidance for nutrition support for adults says healthcare professionals should consider tube feeding in people who are malnourished or at risk of malnutrition, and have:

• inadequate or unsafe oral intake and • a functional, accessible gastrointestinal tract.

85. We can see that on 25 August, the nursing documentation suggests Mrs M only managed five teaspoons of fluid and her urine output was low.

86. Our physician adviser said that on 26 August, said the medical records show Mrs M’s sodium and potassium levels indicated she was dehydrated. We can see no evidence the clinical team reviewed or acted on this.

87. On 27 August, SALT reviewed Mrs M again and she also had a medical review. By this time, Mrs M was very unwell, and SALT recommended she required NG feeding.

88. There was then a further review by SALT on 28 August where they documented Mrs M had not had adequate nutrition for six days and they were concerned that no plan had been made for NG feeding.

89. A discussion between the medical team and Mrs M’s family then took place. Mrs M’s family stated they were in favour of an NG tube, but the medical team felt Mrs M was too confused and may remove it. They wished to give the medical therapy including intravenous fluids a further day. On 29 August, the treating team inserted an NG tube.

90. Overall, there is evidence over the bank holiday weekend that Mrs M’s nutritional intake was poor and that she was dehydrated. Our physician adviser said although Mrs M’s NEWS2 scores were reassuring, her poor intake, confusion, and worsening blood results should have prompted an escalation for medical review to consider enteral feeding.

91. Our physician adviser said whilst NG feeding may not have started immediately, there was a six-day period of very poor nutrition. They felt there was a missed opportunity to escalate this to the medical team and start Mrs M on NG feeding at an earlier point.

92. Taking this advice into account we consider there are indications of failings in this area of the complaint. Mrs M’s intake was very poor over this weekend, with the treating team taking little action to address this. Mrs M also had no medical review at this time.

93. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether we can link the events complained about with the negative impact claimed. In this case, we have considered whether there is a link between the lack of a review from a consultant and lack of action for Mrs M’s poor nutritional intake and her death.

94. Our physician adviser explained the delay in addressing nutrition and dehydration was at the most contributory to Mrs M’s death rather than the primary cause. They explained Mrs M had advanced frailty, and underlying significant comorbidities including heart failure and kidney function. She also had COVID-19 and doctors were treating her for pneumonia.

95. Our physician adviser said it could be argued that even prior to the hospital admissions, Mrs M was already approaching the end of her life and had experienced a gradual but progressive worsening in overall function.

96. Overall, our physician adviser said it is possible the gap in addressing Mrs M’s nutrition and dehydration may have contributed to or hastened her death. However, they said her death was ultimately caused by her aspiration pneumonia, frailty, and clinical condition.

97. Taking this advice into account, we do not think we would be able to robustly conclude that the issues in care caused Mrs M’s death should we investigate this matter further.

98. Nonetheless, we consider there are indications the Trust missed opportunities to provide Mrs M with the best care. We recognise this lack of care has been distressing to Ms O at what was an already difficult time.

99. The Trust has not addressed any of the indicated failings we have identified or acknowledged the potential impact on Ms O.

100. We asked the Trust if it would consider reopening Mrs M’s complaint to address these issues and provide her with the remedy she seeks. The Trust has agreed to do this. We consider that in doing this, this is the best way to resolve Mrs M’s complaint and so we have decided not to take this part of the complaint forward to a detailed investigation.

Missing jewellery

101. Ms O says the Trust did not carry out a property disclaimer following admission and one of her mother’s rings went missing during her time on ward 5C. We were very sorry to hear that Mrs M’s ring went missing during her time in hospital. We understand this ring had sentimental value and that this has been upsetting to Ms O.

102. In response to this complaint, the Trust has already acknowledged that staff did not complete a property disclaimer during the admission which is not in line with the Trust’s policy. We can therefore see an indication of a failing here.

103. Ms O has said that as an outcome to this part of the complaint, she would like the Trust to compensate her for the loss of the ring. We a see that in its complaint response, dated 11 February 2025, the Trust said if Ms O sent a valuation of the ring, it would look at the possibility of providing this.

104. We have advised Ms O to attempt to get a valuation of the ring (using photos) and send these to the Trust. Ms O has said she will do this.

105. As the Trust has already offered to consider the remedy sought by Ms O, we consider this will provide a resolution to her complaint.

106. We would like to thank Ms O for bringing her complaint to us. We hope we have fully explained the reasons for our decision.

1. We were very sorry to hear of the serious concerns Ms O has about the care Calderdale and Huddersfield NHS Foundation Trust (the Trust) provided to her late mother, Mrs M. We offer our sincere condolences to Ms O. We have carefully considered Ms O’s complaint about this matter.

2. For many areas of the issues Ms O raised with us, we could not see any indication that anything went seriously wrong. This includes in relation to the administration of medication and Mrs M’s discharge from hospital on 14 August.

3. However, we have seen indications of failings in relation to Mrs M’s care over the bank holiday weekend. Whilst we cannot link these to Mrs M’s death, we have seen indications these issues have caused Ms O distress at an already difficult time. We have also seen indications of failings relating to the care of Mrs M’s pressure sores.

4. The Trust has agreed to carry out further work to address the indicated failings we have seen and work on a remedy to put right any impact they had on Ms O. We are satisfied this further work should help to resolve the concerns Ms O has raised about the Trust. We hope it is able to bring her some closure over those concerns.