Leeds Teaching Hospitals NHS Trust

5. Mrs C complains about the care and treatment the Trust provided to her father during an inpatient admission in 2023.

6. Mrs C complains the Trust injured her father’s right leg, has no record of this and failed to investigate what happened. She says the Trust misdiagnosed this injury as gout and failed to treat it. She also says the Trust discharged him to an assessment bed with no planned follow-up investigations or treatment.

7. Mrs C has told us the injury was debilitating for her father as it greatly affected his mobility. She says this was compounded by the Trust discharging him to a setting where he received no physiotherapy. We understand it readmitted him to hospital later that months and he died three months later. Mrs C has told us he gave up on life because of the injury.

8. Mrs C would like the Trust to acknowledge failings and pay her a financial remedy.

9. Mr L was in his 80s. He previously had a stroke that left him with right-sided weakness and slurred speech. Mrs C visited him at home and found him unable to stand from his armchair. She phoned 999 and an ambulance took him to the Trust’s A&E.

10. The Trust admitted Mr L to hospital the following day with generalised weakness. When Mrs C visited him three days later, she noticed his right leg was stuck in a bent position at the knee. She raised this with the nursing and physiotherapy teams both verbally and in writing two days after this.

11. The Trust discharged Mr L to an assessment bed in a nursing home with his leg still in this bent position. An assessment bed is where patients receive ongoing care before being fully discharged. It involves monitoring them to ensure they are ready to go home, assessing their long-term needs and putting any appropriate support in place.

12. The Trust re-admitted Mr L from the care home twelve days later, and he very sadly died around three months after this. The death certificate lists his cause of death as frailty of old age. This is where a person, typically 80 years or older, has experienced a general decline in physical and mental function often alongside other medical conditions.

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

Injury to Mr L’s leg

17. Mrs C complains her father suffered an injury during the first few days of his admission and this caused his right leg to become stuck in a bent position at the knee. She says he told her a member of staff had caught his leg under his bed.

What happened:

18. Mr L’s A&E notes say he had felt under the weather the day before admission, had been unable to get out of his armchair and now had generalised pain all over his body. The doctor spoke with Mrs C by telephone. She told them his speech and mobility had been deteriorating over the past few months.

19. Mrs C told the doctor Mr L could not move his legs and looked tired. She also said something similar happened four years earlier and he fully recovered after two month in a community bed. The doctor admitted him with possible COVID-19 or flu as he had crackles in the bases of both lungs.

20. A consultant saw Mr L on the day he was admitted (day 1). They noted a slow decline in his mobility over the past year and that he had been unable to get out of his armchair the day before. They also noted his right arm was contracted (stiff and shortened with limited movement) following his previous stroke.

21. A junior physiotherapist saw Mr L that morning and their notes say he was sat in his chair when they arrived. They say he moved himself to the edge of the chair and tried to stand but was unable to push himself up using his left arm. He was instead straightening or locking his trunk, hips or knees to try and get himself upright.

22. The junior physiotherapist’s notes say Mr L needed assistance to stand but then lost his balance and struggled to bring his weight forward. They say they sat him down and helped him try and stand again. He then bent forward enough to shift his body weight over his toes but could not stop himself from falling backwards so they sat him down again.

23. The falls assessments from before and after the physiotherapy session say Mr L was unsteady on his feet and unable to stand. A nursing note that evening says they checked his skin and it was intact with no bruises or lesions. A nursing note on day 2 says his daughter and grandson had visited and there is nothing to indicate they raised any concerns.

24. A physiotherapist saw Mr L on day 3. They noted it took him a lot of effort to move his right leg, and he was shifting his weight to his left side to help him move. They had to manually guide his right hip and right leg so he could move to the edge of the bed and get his feet on the ground.

25. The physiotherapist noted he had increased muscle tightness or stiffness and limited movement in his right leg. He could not fully bend or straighten his right knee. He could only bend it to about 40° though this improved to 70° when they moved it. This usually means the patient has significant spasticity (stiffness) or weakness affecting the knee.

26. The physiotherapist noted Mr L appeared significantly off his usual ability. They noted he had been in a community care bed in 2018 and made significant progress but queried whether this time it was a more gradual and chronic decline. They said he needed further assessment to explore the potential for rehabilitation.

27. A nursing note on day 6 says Mr L complained of pain in his legs, and they gave him pain relief. The same note says Mrs C had raised concerns about his right leg being bent and had given them a letter to pass to the physiotherapy team. This letter says she noticed his leg was bent on day 4.

What we have seen:

28. NMC professional standards say nurses must act immediately to put right the situation if someone has suffered actual harm for any reason or an incident has happened which had the potential for harm. HCPC professional standards say physiotherapists must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.

29. Our adviser thought it was very unlikely an injury or some kind of trauma led to the rigidity in Mr L’s right leg. They said it would take a great deal of manipulation by a member of staff to cause this type of issue. We note the junior physiotherapist’s notes say they only tried to help him stand and the nursing notes do not mention any injury.

30. Our adviser said they would expect there to be some evidence of an injury such as bruising or a wound if there had been trauma severe enough to cause the level of rigidity Mr L had. We note a nurse said his skin was intact with no bruising on the evening of 28 March. We also note neither Mr L nor his family raised any concerns.

31. Our adviser felt the rigidity in Mr L’s leg was very likely a contracture. This is the chronic loss of joint mobility due to structural changes in the muscles, ligaments, connective tissue or tendons. This happens when normally elastic tissues are replaced by inelastic ones causing rigidity, joint deformities and total loss of movement around the joint.

32. PM&R Knowledge NOW says 60% of stroke patients develop contractures. Our adviser said a very old stroke can leave abnormal muscle tone (residual tension even at rest) for decades. Over time, especially when there is reduced mobility, patients can develop involuntary contractions, increased tone, painful contractures and an inability to extend their knee or hip.

33. We note the rigidity was on the same side of Mr L’s body as the arm affected by his stroke. Our adviser said it is likely a significant part of the contracture was present prior to admission. They said Mr L’s reported reducing mobility and/or acute illness likely exacerbated this contracture making it more pronounced.

34. Overall, we have seen no evidence in either the medical, nursing or physiotherapy notes to suggest Mr L suffered an injury in hospital. It seems much more likely the rigidity in his right leg was a contracture. We sincerely hope this provides Mrs C with some reassurance.

No record of an injury to Mr L’s leg or the family raising concerns

35. Mrs C complains the Trust has no record of a member of staff catching her father’s leg under the bed. She also complains the Trust has no record of the family raising concerns about this and that it did not investigate what happened.

What happened:

36. Looking at Mr L’s clinical notes, we can see no reference to him injuring his leg at any point during this admission. Mrs C has told us she raised concerns with the nursing and physiotherapy teams day 6 of admission and then when the physiotherapist telephoned her on day 7.

37. We cannot see any reference to Mrs C raising concerns about an injury to Mr L’s leg. The physiotherapist’s note on day 7 refers to a very sudden decline in his function on this admission. It says Mrs C said his leg was fine on day 2 and then she noticed it was bent on day 4. It says his right knee was stiff on day 3 and then significantly worse on day 7.

38. The ward doctor’s note on day 7 says Mrs C had said Mr L’s leg was straight on day 2. It says his range of movement declined between physiotherapy sessions on day 3 and day 7 and he was now unable to straighten it. It also says the rigidity had developed gradually between day 2 and day 4. They noted there were no recent falls or trauma.

What we have seen:

39. GMC professional standards say doctors must record relevant clinical findings. NMC professional standards say nurses must identify any risks or problems that have arisen and the steps taken to deal with them. HCPC professional standards say physiotherapists must keep full, clear and accurate records.

40. It is difficult for us to say whether there is poor record keeping and there should be a record of the incident Mr L told Mrs C about. We do not know exactly what happened or if the incident was serious enough to mean the member of staff involved should have noted it.

41. Mr L’s clinical notes say he reported feeling pain all over his body on day 1. The physiotherapy notes from day 1 and day 3 show his mobility was poor and that it became increasingly difficult for him to move his right leg. It therefore seems likely even a minor impact to his leg would have caused him pain.

42. We accept Mrs C’s account that her and her family raised the incident with various members of staff at the time. We can appreciate why she is concerned there is no clear record of this. It is difficult to say whether something went wrong here. The Trust recorded the family’s concern that the leg rigidity had started following Mr L’s admission and investigated the cause.

43. In any event, it seems very unlikely the medical team would have taken different action had staff specifically noted the incident with Mr L catching his leg under the bed. We also note our adviser thought it was very unlikely an injury had caused the rigidity and that the rigidity was a contracture.

The Trust’s care and treatment for Mr L’s right leg

44. Mrs C complains the Trust did not fully investigate the rigidity in her father’s right leg and queries its diagnosis of gout. She believes he had ligament damage which would have needed an MRI to diagnose.

What happened:

45. Mr L’s clinical notes show a physiotherapist first noticed the rigidity in his leg on day 3 and, at that point, his range of movement was 40°. Mrs C raised concerns on day 6, and a physiotherapist saw him on day 7. They noted he only had 10° range of movement in his knee, and his hamstrings were very tight.

46. The physiotherapist raised this with the medical team, and a doctor reviewed him that afternoon. They noted the rigidity seemed to have developed gradually between day 2 and day 4 and there were no recent falls or trauma. Their impression was that the rigidity was due to his previous stroke. They prescribed diazepam to treat his muscle spasm and requested an Xray.

47. The medical team reviewed the X-ray on day 8, and this showed osteoarthritis (a common condition affecting the joints causing pain, stiffness and problems moving). The medical team asked orthopaedics for their input. They recommended an MRI if there were concerns it was an issue with the joint itself and there was no other cause for the rigidity.

48. The medical team also requested a head CT to rule out new stroke and discussed Mr L with the on-call elderly consultant. They advised checking his inflammatory markers (for infection), calcium levels and magnesium levels (minerals that support bone health and muscle function), continuing diazepam and liaising with the complex neurological rehabilitation team.

49. The medical team then discussed Mr L in a multi-disciplinary team meeting on day 9. They agreed to start colchicine (an anti-inflammatory) for suspected gout (a type of crystal arthritis) and continue pain relief. On day 10, the medical and physiotherapy teams reviewed the results of the head CT and agreed they did not explain the severity of Mr L’s rigidity.

50. Physiotherapy asked the complex neurological rehabilitation team for their input. They saw Mr L on day 16 and said he needed further investigation. The medical team noted a plan to try Botox (to treat muscle spasticity) for Mr L’s tight hamstrings the following week if there was no change.

51. On day 18, the medical team asked rheumatology to review Mr L. They said it would be very difficult to aspirate his knee (remove fluid for diagnosis or to relieve pain and/or swelling). They felt he had crystal arthritis. This is a group of joint disorders caused by the deposition of microscopic crystals leading to sudden pain, swelling and inflammation. They recommended prednisolone (an anti-inflammatory).

52. Mr L had a joint session with physiotherapy and the complex neurological rehabilitation team on day 21 and then a physiotherapy session on day 22. The complex neurological rehabilitation team injected Botox into his hamstrings on day 23. During a physiotherapy session on day 24, the physiotherapist noted pain in his right hip.

53. The medical team requested an X-ray of Mr L’s pelvis and right hip, and he had this later that day. They reviewed the results on day 25 and noted they showed osteoarthritis only. Mr L had a physiotherapy session later that day and they noted little response to the Botox.

54. On day 28, the medical team said to allow a couple of weeks to see if the Botox had any impact. Mr L had a physiotherapy session later that day and they noted very little improvement. They felt this suggested his long-term needs were now vastly different to what they were pre-admission.

55. Mr L then had physiotherapy sessions on day 29, 30, 32, 37, 39 and 43. On day 43, physiotherapy noted there was still no change. They felt this was now his new baseline and discharged him from their list. The Trust then discharged him on day 49 with established right lower leg spasticity.

What we have seen:

56. GMC professional standards say doctors must adequately assess a patient’s conditions by taking account of their history, views and values, and examining them where necessary. They say doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary. They also say doctors must refer patients to another practitioner when this serves their needs.

57. We can see the Trust did blood tests (to check inflammatory markers, calcium levels and magnesium levels), X-rays of the knee, pelvis and right hip (to check for orthopaedic issue) and a CT head (to check for new stroke). They considered knee aspiration but felt this would be very difficult which our adviser said was reasonable.

58. The Trust also consulted relevant specialties including physiotherapy, orthopaedics, complex neurological rehabilitation, and rheumatology. Based on what we have seen, it appears the Trust carried out appropriate investigations into the sudden cause of the rigidity in Mr L’s right leg.

59. Our adviser explained that, with contractures, diagnosis is generally based on clinical features (signs, symptoms and measurable indicators that reflect a patient’s health status or condition) rather than the results of investigations. We recognise Mrs C is particularly concerned the Trust did not do an MRI.

60. Our adviser said an MRI would have been very uncomfortable for Mr L as he would have had to straighten his leg for around 20-30 minutes. They also said the medical team would generally only request an MRI in this situation if they were considering surgery or did not have a diagnosis.

61. Our adviser said surgery would not have been an option as Mr L was too frail and the risks of surgery would have outweighed any possible benefits to him. They also said the medical team had a diagnosis and this was muscle spasticity following his previous stroke and gout.

62. Overall, we have not seen any indications of failings in the Trust’s care and treatment. It appears the Trust carried out appropriate investigations into Mr L’s sudden leg rigidity and came to a reasonable diagnosis based on the clinical picture at the time. We hope this addresses Mrs C’s concerns.

63. Our adviser felt the main cause of Mr L’s rigidity was a contracture on the background of his previous stroke which had been exacerbated by a decline in his mobility and/or acute illness. They said the additional diagnosis of gout was reasonable based on Mr L’s presentation and X-rays.

The Trust’s decision to discharge Mr L

64. Mrs C complains the Trust discharged her father with no plans to treat or investigate the issue with his right leg any further. She also complains it discharged him to an assessment bed rather than a rehabilitation bed. She says this meant he received no physiotherapy.

What happened:

65. At Mr L’s physiotherapy session on day 1, they noted the plan was to discharge him to a community care bed. However, he needed further assessment to explore his rehabilitation potential. Community care bed is a broad term for a bed outside an acute hospital usually in a care home, community hospital, rehabilitation unit or nursing facility.

66. Mr L sadly developed COVID-19, hospital acquired pneumonia (chest infection), an acute kidney injury (where the kidneys suddenly stop working properly) and haematuria (blood in the urine). By day 38, these issues had resolved and the medical team decided he was medically fit for discharge.

67. Mr L’s notes say physiotherapy spoke with Mrs C on day 28 and explained there had been no improvement with his leg. They said this suggested his care needs were now vastly different than they were pre-admission. On day 37, physiotherapy noted it looked like Mr L would need 24-hour care as he had very little rehabilitation potential.

68. On day 43, physiotherapy reviewed Mr L and discharged him from their service. They noted the rigidity in his right leg had not improved despite pain relief, anti-inflammatories, Botox, and physiotherapy. They concluded there would be no further improvement in his condition and there was no scope for rehabilitation.

What we have seen:

69. NHSE guidance sets out criteria doctors should consider when deciding whether a patient needs to remain in hospital, such as do they need intensive care, do they need oxygen, do they need IV fluids, do they have diminished consciousness, etc. Mr L did not meet any of these criteria.

70. Based on what we have seen, the decision to discharge Mr L to an assessment bed was appropriate. He was no longer acutely unwell and was not receiving any treatment. The medical team had diagnosed established spasticity and physiotherapy felt there was no scope for rehabilitation. Our adviser said this was reasonable based on his presentation.

71. Sadly, once contracture is established, physiotherapy often has a limited effect. We sincerely hope our consideration goes some way in addressing Mrs C’s concerns. We recognise how incredibly difficult it must have been to watch her father deteriorate. We would like to take this opportunity to wish her the very best for the future.

1. Mrs C complaints about the care and treatment Leeds Teaching Hospitals NHS Trust (the Trust) provided to her father, Mr L, during an inpatient admission in 2023. We have carefully considered her complaint and seen no indications anything went seriously wrong.

2. Mrs C complains her father sustained an injury while in hospital and this caused damage to his right leg. She complains the Trust failed to appropriately investigate and treat this. She also complains it discharged him to an assessment bed with no planned follow-up investigations or treatment.

3. Based on what we have seen, it is very unlikely the issue with Mr L’s leg was caused by an injury. We consider the Trust carried out suitable investigations and provided appropriate treatment. We also consider the Trust’s decision to discharge Mr L to an assessment bed was appropriate.

4. We recognise how difficult it can be to complain about the care a loved one received and to then keep pursuing this while trying to grieve their loss. We hope our investigation provides Mrs C with answers about what happened and brings her some sense of closure.