Royal United Hospitals Bath NHS Foundation Trust

5. Miss E complains about aspects of the care and treatment of her father, Mr E, by Royal United Hospitals Bath NHS Foundation Trust between November and December 2024. She specifically complains the Trust:

• failed to correctly administer Mr E’s IV medications on 22 and 23 November • failed to appropriately secure Mr E’s bedrails and assist him when he fell from his bed on 29 November, or to assess his condition afterwards • failed to provide Mr E with oxygen for several hours on 2 December • kept poor records during his admission.

6. Miss E says the failure to correctly administer her father’s IV medication, his fall and the subsequent lack of assessment of his condition, and the failure to provide oxygen for several hours caused Mr E’s condition to deteriorate and contributed to his death. She says the poor record keeping meant the Trust could not accurately account for Mr E’s care and treatment.

7. Miss E say these events have been incredibly upsetting for her, have caused her grief, and have significantly impacted her mental health.

8. As an outcome to her complaint, Miss E seeks service improvements.

9. Mr E had a stoma due to a history of Crohn’s disease. He was taken to hospital by ambulance on 20 November 2024 after feeling ill overnight. The content of his stoma was dark in colour and a bleed was suspected. On 21 November, an examination with an internal camera found damage to Mr E’s oesophagus, which was the suspected cause of the bleed. It was decided Mr E would be kept in hospital and he was moved to the OPUSS (Old Persons Unit Short Stay) ward on 22 November.

10. It was explained Mr E’s treatment would continue with IV omeprazole (a medication to treat stomach acid), antibiotics and saline. When Miss E visited her father on 23 November, she found he had no infusions or a canula in place. Miss E asked the nurse why this was the case and they showed her greyed out medical notes explaining the prescription had been ‘closed’. It was later re-prescribed.

11. In the early hours of 29 November Mr E fell from his bed, and it was reported he was found sitting on the floor at his bedside. The next morning a consultant reviewed Mr E. No new concerns were noted relating to the fall and no imaging was requested.

12. The Trust moved Mr E into a side room on 2 December as his condition was deteriorating with multiple organ failure. It was explained that Mr E was dying and the focus should be on his comfort and dignity. Mr E was to remain on oxygen to support his symptomatic management. During shift handover, a member of staff found the oxygen was turned off at the wall and Mr E’s oxygen level was very low. The oxygen was turned on and Mr E’s oxygen level increased. Mr E died the next morning, 3 December, at the age of 97. The primary cause of death was pneumonia.

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 address each aspect of the complaint below.

Administration of IV medications

16. On 21 November 2024 the Trust inserted a cannula and treated Mr E with omeprazole and IV fluids. This remained in place the next day, and the Trust explained Mr E’s treatment would continue over the weekend with omeprazole, antibiotics and saline administered by an IV drip, as well as liquid alternatives to his usual medication, as he could not swallow tablets.

17. Miss E says when she arrived on the morning of 23 November, her father did not have any infusions or a cannula in place, and Mr E told her the medications had finished late the night before. A nurse explained the prescription had been closed and showed her the prescription medical notes were greyed out.

18. The nurse contacted an on-call doctor who re-prescribed the medication. A cannula was reinserted, and the medication was re-started at approximately 1.30pm.

19. In its complaint response dated 14 April 2025, the Trust says the medications were prescribed at set times rather than a continuous infusion, and all doses of medication are recorded to have been given, but there may have been a delay in doses while IV access was regained. It says it is unclear why IV access was lost.

20. RPS guidance says medicines are administered in accordance with a prescription, Patient Specific Direction, Patient Group Direction, or other relevant exemption specified in the Human Medicines Regulations.

21. We reviewed Mr E’s medication administration charts with the help of our nursing adviser. The charts show Mr E’s medications and IV fluids were given as prescribed, with IV fluids being given over a six-hour period.

22. It is unclear from the records why the prescription was closed and the cannula removed. We can see when Miss E raised this concern with the Trust, it acted in a timely manner to re-prescribe and administer the medication. We therefore consider the Trust took appropriate action to put this right.

23. The medical records confirm IV fluids and omeprazole were running on 22 November. On 23 November there was a slight delay in providing the antibiotic, as it was not given at 12.30pm, but was given shortly after at 1.45pm. Our nursing adviser told us as the antibiotic was to be given three times a day and not continuously, the delay would have no impact on Mr E’s condition. Overall, we consider the Trust administered the medicines and IV fluids in accordance with the prescription, and in line with the above guidance.

Fall on 29 November

24. Mr E fell from his bed in the early hours of 29 November. The fall was unwitnessed and he was found sitting on the floor. Miss E says the handrails should have been up on Mr E’s bed, but they were not. She says staff did not assist him when he fell or assess his condition afterwards.

25. In its response, the Trust says a risk assessment was carried out showing bed rails were not recommended for Mr E. It acknowledged it should have supported the use of bed rails against the clinical risk if it knew Mr E wished for his bed rails to be used.

26. MHRA guidance says to prevent inappropriate or unintended restraint through the use of bed rails, there must be a robust assessment of whether the use of the bed rail will prevent the person from moving freely or make the person feel restricted from moving freely.

27. It says risk assessments should be carried out before the initial prescription of bed rails.

28. We have seen the Trusts’ bed rail assessments from 28 and 29 November. We can see Mr E was assessed as having a score of two. Bed rails were not used in line with the assessment outcome, which notes if a total score is between one and four, then bed rails are not recommended.

29. Mr E’s records note on admission, he was orientated, with no signs of confusion. He was mobile with a stick prior to admission. From admission, his mobility was reduced as he was mobile with a wheeled zimmer frame and the supervision of one.

30. Our nursing adviser told us based on this presentation, they consider the outcome of a bed rail assessment would have been not to use them, as they would have been a form of restraint rather than a safety measure. The exception to this is when the patient specifically requests them. We have seen no evidence that such a request was made.

31. Based on the evidence we have seen, we consider the Trust acted in line with the MHRA guidance.

32. Miss E says the Trust did not appropriately assess Mr E’s condition after the fall. She says no imaging was carried out despite Mr E developing bruising over the following days.

33. RCP guidance on post fall management says the post-fall check seeks to identify potential injuries, not to make a formal diagnosis, and should guide observation and assessment and the urgency of a post-fall medical review.

34. Mr E’s records show a full falls assessment was carried out by the on-call doctor and documented at 7.09am. We can see additional nursing and medical entries which document further post-fall assessments.

35. Our geriatrician adviser explained physicians do not immediately resort to X-rays or scans; rather, they apply their judgment based on the symptoms, findings from the examination, and whether imaging would influence treatment decisions.

36. They told us the evaluation of Mr E’s bruising on 2 December appears thorough, and the findings do not indicate a fracture. Therefore, there were no indications for an X-ray to be carried out.

37. The assessments showed no evidence of a head injury. Our geriatrician adviser explained therefore it is improbable, though not impossible, there would be bleeding or other brain injuries that would indicate a CT scan was necessary.

38. Based on the evidence we have seen, we consider the Trust acted in line with the RCP guidance in its assessment of Mr E’s condition following his fall. We understand how worrying this was for Miss E and her family, and hope our explanations provide some assurance to her.

Oxygen support on 2 December

39. The Trust moved Mr E from the ward to a side room on 2 December as his condition was deteriorating. He was supposed to be receiving oxygen support, however his levels were very low when observed at around 6.45pm. The oxygen machine was found to be turned off, and Mr E had not been receiving oxygen.

40. The machine was turned back on and Mr E’s oxygen levels improved to 91%. This is in line with BTS guidance which says the target is between 88-92% for patients at risk of hypercapnic respiratory failure (where the lungs are unable to clear enough carbon dioxide).

41. The Trust explained this had been reviewed with the staff involved and their statements had been taken, but it was unable to give a full account of events. It acknowledged this was a mistake in its complaint response. It explained it had arranged for all staff to attend or reattend a respiratory study day, and the senior team to attend a life support study day.

42. GMC guidance says you must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities.

43. We do not consider the Trust acted in line with the above guidance by not providing Mr E with oxygen.

44. We must now consider the impact this had on Mr E. Our geriatrician adviser explained Mr E was a deteriorating patient who had been seen by the palliative care team and was approaching the end of life. They explained oxygen was given for symptom relief, as typically measurement of oxygen saturations and other observations are often discontinued at this stage.

45. We can see from Mr E’s records a discussion about oxygen support took place with his family, recorded at 9.45pm on 2 December. The Trust informed Mr E’s family that the oxygen would keep his saturations up but probably not change his overall prognosis.

46. Based on the evidence, we do not consider these events contributed to Mr E’s deterioration or death. It is unclear how long the oxygen was turned off for, but we know Mr E was without oxygen support for some time. We consider this meant Mr E was less comfortable during this period than he would have been if it was turned on. We do not underestimate how distressing this must have been for Miss E and her family to learn.

47. It is important the Trust takes steps to put things right when there is an indication of a failing. We are satisfied the Trust has taken appropriate steps to make improvements by acknowledging these events as a mistake and arranging further training for staff.

Record keeping

48. Miss E complains the Trust kept poor records during Mr E’s admission. She says this means the Trust could not accurately account for Mr E’s care and treatment.

49. The Trust explained it was limited in the answers it could provide in response to Miss E’s concerns about the administration of IV medications because of the lack of records related to this. We asked the Trust for further information on this. Unfortunately, it could not provide an explanation but told us it is not uncommon for cannulas to become dislodged or non-functional, requiring reinsertion. It said this would not have caused harm nor did it contribute to any significant delay in the administration of omeprazole. We recognise this leaves Miss E without a clear explanation.

50. Although it is unclear why IV access was lost, we explained earlier the Trust acted in a timely manner to re-prescribe and administer the medication, and the slight delay in providing the antibiotic would have no impact on Mr E’s condition.

51. The Trust said the healthcare assistant on duty when Mr E fell from bed was a bank staff member and could not recall enough detail to provide a clear statement.

52. Our nursing adviser reviewed the documentation concerning Mr E’s fall. They told us although the fall was unwitnessed, many are within the hospital environment, as only patients who are on an Intensive Care Unit (ICU) or receiving enhanced care have 1:1 monitoring.

53. We can see an account of the fall within Mr E’s records and an incident report was completed. This is in line with NMC guidance, which says nurses should demonstrate the ability to keep complete, clear, accurate and timely records.

54. The Trust said it was very difficult to be certain of events regarding the lack of oxygen support.

55. While the reason why the oxygen was turned off is unclear, we explained earlier that we do not consider there was a serious clinical impact on Mr E.

56. Whilst there are insufficient records regarding the IV prescription and administration and the oxygen support, we have been able to consider these aspects of the complaint.

57. We acknowledge the lack of clear documentation on these issues left Miss E without answers and meant the Trust was unable to provide a full response when she first raised her concerns. We hope our explanation provides Miss E with some reassurance as to what happened during her father’s care and treatment.

Summary

58. Based on the evidence considered, we have seen no indication that anything went seriously wrong with the care and treatment provided before and after Mr E’s fall on 29 November. In relation to the prescription and administration of Mr E’s IV medications on 22 and 23 November, we are satisfied the Trust took appropriate action to address this at the time.

59. Regarding the oxygen administration on 2 December, and the record keeping, we cannot link these events to the claimed impact. We will therefore not consider the complaint further.

60. We understand this has been an incredibly difficult time for Miss E. We were very sorry to hear of the circumstances which led her to approach us and her father’s death.

1. We have carefully considered Miss E’s complaint about Royal United Hospitals Bath NHS Foundation Trust (the Trust). We understand the circumstances of the complaint have been very upsetting for Miss E, and we offer our sincere condolences following the death of her father. We thank Miss E for bringing her complaint to us.

2. We have seen no indication that anything went seriously wrong with the care and treatment provided before and after Mr E’s fall on 29 November. Regarding the prescription and administration of Mr E’s IV medications on 22 and 23 November, we consider the Trust took appropriate action to address this at the time.

3. Regarding the oxygen administration on 2 December, and the record keeping, we have decided we cannot link the events complained about to the claimed impact.

4. We will therefore not be considering Miss E’s complaint further and explain the reasons for our decision below.