Mid Cheshire Hospitals NHS Foundation Trust

4. Mr B complains about the care and treatment his mother Mrs B received from the Trust during her hospital admission in June 2024. Specifically, Mr B complains:

• his mother was moved to a side room and was isolated• his mother was left unwashed and not repositioned in bed• his mother did not receive appropriate physiotherapy.

5. Mr B says the Trust’s actions caused distress to the family and adversely impacted on his mother’s mental health. He says his mother stopped talking and he witnessed her in tears due to the Trust’s neglect. Mr B says his mother’s poor experience has impacted on the family’s ability to move forward.

6. As an outcome to his complaint, Mr B is seeking an explanation into the circumstances surrounding his mother’s care, service improvements, financial compensation and an apology.

7. On 29 June 2024 Mrs B was admitted to hospital with a fractured femur following a fall. She received care in the emergency department and was transferred to a ward on the same day.

8. On 3 July 2024 Mrs B underwent surgery for her fractured femur which was successful. On 11 July 2024, Mrs B’s hospital bay was closed for further admissions due to an infection.

9. On 19 July 2024 Mrs B tested positive for an infection unconnected to the infection identified on 11 July. Following this, she was moved to a side room and isolated.

10. Mrs B was discharged from hospital in September 2024. Mrs B died on 13 December 2024.

Side room

14. Mr B complains Mrs B was left in an infected bay for too long. He also complains that she was subsequently moved to a side room where she was isolated.

15. Mr B says the issues arose when an infection was identified in his mother’s hospital bay. He says Mrs B was kept in the infected bay for two days with the windows shut which meant there was no fresh air, increasing the risk of more infection.

16. Mr B explained that when his mother tested positive for glutamate dehydrogenase (GDH- a chemical found in clostridium difficile), which is a bacterial infection in the bowel, she was placed in a side room with the door shut and she had little to no communication with anyone. He said these issues had a detrimental impact on his mother’s mental health and affected her ability to communicate.

17. In its complaint response, the Trust explained that once the infection had been identified in Mrs B’s hospital bay, it closed the bay to prevent further admissions. The Trust said the infection was not airborne (which means it could not be contracted by contact with droplets in the air) but was spread by contact. It said it also kept the doors closed to reduce the risk of the infection spreading.

18. The Trust said all patients within the bay required isolation into single rooms for their protection and this was accommodated when it had the capacity to move patients. The Trust also said open visiting was authorised for Mrs B to help support her wellbeing and staff checked on patients on a regular basis.

19. The NIPCM guide says cohorting (grouping patients together in the same designated area) of infectious patients can be considered where single rooms are in short supply.

20. The Trust acknowledged that all patients within the infected bay required to be isolated in single rooms and it isolated patients when single rooms became available. We consider, the Trust’s decision to keep Mrs B in her ward with the other patients while it waited for a single room to become available, was appropriate and in line with the NIPCM guide.

21. Our nursing adviser said given the infection was not airborne but spread by contact, staying in the infected, cohorted bay with the windows closed would not have compromised Mrs B’s care, provided that all staff took the recommended infection control procedures.

22. We have seen no indication from the records that infection control procedures were not adhered to, and we note that Mrs B did not test positive for the infection identified in her bay.

23. We understand Mr B’s concerns about the infection identified in his mother’s hospital bay. We consider the Trust’s actions were in line with the NIPCM guide and there is no evidence to suggest that Mrs B’s health and safety were compromised.

24. With regards to the Trust’s decision to move Mrs B to an isolated room after she had tested positive for GDH, an infection, unrelated to that identified in her bay, the NIPCM guidance recommends single room isolation while a patient is considered infectious.

25. The NIPCM guidance specifically says patients should remain in their bedroom and the door should remain closed. This advice is supported by the UK HAS Clostridioides difficile infection guidance which says appropriate and timely infection control measures are key prevention strategies, including barrier nursing of hospitalised patients in a side room. As such, the decision to isolate Mrs B in a side room was reasonable and in line with national infection control guidelines.

26. Mr B would have understandably been concerned that his mother had tested positive for an infection and that she had to be isolated. We acknowledge how difficult the isolation would have been for Mrs B and for her loved ones to witness, including the impact on Mrs B’s mental health during an already difficult time. We have considered whether there is evidence that Mrs B’s care and treatment was adversely impacted by being isolated, in a side room.

27. The records show that Mrs B continued to be seen by nurses, doctors, dieticians, and therapy staff, whilst she was in the side room. Furthermore, Mrs B’s opinion on being in a side room was sought on 1 August 2024 and she is documented as saying that she was ‘quite happy in the side room’. The records do not indicate that Mrs B was adversely impacted by being isolated in a side room.

28. Taking into account all the evidence, we consider the Trust acted in line with the NIPCM guide and the UK HAS Clostridioides difficile infection guidance when addressing the infection in Mrs B’s bay and treating her subsequent infection by isolating her in a side room. Therefore, we have not seen any indication of a failing here.

Hygiene and repositioning

29. Mr B complains his mother was left unwashed and not repositioned in bed. He says when he had asked how his mother was doing, he was told she was well with no concerns, however there were occasions he would visit her and she would be unwashed and still in bed.

30. Regarding Mrs B’s hygiene needs, the Patient experience in adult NHS services guidance says clinicians should ensure that a patient’s personal needs, including personal hygiene, are regularly reviewed and addressed. It says clinicians should regularly ask patients who are unable to manage their personal needs what help they need and should address their needs at the time of asking and ensure maximum privacy.

31. This recommendation is echoed in the NMC guidance which says clinicians should observe, assess and optimise skin and hygiene status and determine the need for support and intervention.

32. We understand how upsetting it would have been for Mr B to visit his mother in hospital and have concerns about whether her hygiene needs were being met.

33. We have reviewed Mrs B’s nursing records and can see that care rounds were in place and are well documented. Mrs B had a urinary catheter with fluid balance charts monitoring her output and she wore a pad for faecal incontinence, with stool charts monitoring frequency and type of stool. This is in line with the NMC Patient experience in adult NHS services guidance.

34. Our nursing adviser said the records show Mrs B was adequately assisted with her hygiene. It is also recorded that staff ensured that the call bell was within Mrs B’s reach, as such Mrs B or her visitors could notify staff if they felt her hygiene needs were not being met.

35. With regards to Mrs B’s repositioning, the NICE guidance says clinicians should encourage patients who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. The NICE guidance also says if patients are unable to reposition themselves, clinicians should offer help to reposition them using appropriate equipment if needed and the frequency of repositioning should be documented.

36. We can see that Mrs B was at risk of pressure ulcers and it is documented that she required repositioning 2 hourly through the day and 3 hourly at night. There are repositioning charts on record showing 2 hourly positional changes through the day and care rounds showing that Mrs B was checked 2-3 hourly overnight but not disturbed if asleep.

37. The frequency of Mrs B’s positional changes was therefore greater than national guidance which says at least 4 hourly. Our nursing adviser says Mrs B’s positional changes were appropriate and tailored to her needs. Our nursing adviser also says the quality of Mrs B’s repositioning was demonstrated when Mrs B was discharged from hospital with no pressure or moisture damage to her skin.

38. We understand that Mr B had concerns about the quality of his mother’s hygiene and repositioning during her hospital stay. The records demonstrate that the Trusts actions relating to her hygiene and repositioning needs were appropriate and in line with NICE, NMC, and Patient experience in adult NHS services guidance.

Physiotherapy

39. Mr B complains his mother did not receive appropriate physiotherapy. He says his mother had only made two or three steps in a three-week period and the physiotherapy that she received on occasion did not involve encouraging her movement.

40. Within the Trust’s complaint response, it said Mrs B was doing well with physiotherapy sessions during her admission and progressed to a gutter frame. It explained on 1 August Mrs B was seen by the Therapy Team and practiced standing in a Zimmer frame with maximum assistance of two people but unfortunately during treatment, Mrs B opened her bowels.

41. It said following this incident, it became evident Mrs B was very fatigued and her balance and ability to maintain a safe stand had deteriorated. It said, at this point therapists did not feel it was appropriate to proceed to stepping or walking due to a risk of falls and Mrs B’s safety.

42. The Trust also said Mrs B’s fear of falling during the treatment sessions became a limiting factor to her progress in rehabilitation. It said this led to a reduction in the frequency and intensity of her physiotherapy sessions.

43. The Chartered Society of Physiotherapy guidance provides information for physiotherapy management and treatment. It says clinicians should ensure patients have fair and equitable access to physiotherapy services according to need. It also says intervention should be constantly evaluated to ensure that it is effective and relevant to the patient’s changing circumstances and health status.

44. We can see from the notes that Mrs B received approximately 37 therapy sessions. The notes show that Mrs B’s engagement with the sessions fluctuated, with some sessions reporting steady progress with no pain reported by Mrs B and others noting that she was in pain, fearful of falling and asked to sit down. It is also recorded that Mrs B declined therapy on one occasion as she did not want to get out of bed; the physiotherapy session was stopped, and she was left settled on the bed with the call bell to hand.

45. The notes show that Mrs B was encouraged with her physiotherapy sessions, but clinicians were also mindful of her health circumstances and stopped sessions when Mrs B was not able to engage with them due to her health circumstances. This is in line with the Chartered Society of Physiotherapy guidance which says physiotherapy intervention should be constantly reviewed and adapted to the patient’s changing health circumstances.

46. Our physiotherapy adviser said all sessions were clinically appropriate for Mrs B’s clinical presentation and were aimed at improving her mobility.

47. We consider the physiotherapy care provided to Mrs B was appropriate and in line with the Chartered Society of Physiotherapy guidance and we have not seen any indication of a failing here.

48. We are sorry to hear of Mr B’s concerns about his mother’s care and treatment during her June 2024 admission and we hope our decision provides Mr B with reassurance about what happened with his mother’s care.

1. We are very sorry to hear of the death of Mrs B on 13 December 2024. We recognise this has caused her son Mr B, and his family significant distress and upset, worsened by the complaints about the care and treatment she received. We would like to offer our sincere condolences for their loss and the grief they have experienced.

2. We have carefully considered Mr B’s complaint about Mid Cheshire Hospitals NHS Foundation Trust (the Trust). We have decided that we cannot investigate this complaint further. This is because we have seen no indications of failings in the care and treatment the Trust provided to Mrs B during her admission in June 2024.

3. We understand that this was, and continues to be, an upsetting time for Mr B. Our decision is not made without recognition of the upsetting circumstances around the events. We have explained the reasons for our decision below.