Frimley Health NHS Foundation Trust

3. Miss A complains about the following aspects of care the Trust provided to her father in October 2024. She says:

• Mr X’s discharge to an intermediate care unit on 18 October 2024 was inappropriate, as he should either have been discharged home or kept in hospital • Mr X’s family were given no prior notice about his discharge to the intermediate care unit; therefore, they were unable to discuss this decision with Trust staff • The Trust did not complete an appropriate falls risk assessment and Mr X had a fall at the Trust on 25 October 2024, sustaining an eye injury as a result • Mr X was increasingly drowsy, but a second head scan was not done.

4. Miss A says the failings in care caused her father’s death. She also says she has experienced significant emotional distress due to the circumstances around his death, particularly given that at the time she was employed within the same department at the Trust.

5. As an outcome of this complaint Miss A would like the Trust to acknowledge the failings in the care her father received.

6. Mr X, a gentleman in his eighties, was admitted to the Trust following a fall at his home on 10 September 2024. Mr X had a history of recurrent falls following a previous stroke.

7. On 18 October 2024 Mr X was transferred to an intermediate care unit for rehabilitation. An intermediate care rehabilitation unit provides short-term support after a hospital stay when a patient is medically stable but not yet ready to return home safely. It focuses on recovery and independence through occupational therapy (help with everyday activities) and physiotherapy (improving strength, mobility, and balance).

8. On 19 October 2024 Mr X fell at the intermediate care unit. As the fall was unwitnessed, staff wanted to rule out a head injury; therefore, he was readmitted to the Trust on the same day for assessment.

9. On 25 October 2024 Mr X had a fall at the Trust and sadly died later that day. The Trust found multiple medical conditions contributed to his death.

Discharge to the intermediate care unit

13. Miss A complains her father’s discharge from the Trust to the intermediate care unit on 18 October 2024 was inappropriate, as he should either have been discharged home or kept in hospital. She says the fall he had at the intermediate care unit could have been avoided if he not been moved there, and this decision was not discussed with her before it was made.

14. We can see from the available evidence Mr X was assessed by the consultant doctor responsible for his care on 7 October 2024 and was considered medically fit for discharge. All following reviews by the clinical team, up until his discharge, continued to record that he remained medically suitable for discharge. We understand from this that, at the time of these assessments, no medical needs had been identified that required Mr X to remain in an acute hospital setting.

15. The records show that, when Mr X was transferred to the intermediate care unit, the plan remained for discharge planning to continue. This included ongoing occupational therapy and physiotherapy to support his recovery and prepare him for a safe return home. We can also see that occupational therapy assessments of his home environment were being undertaken to facilitate his discharge.

16. We can see from the Trust’s response that, at the time the decision was made to transfer Mr X to the intermediate care unit, the Trust was experiencing significant pressure on its emergency services and inpatient bed capacity. The Trust says that decisions about bed allocation were made according to patients’ clinical needs.

17. We understand from our conversations with Miss A and from Mr X’s medical records that an occupational therapist who was caring for him documented the following day, after his discharge, that she did not think he was ready for discharge at that time. The Trust’s response indicates that although it found Mr X to be medically suitable for discharge, it did recognise that he still required support with complex discharge planning, including the need for ongoing occupational therapy. Therefore, it had decided to transfer him to the intermediate care unit so that this work could continue. The Trust also explains that decisions of this nature are usually made by its bed management team, which is made up of experienced clinical nursing staff.

18. We understand from our adviser that there is no specific guidance on discharge decisions in circumstances such as these. Instead, decisions must be made by weighing the potential risks and benefits for the individual patient, in keeping with the DHSC and NHS England guidance mentioned above. We can see from the medical records and from our clinical advice that an intermediate care unit was an appropriate setting to meet Mr X’s ongoing rehabilitation needs, as such units are typically staffed by healthcare professionals including physiotherapists and occupational therapists.

19. Our adviser notes that, for a patient such as Mr X, any move between care settings may be unsettling and could temporarily increase confusion, which in turn may raise the risk of falls. We recognise this was an understandable concern Miss A raised. Having reviewed the available evidence with our adviser, we understand that Mr X remained at a high risk of falling in any care setting, whether in an acute hospital ward, an intermediate care unit, or at home. This reflects the complexity of his condition and means that, despite appropriate care and preventative measures, the risk of falls could not be fully removed in any environment.

20. In view of the above, there is nothing to suggest the Trust failed to follow relevant clinical guidance when it decided to transfer Mr X to the intermediate care unit. We recognise that the occupational therapist’s account has caused distress to Miss A by contributing to her fear that mistakes were made in Mr X’s discharge. We hope that setting out our views provides some clarity and reassurance that, based on the information available to us, there is no evidence to indicate that the decision-making process was inconsistent with relevant clinical guidance.

21. Miss A also complains she and other family members were given no prior notice about Mr X’s discharge to the intermediate care unit, and so they were unable to discuss this decision with Trust staff.

22. We can see from Mr X’s medical records that the Trust informed Miss A of his transfer to the intermediate care unit at approximately 9pm on the evening of the discharge. The records indicate that this notification was made shortly after the decision to transfer him had been taken.

23. In its response, the Trust explained that ward staff are often given limited notice when beds become available and that, particularly during periods of significant hospital pressure, patients may need to be transferred promptly. The Trust says that the ward nursing team was informed that evening that a bed had become available in the intermediate care unit and that Mr X was to be transferred there.

24. The available evidence suggests that, because the decision and bed availability arose at short notice, staff were unable to provide Mr X’s family with more advance notice of the transfer. The Trust has acknowledged this and apologised for the lack of notice given.

25. We understand from the DHSC and NHS England guidance referred to in our ‘evidence’ section that discharge arrangements can progress quickly once a patient has been assessed as medically suitable for discharge. The guidance recognises the importance of involving patients, families and carers in discharge planning where appropriate and possible. However, we understand there is no requirement for a minimum notice period before a patient is discharged or transferred to an intermediate care setting.

26. The available evidence indicates that the Trust informed Mr X’s family shortly after staff became aware that a bed was available in the intermediate care unit and the transfer would take place. We have not seen evidence of any significant or avoidable delay between the Trust being notified of the bed availability and Miss A being informed of the transfer.

27. In view of the above, we cannot see anything to suggest the Trust failed to act in line with relevant guidelines in not providing Mr X’s family with more notice about his discharge to the intermediate care unit. We are sorry to hear that the communication regarding her father's discharge caused Miss A distress and understandable concern about his care. We hope our report provides some clarity on the matter.

Falls risk assessment

28. Miss A complains the Trust did not complete an appropriate falls risk assessment and Mr X had a fall at the Trust on 25 October 2024, sustaining an eye injury as a result.

29. We understand from the Trust’s response that during Mr X’s stay on the ward, staff completed falls risk assessments and put measures in place to reduce the risk of falls. This included the use of falls mats fitted with movement-triggered alarms. The Trust also explained that its patient safety team reviewed the falls risk assessments as part of its investigation into the incident. The Trust says the review found that the appropriate assessments had been completed and that the preventative measures identified as necessary were in place at the time.

30. The NICE CG161 falls risk guidelines referred to in our ‘evidence’ section say that hospitals should consider a multifactorial falls assessment for any patients over the age of 50 who are considered to be at a higher risk of falls.

31. We can see from the available evidence that, prior to Mr X’s fall on 25 October 2024, the ward staff did complete falls risk assessments for him and put a falls alarm in place. We understand the fall unfortunately occurred when Mr X was walking to the toilet using a zimmer frame, which is a walking aid. We are aware from our adviser that falls risk assessments and preventative measures are used with an aim to reduce the risk of falls. As recognised earlier in this report, even where appropriate assessments have been completed and preventative measures are in place, it is not possible to eliminate the risk of falls entirely.

32. Therefore, our view is that the Trust did complete appropriate falls risk assessments for Mr X during his admission on the ward and followed the applicable guidance in doing so. We recognise the seriousness of Miss A’s concerns, and we hope our explanations provide some reassurance that appropriate assessments were carried out in line with recognised guidance at the time.

Repeat computed tomography (CT) head scan

33. Miss A complains that, although Mr X became increasingly drowsy after his initial CT head scan, a second scan was not carried out on 25 October 2024.

34. We can see from the available evidence that Mr X sustained a visible head injury following his fall on 25 October 2024. His medical records show a doctor examined him at approximately 10.25am and he was noted to be drowsy. Mr X then underwent a CT head scan, which showed ‘no acute intracranial pathology’. This means no abnormality was identified, including no evidence of bleeding in the brain. It was noted from the records that he had an acute Covid-19 infection at the time, together with raised infection markers.

35. Mr X was reviewed by a consultant later that day during the ward round at 1.05pm. He was noted to remain drowsy and unwell. At 5.20pm, the clinical team found his oxygen levels and blood pressure were low, and provided treatment for his chest, which improved his oxygen levels. At 7.49pm, shortly before his death, Mr X’s condition sadly deteriorated further, with another drop in both oxygen levels and blood pressure. We understand from our adviser a low blood pressure and oxygen levels can also cause drowsiness.

36. We can see that, the day before the fall, Mr X was reviewed by a doctor who noted blood test results indicated a worsening infection. We can see from the medical records, in response to this, his antibiotic treatment was escalated from a single oral antibiotic to a combination of intravenous antibiotics, which are antibiotics that are given straight into a vein through a drip or cannula. We understand that Mr X had tested positive for Covid-19, and that a repeat chest X-ray showed worsening signs of infection together with fluid build-up in the lungs.

37. We understand from our adviser that Mr X’s medical records show his condition was gradually deteriorating, before his fall on 25 October 2024, from a worsening chest infection, and there is nothing in the available records to suggest that a repeat CT head scan would have identified any treatable or reversible cause for his condition. Our adviser also explained that carrying out a further scan may have caused Mr X further discomfort and may have negatively affected the delivery of his care while he was critically unwell. In those circumstances, we understand it would not have been appropriate to perform a repeat scan.

38. The NICE NG232 guidelines referred to in our ‘evidence’ section say the decision to undertake further imaging is based on the patient's overall clinical assessment, and our independent clinical advice shows a repeat CT head scan was not considered clinically indicated at that time.

39. In view of the available evidence, we can see that the Trust did not fail to act in line with applicable guidelines in not carrying out a repeat CT head scan for Mr X.

40. In light of the above we have decided to take no further action. We are sorry to hear of the distress Mr X’s daughter experienced, and we hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it. We hope our independent view offers some clarity and reassurance to Mr X’s family. We would like to thanks Miss A for bringing her concerns to our attention.

1. We have carefully considered Miss A’s complaint about the care and treatment provided to her late father, Mr X. We were very sorry to hear of her loss and the experience she has shared with us.

2. Having reviewed the evidence available to us, we have not seen any failings in Mr X’s care and treatment by the Trust. For this reason, we do not uphold the complaint. We hope this report fully explains the reasons for our findings.