County Durham and Darlington NHS Foundation Trust

5. Mr G complains about the following aspects of care and treatment County Durham and Darlington NHS Foundation Trust (the Trust) provided him in October 2021.

6. Mr G says the Trust did not properly assess his risk of falls throughout his admission as a vulnerable patient with a history of collapsing. Staff did not include this detail in the ward handover.

7. He says this meant staff allowed him to go to the toilet unattended. He collapsed and this has had a significant mental and physical impact on him, including blurred vision, poor memory, change in character and emotions, and insomnia.

8. Mr G complains the Trust did not act on or investigate the concerns he then reported about his blurred vision before it discharged him.

9. Mr G also complains the Trust did not investigate his complaint in line with the seriousness of it. He says it had informal, undocumented conversations with staff, which meant it has been difficult to get clear answers. He says it took too long to respond to his complaint and withdrew the offer of a meeting after several months. He complains the Trust gave contradictory responses about whether staff left him to go to the toilet alone and wrongly said he did not report blurred vision.

10. He says the Trust’s failure to care for him as it should have, and how it handled his complaint caused him frustration and he feels deeply hurt by the experience. It occupies his thoughts most of the time and has had a significant impact on his mental health. He has also lost trust in hospitals, and he avoids medical treatment.

11. Mr G would like the Trust to acknowledge what it got wrong and apologise for the significant impact this has had on him. He would also like the Trust to improve its service so no one else has to experience what he has gone through. He would like the Trust to pay him a financial remedy for the impact this has had on him.

12. In September 2021 Mr G was referred to cardiology at the Trust as he had been having blackouts since March 2021 which were worsening. By this time they were leading to a loss of consciousness followed by memory loss. The events mainly happened when standing but did also happen when sitting.

13. After investigations, the Trust decided he needed to have a pacemaker implant fitted. Mr G attended for this on 1 October. Shortly before his procedure he had an episode of losing consciousness whilst in a chair and staff held him up.

14. Mr G says before his procedure he also had an episode when alone in the toilet causing him to fall. He cannot remember what happened after that and his next memory is in theatre as his procedure began. The Trust has no record of any fall and says staff were not made aware of any fall, but it acknowledges Mr G went to the toilet alone as staff saw him return to his bed. Mr G says after his surgery he had difficulties with his vision for about a week. The Trust discharged him on 4 October.

The Trust did not properly assess his risk of falls

19. NICE guidance for assessing the risk of falls says staff should do a multi-factorial risk assessment where the patient has suffered falls within the past year. It says the assessment should identify the patient’s individual risk factors for falling in hospital so these can be treated, improved or managed during their stay. This includes where the patient has a falls history, health problems which increase their risk of falling and syncope syndrome (fainting/ temporary loss of consciousness). The guidance says all patients aged 65 and over should automatically be considered at risk of falls.

20. The Trust reviewed Mr G in the ED on 30 September and correctly noted he was at risk of falls due to syncope episodes. His age, early 70s at the time of his admission, would also be a factor. However, when the Trust assessed his falls risk at in the early hours of 1 October, it said he was not at risk of falls. Our nursing adviser says this was not an accurate representation of Mr G’s falls risk in line with NICE guidance. The risk assessment should have identified Mr G’s age, falls history, health problems that increased his risk of falling and syncope episodes.

21. There is also no evidence Mr G’s falls risk was communicated on handover from the ward to the cath lab (an examination room where imaging and pacemaker insertion is done). We think this was important, particularly due to the nature of Mr G’s episodes as he can seem well and mobilise but then have a sudden episode. There is a checklist which suggests staff reviewed his medical notes, meaning staff should have been aware of Mr G’s history of syncope episodes. Mr G says despite this, staff left him unattended to go to the toilet in the cath lab.

22. We know before his procedure Mr G briefly lost consciousness and staff caught him in a chair. The record says this happened ‘just after arrival at cath lab’. The Trust says staff saw Mr G go to the toilet before this episode. Mr G’s view was that he went to the toilet and collapsed after it, and it was the last thing he remembered before being in his operation. There is not enough evidence for us to say whether the syncope episode staff saw was before or after his fall in the toilet.

23. Either way, NICE guidance says there should be interventions to address the risk factors of falling in hospital and to improve and manage this risk. Our nurse adviser says as Mr G had capacity, the Trust should have informed him that he was at a high risk of falls and offered interventions such as assisting him with mobilising, going with him to the toilet or offering him a bed pan. This is in line with the NMC code which says you must work in partnership with people to deliver care effectively, and encourage and empower people to share decisions about their care. It would then have been Mr G’s decision whether to accept this support.

24. Mr G disagrees that he should have been given the choice, given the nature of his episodes. He was able to mobilise but his syncope episodes were occurring more often and there was no warning. In any event, there is no indication the Trust gave these options of support and we cannot see any evidence staff put in place any interventions to mitigate the risk of Mr G falling.

25. We acknowledge the records show that throughout the admission staff assessed Mr G as being independent with mobility and hygiene needs. Our nursing adviser says this may be why the Trust felt that Mr G was a lower risk of falls. Mr G may have been able to independently mobilise, but he was still at a high risk of falls due to the factors set out above and in the NICE guidance. We have therefore found a failing as the Trust did not properly identify and communicate this between staff, or put any interventions in place. We consider the impact of this below.

Impact

26. Mr G says because of these failings it meant staff allowed him to go to the toilet unattended. He says he then collapsed in the toilet and this has had a significant mental and physical impact on him, including epilepsy, blurred vision, poor memory, a change in character and emotions and insomnia. He also says the Trust’s failure to care for him as it should have caused him frustration and he feels deeply hurt by the experience. It occupies his thoughts most of the time. He has also lost trust in hospitals, he does not like to be left alone or treated there and will not be anaesthetised.

27. The Trust has no evidence of Mr G’s fall or injuries. So we got clinical advice to look at whether any of the impacts Mr G describes are linked to injury from a fall, to consider whether these could have been avoided.

28. Our neurology adviser reviewed Mr G’s imaging from a few months later and said this showed no signs of a head injury. We do not doubt Mr G’s account that he fell. For a head injury to cause epilepsy and the symptoms Mr G describes, our neurology adviser said you would expect to see evidence of a significant head injury on his imaging. The symptoms Mr G had before his admission indicate his epilepsy is more likely than not to have been present but undiagnosed rather than caused by a fall. The episodes he was having are consistent with epilepsy. Our neurology adviser says it is not uncommon for patients to also be investigated for cardiac episodes and need a pacemaker as Mr G was. These conditions can be concurrent or related to each other.

29. We acknowledge there was a delay between when Mr G had the fall and when he had scans. Our neurology adviser explained a smaller injury would not necessarily show on the scans, but if Mr G had the chronic symptoms he describes as a result of an injury, you would expect to see that significant a head injury on a later scan. A smaller injury would not have those impacts. We also cannot say Mr G’s blurred vision was as a result of a head injury. Again, there is no evidence of an injury on the scans. This would indicate it was related to something else, rather than a fall.

30. Mr G describes other symptoms, such as memory difficulties, a change in character and emotions and insomnia. Whilst we cannot know for certain, our neurology adviser says these symptoms could be linked to Mr G’s epilepsy medication, as these are side effects of lamotrigine and epilepsy itself.

31. When we weigh up the evidence, this does not show us Mr G developed the symptoms he described because of a fall and a head injury. We therefore cannot say these symptoms could have been avoided if the Trust had identified him as at risk of falls as it should have.

32. We can, however, see why Mr G has been left feeling frustrated and deeply hurt by the experience, which occupies his thoughts most of the time. He has also lost trust in hospitals, and avoids medical treatment. We appreciate he feels this way because the Trust did not do what it should have. We think he would have avoided this if he had been confident the Trust had done what it could to keep him as safe as possible from falling.

The Trust did not act on or investigate his concerns about blurred vision

33. Mr G complains the Trust did not act on or investigate the concerns he then reported about his blurred vision before it discharged him.

34. The NMC code says nurses must accurately identify, observe and assess signs of normal or worsening physical health in the person receiving care and make a timely referral to another practitioner when any action, care or treatment is required. The GMC’s Good medical practice says when providing clinical care you must adequately assess a patient’s condition, taking into account their symptoms.

35. A nursing note on 1 October at 11.45am, after his pacemaker procedure, says Mr G said ‘he has been experiencing sight disturbances from yesterday. Unable to read using both eyes due to his vision being unbalanced.’ This indicates Mr G may even have had sight disturbances from before his admission, although he feels this started after he fell. We cannot, however, see any evidence the nurse escalated these visual issues to the medical team for further investigation. This is not in line with the NMC code.

36. The Trust assessed Mr G later the same day, at 1.20pm. There is no indication this assessment was because Mr G told a nurse about his sight concerns. It was a post-operative cardiology check. This noted on examination he had no nystagmus (uncontrolled eye movement affecting vision), double vision or dizziness on ‘H test’. A H test is an eye movement examination, to check for dizziness and vestibular disorder (conditions impacting the inner ear and brain, disrupting balance). Mr G cannot recall an examination in relation to checking his vision or what that involved.

37. Whilst the Trust did not identify any concerns when it later examined Mr G, we think had the nurse escalated his concerns to the medical team at the time, the Trust would have specifically investigated this symptom to rule out a possible cause, in line with the GMC guidance. Mr G has little memory of this assessment and the nurse had not made the doctor aware of Mr G’s reported sight difficulties.

38. We have found a failing as the evidence we have seen indicates the Trust did not escalate or thoroughly investigate Mr G’s symptoms of blurred vision when he reported them, as it should have in line with the NMC code and GMC guidance.

Impact

39. We think the Trust should have done more, but we cannot say exactly what it should have done. Our neurology adviser says further investigation could have included CT scan if indicated. But we do not know whether it would have been indicated. However, even if Mr G did not need any further treatment, the Trust could have at least reassured him.

40. Mr G says his blurred vision lasted up to a week. Our neurology adviser says this could be due to multiple reasons. Our neurology adviser says medications used during and after surgery can lead to temporary vision changes, including blurred vision. These effects usually resolve in the fullness of time, as in this case. For example, he was given levobupivacaine during surgery and a possible side effect of this is blurred vision.

41. As we do not know the exact cause, we cannot say Mr G could have avoided his blurred vision if the Trust had done further investigation or whether this was treatable. We know it lasted up to one week and resolved itself. However, we understand further investigation and a possible explanation for this would have been reassuring for him at a worrying time, particularly following his fall. We understand why Mr G thought this was a side effect of his fall, and possible concussion. We have seen no indication of this. But we appreciate why Mr G feels upset by what happened, and that this contributed to him losing trust in future hospital care.

Complaint handling

Timescales

42. Mr G says the Trust took too long to respond to his complaint and withdrew the offer of a meeting after several months.

43. The Trust’s complaints policy says a standard complaint will take up to 30 working days to investigate and respond to, and a complex complaint up to 60 working days. A complex complaint is in excess of 20 issues, in excess of three care groups and/or multiple organisations. It also says it will consider whether a meeting with the complainant would be an appropriate way to address their concerns.

44. Mr G initially made enquiries with the Trust about his concerns in December 2021, but raised a formal complaint on 29 January 2022. It is not clear whether the Trust categorised Mr G’s complaint as complex, but looking at the response there were six questions. It should therefore have sent the response within 30 working days.

45. The Trust responded on 20 May, 78 working days later. The Trust exceeded the timescale for both a standard and complex complaint. The Trust updated Mr G on 22 April about the delay after he had chased this in March. There is nothing in the evidence we have seen to explain why the Trust took so much longer than set out in its policy to respond to Mr G’s complaint. Based on the evidence we have seen, we have found a failing in that it took the Trust four months to respond to the six questions Mr G raised with it.

46. Mr G called the Trust’s response on 1 June, to say he would be responding to its letter, which he did on 9 June. During that call the Trust offered a meeting. Mr G called the Trust again on 11 July to ask when the meeting would happen. He involved an advocate a month later due to a lack of response from the Trust. The Trust told him in September it had little success arranging the meeting and would come back to him. Mr G contacted us in October and then received a response from the Trust on 11 October. It said the Trust no longer felt a local resolution meeting was appropriate and signposted Mr G to us.

47. The Trust acknowledged it should not have done this. We agree as this was not in line with our Principles of Good Administration. These say public bodies should do what they say they are going to do, keep to it or explain why they cannot. The Trust explained why it felt a meeting was not appropriate, but we think it took too long. It took it four months to reach this decision and inform Mr G it was no longer offering the meeting.

48. Mr G brought his complaint to us in December 2022 and on 2 May 2023 we asked the Trust to provide a further response as there were unanswered questions. We sent those to it. The Trust said it would respond by 14 July. It responded on 22 September. It took it five months. We accept on this occasion there were 26 questions answered, so it was a complex complaint. But the Trust exceeded its timescales in its complaints policy as this took 101 working days.

49. On 23 July 2024 we asked the Trust to investigate Mr G’s outstanding concerns about his sight problems during his admission. As the Trust had not yet responded to the issue involving this, as it said there was no record, we asked it to investigate and provide a response to Mr G. It responded on 7 November. We were in contact with the Trust throughout and agreed extensions to providing this response in September. The reason the Trust gave was that it was waiting for information to be in a position to answer the second issue. This response took the Trust 78 days.

50. Overall we can see the throughout its complaint handling the Trust consistently exceeded the timescales in its policy significantly. We also think it took too long to tell Mr G it was no longer offering him a meeting. We have therefore identified failings in its complaint handling due to these delays. We consider the impact of this later in our report.

Quality of its responses

51. Mr G also complains the Trust did not investigate his complaint in line with the seriousness of it. He says it had informal, undocumented conversations with staff, which meant it has been difficult to get clear answers. He feels he has had to push for answers from the Trust for a long time. He also complains the Trust gave contradictory responses.

52. The Trust’s complaints policy says investigating may include undertaking an initial review of the patient’s notes and determining the specific information to be obtained from the staff involved. It says the care group are responsible for requesting statements from those involved, and to collate statements to ensure all issues have been responded to appropriately. The NHS Complaint Standards say NHS organisations should take a thorough and balanced look into the issues in a complaint.

53. We think that due to the nature of this incident, and because there were no records of what Mr G says happened, it would have been helpful for the Trust to get full detailed statements from staff when Mr G first complained, so there was a recent and accurate account of what they could recall from his time in the cath lab. Instead, the Trust had informal conversations due to the lack of evidence in the records of a fall, and later had to go back to staff for more information. This has meant the Trust has disclosed details at various points of its complaint handling, rather than having all the information and a clear picture at the outset that there was a chance Mr G had been to the toilet unattended and fallen.

54. The Trust’s response in May 2022 says the doctor found no evidence in the records that Mr G had been unsupervised in the toilet in the cath lab. But in a later response in November 2024 the Trust confirmed staff did recall Mr G attending the toilet alone, for his privacy. It also says it was after he went to the toilet, whilst sat in a chair in the lab, that he had a vacant episode which was witnessed by the nursing team. Whilst the Trust says this is due to a difference in how the question was asked, the Trust knew Mr G wanted to know whether staff had any information that might help him understand what happened to him in the toilet.

55. The information provided in 2024 was new information the Trust did not provide in its initial responses. As there were no records of what happened, it was even more important to thoroughly investigate and get as much information from the staff members present at the time, to answer his complaint. Had the Trust asked staff about this in 2022, he would have had a clearer answer and understanding much sooner. Instead Mr G had to pursue the matter for a number of years to get these answers.

56. The Trust also did not initially investigate Mr G’s concerns of his reported sight disturbances during his admission, as it said there was no record of this. But this was incorrect. There was a record of this, so we asked the Trust to investigate and respond which it did in 2024. The Trust missed this record when investigating the complaint previously.

57. We think this indicates the Trust did not investigate Mr G’s complaint as thoroughly as it should have when he initially raised it, in line with the NHS Complaint Standards. These are answers the Trust should have given Mr G in January 2022. As it did not, he had to wait over two years for answers to all his questions.

Impact

58. Mr G has told us how the Trust handled his complaint caused him considerable frustration and he feels deeply hurt and upset by the experience. It occupies his thoughts most of the time and has had a significant impact on his mental health. He found it very discouraging that his efforts to raise his concerns with the Trust resulted in unclear or no answers. He has also lost confidence in it, as he feels the Trust was not open and honest with him in its responses. He feels it suggested he had made things up and feels exhausted by trying to pick away at finding out what happened himself.

59. We appreciate how the Trust handled Mr G’s complaint has led to him feeling this way. We acknowledge Mr G would have always felt disappointed to some extent, as the Trust had no evidence of his fall to give him any more information about what happened. But we think he would have felt reassured if the staff involved had provided clear statements about their recollection at the outset, to try and help Mr G piece what happened together as much as possible. We think had the Trust investigated the complaint thoroughly at the beginning, this would have avoided Mr G feeling this way.

What the Trust has done to put things right

60. The Trust acknowledged that given Mr G’s presenting condition, it should have recognised and communicated he was a high falls risk on handover. It did not acknowledge it completed the risk assessment incorrectly, or that preventative measures should have been put in place. It did not fully acknowledged the impact this has had on Mr G. We appreciate due to limited evidence, the Trust could not say the fall had definitely happened. It did not acknowledge it was a possibility, or identify any improvements for the failing it found.

61. The Trust did not recognise it did not escalate Mr G’s symptoms of blurred vision or thoroughly investigate them at the time. It therefore did not outline any service improvements or apologise to Mr G for the impact this had on him.

62. The Trust acknowledged it was wrong to withdraw the offer of a meeting with Mr G to discuss his concerns. It did not apologise for the delays throughout its complaint handling. It also did not acknowledge it told Mr G there was no record documenting his sight disturbance when there was, or apologise for not responding to this issue at the outset. It acknowledged information in its responses seems contradictory, but advised it was due to how the questions were asked. It did not recognise in the circumstances and limited evidence in the records, it would have been appropriate to take staff statements to get an accurate account of their recollection of Mr G’s admission. It did not apologise for the impact these complaint handling issues have had on Mr G.

63. We think there is more the Trust should now do to recognise the failings we have found, to apologise to Mr G for the impact these have had on him and to identify service improvements. Our recommendations are set out below.

1. We partly uphold Mr G’s complaint. We have found the Trust should have assessed Mr G at high risk of falls and put in place preventative measures. We have not found evidence to indicate Mr G’s symptoms are linked to a head injury from his fall. We understand why he has been left feeling frustrated and deeply hurt by what happened and why he has lost confidence.

2. We have also found the Trust did not appropriately escalate or act on his reported vision difficulties. We have not seen any indication this was a result of concussion from a head injury. But we think Mr G’s worries around this could have been avoided had the Trust explained this to him at the time.

3. We have found the Trust took too long to respond to Mr G’s complaint and to tell him it was no longer offering him a meeting. We also do not think it investigated his complaint at the outset as thoroughly as it should have. We think the Trust could have avoided the impact these failings had on Mr G.

4. We recommend the Trust writes to Mr G to acknowledge what it got wrong. We also ask it to apologise for the impact the failings have had on him, and to pay him a financial remedy to recognise this. We also ask it to produce an action plan to explain the improvements it will make to its service to avoid these failings happening again.