Guy's and St Thomas' NHS Foundation Trust

5. Mr A complains about the care and treatment he received at Guy's and St Thomas’ NHS Foundation Trust in July 2024.

6. Specifically, he complains the Trust:

• failed to monitor him appropriately while he was on the ward, which resulted in him falling • delayed providing a necessary blood transfusion, which also contributed to his fall • failed to inform his wife about his fall, which caused significant distress to Mr A and his family.

7. Mr A says because of the fall he spent a prolonged time in hospital and he developed heart failure. He says he continues to suffer from health complications from the incident.

8. Mr A says the lack of communication from the Trust caused significant distress to his wife and family.

9. As outcomes to his complaint, Mr A would like service improvements and a financial remedy.

10. Mr A is in his late seventies and has a history of irregular heartbeat, shortness of breath and heart disease.

11. Mr A had a left hip replacement at the Trust in 2007 which later required revision surgery in 2016.

12. Mr A underwent a further successful revision procedure on his left hip in June 2024.

13. Mr A fell on the recovery ward within several days of his operation. He also experienced seizures and rapid heartbeats in the days after the fall.

14. Mr A received critical care treatment before being transferred to a heart surgery recovery ward.

15. Clinicians discharged Mr A at the end of July.

Monitoring

19. The NMC code states nursing staff must recognise and work within the limits of their competence. It states to achieve this, nursing staff must accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care.

20. Mr A complains staff failed to monitor him appropriately on the recovery ward following his hip operation and after his subsequent fall. Mr A said a nurse told him he could go for a walk if he needed the bathroom. He considers he should have been supported due to his fragile state after his operation and the nurse’s advice put him at risk. Mr A also says his cardiac history made him a high-risk patient and after his fall he should have been monitored every 30 minutes.

21. The Trust apologised for the delay in communication which resulted in Mr A receiving incorrect mobilisation instructions. It explained at the time of his fall there was no documented physical limit from the medical team. The response also said his post-operative observations were satisfactory and he had been advised to call for assistance to mobilise. The Trust also acknowledged Mr A should have received neurological observations up until 8pm on the day of his fall and apologised this did not happen.

22. Mr A had a hip revision surgery in 2016. In the years leading up to 2024 he experienced significant left hip pain. Clinicians placed him on the waiting list for a second revision surgery which would involve the correction of the loosening of the left hip stem. The stem provides support and alignment for the hip joint ensuring effective leg movements.

23. Mr A attended Guys Hospital for his surgery towards the end of June 2024. The surgery was successful and he remained on the orthopaedic ward for recovery and observation. Mr A used a Zimmer-frame to mobilise following his operation and he received support from the physiotherapy team while he was in hospital.

24. Several days after the operation, the physiotherapy team discharged Mr A as he was mobilising independently on the ward with crutches. It is documented Mr A could mobilise around 50 metres and he could get up and down stairs safely. On the evening before Mr A’s fall his records show he was mobilising independently to the toilet with crutches and clinicians planned to discharge him the following day.

25. Clinicians had determined Mr A to be at risk of falling due to a lack of safety awareness. His records show on 29 June he had tried to mobilise without help and used his Zimmer-frame incorrectly.

26. Mr A’s records show that nursing staff monitored his progress and recovery throughout his admission which included his personal care needs, nutrition and hydration requirements, medications, communication issues and pressure areas. Nursing staff also used the NEWS2 scoring tool to monitor his progress.

27. National Early Warning Score 2 (NEWS2) is a scoring system used to monitor and identify critically ill patients at risk of deterioration. There are six physiological measurements which include temperature, respiratory rate, oxygen saturation, blood pressure, heart rate and level of consciousness.

28. Each measurement receives a score of 0,1,2 or 3. The scores are then combined. 0 – 4 is a low clinical risk, 5 – 6 a medium clinical risk and 7 is high clinical risk. A single score of 3 in any parameter is categorised as low to medium risk.

29. On the morning of Mr A’s fall staff recorded stable observations. He scored 1 on the NEWS2 scale due to a low blood pressure reading which was determined to be a low clinical risk. Clinicians stated Mr A was not for physiotherapy that day and advised him to call for assistance if he needed to mobilise. Mr A reported feeling lightheaded and dizzy and staff positioned him in bed with his legs raised. The records note his symptoms improved.

30. Mr A had a fall around 1.30pm which was seen by another patient on the ward, but unwitnessed by medical staff. Clinicians examined Mr A who reported pain at the back of his head, and they referred him for CT imaging.

31. Our adviser said nursing staff monitored Mr A appropriately and in line with NEWS2 guidelines. Our adviser also said Mr A did not require a high level of monitoring as his observations were stable, he was independently mobile, he had capacity and clinicians considered he was ready for discharge.

32. Mr A is concerned he should have received a higher level of monitoring due to his cardiac history, and he should have received hourly monitoring after his fall. From what we have seen, Mr A’s observations were within safe parameters which indicated he was clinically stable even in consideration of his underlying health conditions.

33. NG232 guidelines for suspected head injuries state observations should be carried out every 30 minutes until there is a GCS score of 15. The minimum frequency should be half-hourly for two hours, then hourly for four hours, and then every two hours. Mr A should have received neurological observations for at least eight hours following his fall which the Trust has acknowledged.

34. Our adviser said there does not appear to have been any clinical impact from the shortfall in neurological observations which amounted to just under two hours. Mr A’s CT scan results showed no evidence of injury or abnormality following his fall and these results had been reviewed before his neurological observations were stopped.

35. We hope Mr A is reassured he did receive appropriate monitoring following his hip operation. While we recognise staff stopped his neurological observations prematurely, we hope Mr A is reassured this did not have a clinical impact in him.

36. There is an indication of a failing here regarding Mr A’s neurological observations. We consider this did not result in an injustice to him and we will be taking no further action.

Blood transfusion

37. NG24 guidelines state patients with acute coronary syndrome should be considered for a blood transfusion when their haemoglobin levels drop to 80 g/L or lower. The target range for haemoglobin after receiving the transfusion should be between 80 - 100 g/L.

38. Haemoglobin is a protein within red blood cells containing iron which transports oxygen around the body. Normal levels for an adult male are between 130 - 170 g/L. A deficiency in red blood cells (known as anaemia) leads to a drop in oxygen delivery to the body’s tissues and can result in fatigue, shortness of breath, dizziness, headaches and heart palpitations.

39. Blood transfusions replace blood lost during surgery and for patients with conditions affecting red blood cell counts. Blood is administered intravenously, and the process can take up to four hours depending on the quantity needed. The patient’s observations are monitored before, during and after the procedure to check for possible reactions or complications.

40. Mr A complains there was a delay in giving him a blood transfusion following his surgery. He said this resulted in his haemoglobin levels dropping significantly which led to his collapse on the ward.

41. The Trust said Mr A’s haemoglobin levels had been monitored appropriately since his hip operation. It also said it had been the victim of a cyber-attack which had resulted in delays to patient care and acquiring blood for Mr A. The Trust also explained clinicians stopped Mr A’s transfusion so he could undergo CT imaging.

42. Mr A’s records show that in the days following his operation his haemoglobin remained above the limit of 80 g/L. This was within the safe level for a patient with cardiac concerns and, in line with NG24 guidelines, a blood transfusion was not required.

43. Nursing staff tested Mr A’s haemoglobin level the day before he fell, and the results came back in the early hours which showed a drop to 76 g/L. Nursing staff then requested blood which arrived shortly after Mr A’s fall and clinicians proceeded with the transfusion. Clinicians then stopped the transfusion as they determined it was unsafe for Mr A to have an ongoing transfusion while undergoing a CT scan.

44. Mr A’s haemoglobin level dropped to 69 g/L later that day. Clinicians administered a transfusion in the early hours of the following day which brought his level to 73 g/L. Mr A’s haemoglobin levels remained above 80 g/L for the rest of his stay in hospital and further transfusions were not required.

45. Our adviser said nursing staff did monitor Mr A’s haemoglobin levels appropriately. When his level dropped below 80 g/L they requested a blood transfusion, which was in line with NG24 guidelines and considered Mr A’s cardiac history.

46. Our adviser also said it would not have been appropriate to request a blood transfusion earlier than the morning of Mr A’s fall as his haemoglobin levels prior to this were stable. Mr A’s blood test results came back in the early hours of the morning of his fall. Our adviser said this meant it would not have been possible to prescribe the transfusion until later that morning meaning the blood would likely not be ready until the afternoon.

47. Mr A is concerned the blood transfusion delay was a factor in his fall. Our adviser said his haemoglobin level drop from 82 g/L to 76 g/L was not a significant reduction and there is no evidence the timing of the transfusion was a factor in his fall.

48. We hope Mr A is reassured that nursing staff did monitor his haemoglobin levels within NG24 guidelines. Staff also requested a blood transfusion when his levels dropped, and this was received within the same day.

49. There is no indication of a failing here and we will take no further action.

Communication with family

50. The NMC Code states nurses owe a duty of confidentiality to all those who are receiving care. This includes making sure they are informed about their care and that information about them is shared appropriately.

51. Mr A complains staff did not promptly inform his wife of his fall. He says the doctor contacted his wife the day after his fall and he considers the call should have been made on the same day due to the serious nature of the incident. Mr A also says a clinician told his sister they had spoken with his wife which was incorrect.

52. The Trust apologised for the distress caused and said the electronic records confirmed that a junior doctor had spoken to Mr A’s wife and sister on the evening of his fall. It said the doctor explained the events around the fall to his wife and sister, provided reassurance the CT scan results were satisfactory and tried to address the family’s concerns.

53. Mr A fell at around 1.30pm and a clinician spoke with his sister at around 5.30pm. The records state the clinician informed Mr A’s sister of the unwitnessed fall and that the CT scan of his head and neck were normal. The clinician explained Mr A was advised not to move independently and to call for assistance if needed.

54. The records show a clinician had a further discussion with Mr A’s wife and sister later that evening at around 8pm and explained he had low blood pressure and had been advised not to mobilise without assistance. Mr A’s sister explained a nurse had told him he could mobilise by himself without assistance and the Trust’s complaint response states it was unclear who this was.

55. Mr A’s records confirm clinicians did speak to his wife and sister on two separate occasions on the day of his fall. We appreciate Mr A’s recollection is different and the conflicting accounts mean we cannot take a view on what was said or when this occurred.

56. Mr A told us that he contacted his wife after his fall to inform her what had happened and he considers staff should have contacted her instead. We understand why Mr A’s wife and sister wanted to be informed of his condition promptly in view of his recent surgery and cardiac history.

57. We note Mr A had capacity throughout his hospital admission. He consented to his hip operation on his initial admission, and his records also show he consented to nursing interventions up until the time clinicians discharged him. We have not seen any evidence of a communication plan which details Mr A’s family should have been kept updated.

58. The Trust said that in line with usual clinical practice, patients with capacity are responsible for receiving and passing on updates to family members. It said patients can ask staff to contact their family with updates and this is specifically requested by the patient with an agreement on what is to be disclosed. The Trust said this was to maintain patient confidentiality.

59. We consider it was not mandatory for staff to contact Mr A’s family about his fall in line with the NMC duty of confidentiality guidelines mentioned earlier. The conflict between the Trust and family account of communication following Mr A’s fall means we are unable to know for certain what happened. Even if staff did not speak to Mr A’s wife until the day after the fall, we would not think this fell so far below what was expected as to be a failing.

60. We recognise Mr A had a very difficult time following his hip surgery and subsequent fall which led to a longer hospital stay and recovery time. We hope he is reassured by what we have found in our thorough consideration of his case.

1. We are sorry to hear about the circumstances which led Mr A to bring his complaint to us. We acknowledge his concerns about the fall he experienced when recovering from a significant operation and the effect this has had on his health and recovery. We also acknowledge his concerns around how staff monitored him, delays in his blood transfusion and how staff communicated updates with his family.

2. We have carefully considered Mr A’s complaint about Guy's and St Thomas' NHS Foundation Trust. On the matters of appropriate monitoring and delays in receiving a blood transfusion, we have seen no indication that anything went seriously wrong.

3. The conflicting accounts on Mr A’s concerns about communication between staff and his family following the fall means unfortunately, we cannot take a view on this part of his complaint.

4. This statement explains the reasons why.