Leeds Community Healthcare NHS Trust

4. Mr O complains about the care and treatment that the Practice and the Trust provided Mrs O in June 2023.

5. He says the Practice and the Trust failed to properly manage his mother’s pain throughout June 2023. He says by failing to do so, each organisation failed to identify that his mother had an infection and failed to treat it.

6. Mr O said that all his mother’s symptoms in June 2023 pointed to an infection, but the Practice and the Trust said these were age and dementia related. He said the lack of earlier recognition and intervention meant there was a delay in treating the infection. He said this failure affected his mother’s physical condition and recovery and contributed to her death in September 2023. He said the organisations left his mother to suffer in the last months of her life and this has distressed him.

7. Mr O is seeking service improvements.

8. Mrs O was a 96-year-old lady who was diagnosed with vascular dementia. She was bed bound for around two years. She had support from her family, and carers attended four times a day.

9. Throughout June 2023, Mrs O suffered from unexplained pain, particularly when care staff repositioned her to attend to her personal care. Practice staff attended Mrs O’s home on three occasions to assess her condition.

10. Mr O requested stronger pain medication to help his mother. He also requested antibiotics to help treat her condition. The Practice considered Mr O’s request and decided that a pain patch was not suitable. It advised that Mrs O should continue with regular paracetamol and monitoring and her family should consider whether it was appropriate for her to move into a care home. It explained to Mr O that antibiotics were not clinically appropriate as there was no sign of infection.

11. The Trust’s Neighbourhood Nursing Team attended Mrs O at her home throughout June 2023 to assess and manage Mrs O’s skin. It noted that Mrs O had bed sores to her sacrum (the area at the base of the spine) and heels and moisture-associated skin damage (MASD) to her armpits, groin and breasts.

12. The Trust continued to assess Mrs O’s condition throughout June 2023 and reached the conclusion that Mrs O’s long terms needs would be better served in a care home. It started to discuss this with Mrs O’s family. Mrs O was admitted into hospital before a plan could be agreed. Sadly, in September 2023, Mrs O died from pneumonia while in hospital.

16. Mr O told us that his mother was struggling with her pain levels in June 2023. He said that she would cry out in pain and at first, he thought she had pain in her hips or was suffering with stiffness. Mr O said she had open wounds and in the past these had healed quickly. As the month went on, her symptoms did not improve, and her wounds showed no signs of healing. He said the wounds and ongoing pain led him to believe that Mrs O had an infection. He said that he asked for stronger pain medication and antibiotics to help manage his mother’s symptoms, but his request was refused.

17. He said that in June 2023, both the Practice and the Trust attended his mother at home and after seeing the poor condition his mother was in, the Practice and the Trust focused on his mother’s vascular dementia diagnosis as the cause of her symptoms and pushed the family into considering a care home placement.

18. Mr O said he made his worries about Mrs O’s health clear to both the Practice and the Trust at the time. His mother suffered in the last weeks of her life and had the infection been picked up and treated in June, then her physical condition may not have worsened. He said that the delay in identifying and treating the infection contributed to Mrs O’s death in September 2023.

The Practice

19. We considered, with the input of our GP adviser, the actions of the Practice in managing Mrs O’s pain.

20. Mrs O’s GP records show that Practice staff visited Mrs O three times, on 7, 16 and 27 June 2023. Our GP adviser explained that the medical records say that Mrs O’s condition was difficult to assess due to a lack of cooperation and at times she displayed aggressive behaviour.

21. The GMC’s guidance for Good Medical Practice sets out how clinicians provide good medical care.

22. ‘Domain 1 – Knowledge, skills and performances’ sets out how clinicians apply knowledge and experience to practice.

23. Point 15 says ‘you must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

• Adequately assess the patient’s condition(s), taking account of their history (including the symptoms and physiological, spiritual, social and cultural factors), their views and values; where necessary examine the patient.

• Promptly provide or arrange suitable advice, investigations or treatment where necessary.

• Refer a patient to another practitioner when this serves the patient’s needs’.

24. Point 16, a-f says ‘in providing clinical care you must:

• Prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.

• Provide effective treatments based on the best available evidence.

• Taken all possible steps to alleviate pain and distress whether or not a cure may be possible.

• Consult colleagues where appropriate.

• Respect the patient’s right to seek a second opinion.

• Check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving, including (where possible) self-prescribed over-the-counter-medication.

25. On 27 June, the Practice had its paramedic staff member attended Mrs O’s home and was able to take a ‘fairly thorough’ examination. Paramedics like these work outside of the ambulance service in primary care multi-professional teams to support general practice in the community. Mrs O’s medical records do not show that she was in severe pain and showed no clinical signs of infection. The records show that the Practice explored other options for pain relief due to Mr O’s concerns that paracetamol was not controlling his mother’s pain. Our GP adviser said that there was an appropriate treatment plan in place and the Practice followed through on this. This is in line with the GMC guidance.

26. On 28 June, the Practice had a telephone consultation with Mr O, who was with his mother at the time. A clear medical history for Mrs O is recorded in the medical records. Mr O requested a pain patch and antibiotics to help treat his mother’s condition. The Practice declined the request for antibiotics as there seemed to be no clear indication for them from the history taken. Our GP adviser said that this decision appears appropriate and in line with the GMC guidance.

27. During the telephone consultation, the Practice said that it would discuss the pain patch with a GP. Our GP adviser said that there appeared to be a question about the level of pain Mrs O was in and the Practice decided not to prescribe a pain patch. This decision appeared reasonable as we understand from our adviser that prescribing strong, opiate pain medication in a frail, elderly patient without a strong reason to do so would put them at risk of significant sedation, which puts the patient at a higher risk of falls.

28. Based on Mrs O’s medical records and the advice we have received, the Practice rightly considered that Mrs O was a very frail, elderly lady with vascular dementia and was bed bound. Such patients’ needs are difficult to assess, but Practice clinicians were able to examine Mrs O, and the examination was as thorough as could be reasonably expected in the circumstances. There is no evidence from Mrs O’s clinical history or examinations that she had an infection at the time (prior to her hospital admission).

29. Such patients’ conditions can change very easily and rapidly. We can see that Practice staff always appeared to provide safety netting advice (advice which explains what the family could do if Mrs O’s condition deteriorated) so that if there were any changes in Mrs O’s condition, her family had been informed what to do.

30. We have not found any indications that the Practice failed to manage Mrs O’s pain in June 2023, nor have we found that it failed to identify that she had an infection, and so we will take no further action.

The Trust

31. We can see from the nursing records that the Trust’s neighbourhood nursing team was primarily involved in Mrs O’s care to help manage the breakdown of her skin rather than her pain.

32. The nursing records show that the Trust recorded care plans within its system noting that it needed to discuss Mrs O’s pain over her pressure areas, complete a pain assessment (if necessary) with her carers and monitor that a repositioning regimen was being followed. These care plans noted that any problems or issues should be reported to an appropriate registered member of staff. We have limited information to explain the exact instructions left for the nursing team and Mrs O’s carers.

33. We considered the management of Mrs O’s pain with our nursing adviser. Our nursing adviser highlighted that there are many different reasons why people with dementia could have pain, such as inactivity or poor positioning. Healthcare professionals can use the Pain Assessment in Advanced Dementia (PAINAD) scale to determine if someone is in pain. The Abbey Pain Scale is another tool that can be used to assess pain in patients who cannot verbalise what they are feeling. There is no evidence in the nursing records that a pain scale was used.

34. It is clear from the nursing records Mrs O was very agitated. There is no evidence in the records that the nurses considered whether this agitation may have been due to pain, nor is there evidence that the nurses formally assess Mrs O’s pain.

35. Section 3.3 of the NMC code says nursing staff should ‘act in partnership with those receiving care, helping them to access relevant health and social care, information and support when they need it’. There is no evidence in Mrs O’s nursing records that a pain scale was used. From the evidence we have seen and the clinical advice, this indicates a missed opportunity from a nursing perspective to thoroughly assess Mrs O’s pain. This is not in line with the NMC code.

36. We also considered with the input of our nursing adviser if in failing to assess Mrs O’s pain as thoroughly as it should, the Trust failed to identify that she had an infection and failed to treat it.

37. The care planning in Mrs O’s nursing records shows that nursing staff identified the individual areas of concern and noted that if there are signs of infection in any area then its wound infection framework should be followed. It noted that the wounds should be reassessed every four weeks or sooner if the area deteriorated. Other than these notes, there is limited information in Mrs O’s nursing records to say what instructions were left for the nurses and Mrs O’s carers in relation to wound care.

38. Mrs O’s nursing records explain that she had pressure sores to her sacrum, hip and both heels. She also had MASD under her breasts and armpits. Our nursing adviser said that the MASD was due to Mrs O being non-compliant with her hygiene needs.

39. Wounds International Best Practice Recommendations: Prevention and Management of MASD, 2020, identified that intertriginous dermatitis (a form of MASD) has a high likelihood of developing infection.

40. Our nursing adviser explained that while there is no evidence in the medical records of the category, the size or the appearance of the pressure sores, there is also no indication in the records that Mrs O had an infection at that time or that a wound swab (to rule out infection) was required. As such, we cannot say that the Trust failed to identify that Mrs O had an infection in June. It is clear from her medical records that her vascular dementia played a major part in the care the team were able to provide.

41. Section 8 of the NMC code says how staff must work co-operatively. Section 8.3 says ‘keep colleagues informed when you are sharing the care of individuals with other health and care professionals and staff’. Section 8.6 says ‘share information to identify and reduce risk’.

42. The NMC code explains that clear and effective communication and a cooperative approach between the nursing staff is expected. This will ensure that the best care and treatment is provided to a patient. We can see that attempts were made to communicate within the nursing team the importance of monitoring and escalating the care of Mrs O’s wounds if necessary.

43. From Mr O’s explanation of Mrs O’s condition throughout June, we appreciate the distress that seeing his mother in pain caused him and his family. From our work and the advice we received, the evidence does not indicate that the Trust failed to manage Mrs O’s pain. However, we have identified a missed opportunity from a nursing perspective to further assess Mrs O’s pain.

44. We considered whether we could reach the view that the missed opportunity to assess Mrs O's pain meant that there was a failing to identify and treat an infection. We understand that when Mrs O was admitted into hospital, its staff identified an infection and provided treatment. We appreciate Mr O’s view that the infection should have been identified by the Practice and the Trust sooner and had that been the case, this infection may not have contributed to her sad death in September 2023.

45. Based on the information we have seen, we are unable to agree that the Practice and the Trust failed to identify and treat Mrs O’s infection. The evidence we have seen does not indicate that Mrs O had an infection in June 2023. We have not seen any indications of failings in the Practice and Trust’s actions which led to the impact that Mr O describes. This means that we cannot say that the events of June 2023 contributed to her sad death, three months later, nor any other impact from the missed opportunity to further assess pain that the Trust needs to put right.

46. We were sorry to hear of Mrs O’s death and the impact that this had on Mr O and his family. He shared how well loved his mother was and the role she played in her family. We understand that his complaint is important to Mr O and we thank him for sharing his concerns with us. We hope he will be reassured that we have not found anything to make us think that we need to ask the Practice and the Trust to take further action in relation to the issues considered.

1. We have carefully considered Mr O’s complaints about the Practice and the Trust’s management of his mother, Mrs O’s, pain in June 2023. Having done so, we have not seen any indications of failings the Practice’s management of Mrs O’s pain.

2. We have seen indications that there were missed opportunities for the Trust’s nursing staff to assess Mrs O’s pain. We have not seen that those missed opportunities led to the Trust failing to identify or treat an infection in June 2023. This means we have not seen any impact to Mrs O or her son that needs to be put right. For this reason, we will take no further action.

3. We were very sorry to hear about Mrs O’s death, and the impact that this had on Mr O and his family. We hope that he will be reassured by the information in this statement and our independent view.