Sussex Community NHS Foundation Trust

4. Mrs A complains that on 30 May 2024, a district nurse let her husband, Mr A, fall off his bed at home while caring for him. She also complains that the Trust should have sent two district nurses to care for her husband, which might have prevented the fall.

5. Mrs A says that the fall was incredibly distressing for Mr A, and he had a fear of carers following this fall. The fall and the nurse’s actions following the fall also impacted her and her children, as they still have nightmares about what happened.

6. Mrs A is seeking an apology, financial remedy and service improvements.

7. Mr A was in hospital for a month in May 2024 receiving palliative care for terminal cancer. Whilst in hospital, staff diagnosed Mr A with new neurological symptoms, the progressive deterioration of the neurological function of his lower limbs and spinal cord compression (pressure on the spinal cord that stops the nerves working normally) caused by the spread of cancer.

8. On 29 May, Mr A was discharged home. The following day, the hospice that had also been providing care for Mr A made an urgent referral for a community nurse to change his pressure ulcer dressing and assess ongoing wound care.

9. A nurse from the Trust visited Mr A at his home. His daughters were also at home, but were not present in the room when the nurse handled him, due to sickness and work commitments. Mrs A was at the hospital picking up Mr A’s prescription.

10. Mr A was lying on his bed on a satin sheet, which is used to aid independent movement in bed and lower the likelihood of tissue damage and painful pressure ulcers, which Mr A was experiencing and receiving care for at the time.

11. Whilst the nurse was caring for Mr A, he fell off his bed. The nurse asked Mr A’s daughter to phone an ambulance, and paramedics helped Mr A back to his bed using a lift.

12. Mr A sadly died six days later.

Number of nurses sent to Mr A

16. Mrs A told us that she thinks if the Trust had sent two nurses to care for Mr A, then he would not have fallen off his bed. She says that Mr A’s fall was traumatic for him and that it made the last six days of his life incredibly distressing and difficult for him and his family.

17. The Trust conducted an investigation which reviewed Mr A’s clinical records, discussed Mrs A’s complaint with senior members of the community nursing team, and obtained statements from the nurse, Mrs A and her daughters. The Trust said it received an urgent referral from the hospice requesting a visit to assess Mr A’s pressure sore, which did not include any information that indicated he would require two nurses. The Trust said that at the time of the referral, it had not yet received the discharge summary from the hospital he had been admitted to and therefore did not know his latest clinical information including his new neurological symptoms, which might have led to the Trust deciding to send two nurses.

18. Our adviser told us that it is standard practice for one community nurse to visit when providing pressure ulcer care. They said it should have been clearly indicated on the hospice’s referral letter if two nurses were required. The hospice did not indicate that two nurses were required and therefore our adviser said it was appropriate for the Trust to send one nurse.

19. There is no specific guidance on how much information should have been given to the nurse before visiting Mr A. The Nursing and Midwifery Council’s Code says professionals should work with colleagues to keep those receiving care safe and share information to identify and reduce risk. Our adviser said that the nurse was only told that Mr A needed a sacral dressing for a pressure ulcer, which was not enough information. They said that at a minimum, the referral should have included that Mr A was receiving palliative care for metastatic prostate cancer with disease progression and had weakness in his lower limbs, which meant he was unable to stand or move his lower limbs.

20. The nurse told the Trust during its investigation that they would have liked to have known more about Mr A’s background, to understand what they were being asked to support with. The nurse said they had not been told that Mr A has been paralysed from the waist down due to cord compression.

21. It looks like it was the responsibility of the hospice to send more information about Mr A’s clinical background to the Trust. This level of information might have resulted in the Trust sending two nurses to Mr A. We think that with the limited information the Trust had within the referral, it was appropriate for the Trust to send one nurse to Mr A. We found no indications of failings in the Trust’s actions for the number of nurses it sent to Mr A.

The nurse’s actions

22. Mrs A told us that the nurse’s actions led to Mr A falling off his bed, whilst they were caring for him. She said if the nurse had taken different actions, then Mr A would not have fallen off his bed.

23. The Trust said that the nurse should have repositioned Mr A to his back when they left him unattended. It said it was satisfied that the nurse safely and appropriately assisted Mr A in falling onto the floor. It explained that Mr A did not have a record of previous falls from bed and no concerns had been raised about the risk of this, therefore, no falls prevention equipment such as bed rails were in place at the time of the incident.

24. The nurse’s notes described what happened form their perspective. They said Mr A turned onto his side, as requested, then the nurse went to get some water for cleaning. On their return, the nurse described finding Mr A with his legs out of the bed, and that they struggled to hold him in position because of the slippery sheet. They said they placed pillows on the floor, where they laid him onto his side.

25. Our adviser told us that because it was an urgent visit, there was no expectation for the nurse to complete a comprehensive falls assessment prior to delivering wound care. There is no specific nursing guidance which outlines how the nurse should have acted to prevent Mr A from falling. The Nursing and Midwifery Council ‘The Code’ says that nurses should ‘use evidence-based, best practice approaches for meeting needs for care and support with mobility and safety, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions’. Our adviser told us that prior to asking Mr A to move onto his side and leaving him there, the nurse should have assessed if Mr A was able to maintain this position independently, especially as he was lying on a satin sheet. They said that the fall occurred because Mr A was unable to maintain this position for the duration necessary.

26. The Trust and Mrs A disagree about the way Mr A fell. The nurse’s statement to the Trust provides a bit more detail than their note of the incident. They said that they left the room to get water to clean Mr A’s pressure sores and when they returned Mr A’s legs were starting to fall off the side of the bed. The nurse noted that Mr A was laid on a satin sheet that had moved on the bed. The nurse said that Mr A held the support rail as they lowered the bed to the lowest height and put pillows on the floor. The nurse says that they tried to assist Mr A onto the pillow, and Mr A did not want to let go of the grab rail and so was laid on the floor in a long sitting position. The Trust said it was satisfied that the nurse safely and appropriately assisted Mr A in falling onto the floor.

27. Mrs A was not present at the time of the fall. She told the Trust that she returned home to Mr A lying on the floor with a pillow under his head. Mrs A has told us that she believes Mr A fell onto the floor without the nurse present and was not safely assisted onto the floor. We understand that Mrs A is concerned that the nurse may have pushed Mr A off his bed, as Mr A kept asking the nurse why they’d pushed him at the time of the fall and in the days after Mr A kept saying that the nurse had pushed him.

28. Although Mr A’s daughters did not witness the actual fall, they arrived shortly after. In their statements to the Trust, both daughters confirmed the nurse’s account. They said that the nurse had gone to get water for Mr A. One of Mr and Mrs A’s daughters said that when she entered Mr A’s living room after hearing his fall, she saw her dad on his knees leaning on the bed. She said that the nurse had placed pillows on the floor to enable a safe landing. Mr and Mrs A’s other daughter told the Trust that when she entered Mr A’s bedroom after his fall, Mr A was lying on his left side on the floor with one pillow under his head.

29. On the balance of probabilities, based on the accounts that we have and the clinical advice we have received, we think that the nurse failed to assess Mr A adequately and ensure that he could maintain his position independently. As a result Mr A fell off his bed whilst the nurse had left to get water for him. We think that the nurse returned to find Mr A falling and supported the fall by laying pillows on the floor to reduce any injury.

30. We think that the nurse did not act in line with the applicable standards to assess Mr A’s capacity for independence and initiate appropriate interventions.

31. This fell so far short of what should have happened that it amounts to a failing.

32. Having found failing, we went on to found what impact it had on Mr A and his family. We thought about whether Mr A would have fallen if the nurse had appropriately assessed him before leaving him unattended, and on balance, we think an adequate assessment would have identified that Mr A was unable to maintain his position independently. We consider that the nurse would not have left Mr A on the side of the bed unattended if they had known this, which would have prevented Mr A from falling.

33. We think that it is reasonable to believe that Mr A’s fall was extremely traumatic for Mr A. We understand that due to the fall, Mr A’s knees were bleeding and bruised. Mrs A told the Trust during its investigation that after his fall, Mr A’s mauve blotches returned on his arm. Fortunately, there were no other physical impacts.

34. We understand that the fall severely impacted Mr A’s mental health and wellbeing during his final six days of life, as he was fearful of all carers who visited him and kept repeating that the nurse had pushed him. The occupational therapy clinical lead at the nursing agency told the Trust during its investigation that carers had no problems with Mr A before his fall, and that following the fall Mr A resisted moving in the bed and was difficult for carers to roll him due to his fear of falling. The fall was likely all the more mentally distressing for Mr A, given his immense vulnerability at the time. He knew that he was dying and he barely had any use of his legs. He was almost entirely dependent on others to keep him safe and had placed his faith in those caring for him to do just that. A number of errors led to this happening, but we must be fair and say that not all of those were down to the nurse or the Trust. But the final mistake that directly led to the fall was, we think, the nurse’s mistake.

35. Mrs A told us that ultimately the fall caused greater distress for Mr A and their family at a time of already great pain and stress, which made Mr A’s final six days of life even more difficult. Mr A’s daughters told the Trust that Mr A was screaming and crying at the time of the fall. Mrs A told us that Mr A was so happy to return home after his challenging month-long stay in hospital, and that the fall ruined this. We found that witnessing his distress was incredibly upsetting for his family, and that this upset has persisted long after his death. It has negatively affected their final memories of him and we think this has likely worsened their bereavement. All of this was an injustice to Mr A and his family. An adequate assessment of Mr A’s condition would have avoided Mr A’s fall and the ongoing impact that had.

36. Finally, we looked at what the Trust has done to put things right, both for the family, and in terms of learning from what happened. In its response, the Trust apologised that the nurse did not reposition Mr A to his back when they left him unattended. The Trust made an action plan of service improvements, which said it would ensure that all initial nursing assessments include details of moving and handling risk assessments (to be regularly reviewed if their condition is changing) and the number of clinicians required for this. The action plan also outlined that all clinical staff (including agency staff) would receive moving and handling training including the use of satin sheets, which can be significantly more slippery than traditional cotton of linen sheets. It said it would require training resources to be available on Pulse (website for healthcare professionals) and for sign off sheets (competency signoffs) for satin sheets to be completed for new staff and agency staffs. The action plan also said that there would be a complex case discussion of what happened in a team meeting to share learning from it.

37. The Trust told us during our investigation that it has revised its way of giving agency staff information. Now, the duty senior nurse provides a verbal or written handover directly to agency staff and is the main point of contact for them for any questions or concerns.

38. We think that the Trust’s service improvements went far enough to prevent what happened to Mr A from happening again to other patients. Sadly, nothing anyone can do can put things right for Mr A. We do not think that the Trust’s apology for the nurse’s actions went far enough to put right the impact of Mr A’s fall for his family.

1. We found that based on the limited information the Trust received in the referral from the hospice, it was appropriate for it to send one nurse to Mr A. We found that the nurse failed to adequately assess if Mr A was able to maintain his position independently and initiate appropriate interventions. We think this led Mr A to fall from his bed, which was incredibly traumatic for him and his family during his last six days of his life and made an already difficult time even more distressing.

2. The Trust has apologised and made service improvements. We think that the Trust’s service improvements went far enough to prevent what happened to Mr A from happening again to other patients. We do not think that the Trust’s apology for the nurse’s actions went far enough to put right the impact of Mr A’s fall on his family. We therefore partly uphold Mrs A’s complaint.

3. We recommend the Trust pays Mrs A £1,200 as tangible recognition of that impact.

39. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

40. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

41. We have identified that the nurse failed to adequately assess Mr A. We found that this led to Mr A’s fall.

42. Following a review of similar cases and understanding the impact this event had, we found that the injustice Mr A’s family experienced sits in Level 3 on our severity of injustice scale, which includes cases where there were failures in care which caused moderate distress or discomfort to the patient, and/or which added to the family’s bereavement after the patient’s death.

43. The Trust has already acknowledged that the nurse should have repositioned Mr A to his back when they left him unattended, but this acknowledgement does not reflect the full extent of the impact their actions had. Therefore, we recommend that the Trust acknowledge the failings we have identified and apologise for the impact of those failings.

44. With that in mind, we recommend that the Trust: • writes to Mrs A to acknowledge the failings we have identified • apologise for the impact of those failings • pay Mrs A £1,200 in recognition of the impact we have identified.

45. We will ask the Trust to send us evidence it has completed all of the recommendations we have made.

46. These should be done within eight weeks of the date of this final report.

47. We are very sorry to hear of the impact Mr and Mrs A and their daughters experienced; we understand that this was very distressing for all of them and hope our recommendations go some way towards recognising that.