The Royal Wolverhampton NHS Trust

6. Mrs N complains about the care and treatment her mother received from the Trust from 7 October to 7 November 2024. She says:

• The Trust communicated poorly with Mrs N about her mother’s prescribed medications and transfer to a care home and failed to respect her expressed wishes regarding these matters • The Trust did not provide appropriate physiotherapy or rehabilitation so that her mother was equipped to return home as she wished.

7. Mrs N says her mother’s care and treatment at the Trust caused her to become disorientated, frightened and confused. She says her mother further lost her independence, which delayed her returning home, as she wished. Witnessing her mother experience this, made Mrs N feel out of control and caused her and her family a great deal of distress.

8. As an outcome of this complaint, Mrs N would like a written apology from the Trust. She would also like the Trust to implement service improvements to prevent other families going through the same experience in the future.

9. Ms O fell and fractured her hip on 25 September 2024. She was taken by ambulance to hospital, where she was treated. On 7 October 2024, Ms O was discharged and transferred to a hospital within the Trust to begin rehabilitation with a view to her returning home and continuing to live independently.

10. Mrs N says her mother’s transfer to the Trust disorientated her and she grew more confused and anxious, suffering from nightmares. Because of this, Mrs N and her sister requested the Trust stop giving her mother the medication Empagliflozin (a heart medication), as they say it was only being trialled and they were worried it was exacerbating their mother’s symptoms. Mrs N says a doctor told her and her sister they would consult the cardiologist about this request.

11. On 10 October, Ms O had a nightmare and was reported as ‘hitting’ staff, which Mrs N tells us was out of character.

12. The following day, Mrs N says her sister was informed by a doctor that her mother’s calcium levels were high, her vitamin D levels were low, and she was being treated for a chest infection. As Ms O was also dehydrated, she was put on a drip, but she removed this in agitation. The Trust put a Deprivation of Liberty Safeguards (DoLS) in place, meaning that restrictions were implemented. Mrs N told us the Trust also stopped physiotherapy around this time.

13. Mrs N says she and her sister were told on 14 October that the Trust was recommending their mother be moved to a care home. She and her sister discussed this with a ward manager on 15 October, who informed them their mother had failed a capacity assessment and was therefore unable to return home to live independently. Mrs N says there was no discussion regarding this, they were just told. Mrs N described the ward manager as unempathetic, dismissive and rude when delivering this information.

14. At this time, Mrs N told us Ms O was still receiving Empagliflozin, which they had requested be stopped, and daily Propranolol (a medication prescribed for panic attacks). Mrs N explained her mother had been prescribed Propranolol previously by her GP to be taken as and when needed, but her cardiologist had advised she use it sparingly in August.

15. During Ms O’s stay at the Trust, Mrs N and her sister were told she had diabetes, despite having never received this diagnosis previously. Mrs N says they queried this but were ignored.

16. Mrs N says she contacted the ward matron on 18 October to request a meeting, which took place on 23 October. During this meeting, Mrs N explained their concerns regarding the medication and the manner in which they had been treated by the ward manager. Despite this, Mrs N says these issues were never resolved.

17. Mrs N says she also had a meeting with a doctor and ward consultant. During this meeting, she told us she felt coerced into agreeing with her mother be kept on a daily dose of Propranolol and Empagliflozin.

18. On 7 November, Ms O was discharged into the care of a local care home. Mrs N says neither she nor her sister were given a copy of the discharge notification. Once Ms O was transferred, staff at the care home informed Mrs N and her sister their mother had been prescribed Pregabalin at the Trust. Following enquiries with their mother’s GP, they were told it had been prescribed by the Trust for agitation and the GP stopped this immediately at this point. Mrs N also queried the diagnosis of diabetes with the GP and was informed this was incorrect, Ms O did not have diabetes.

22. When we consider a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If we see signs of a mistake, we look at the likely impact caused and what the organisation has done to put things right.

Communication

23. We considered the communication with the family with the help of our physician adviser. GMC’s Good Medical Practice, Domain 2, paragraph 37, says clinicians must be considerate and compassionate to those closest to a patient and be sensitive and responsive in giving them support and information. Our physician adviser explained, although clinicians are required to manage competing priorities, engaging with family members is an essential part of patient care, in line with the above guidance.

24. Based on Ms O’s clinical records, there is evidence some of the Trust’s communication with Mrs N and her sister was in line with good clinical practice and guidance, but this was not consistent.

25. The GMC guidance above does not set out a specific number of times that families should be updated. Rather, it recognises staff must balance keeping families informed with their responsibility to provide direct care to patients.

26. There is evidence staff were in contact with the family on many occasions throughout Ms O’s admission. The records show multiple entries where nurses and, on some occasions, doctors spoke with family members, and some of these entries describe quite detailed discussions. Overall, particularly after the first couple of weeks, the amount and detail of communication appear to be appropriate and in line with the GMC guidance, and in some respects more frequent than average.

27. However, our physician adviser noted that during the first two weeks of Ms O’s admission there is less evidence of clear, consistent communication from doctors specifically about her treatment, medication decisions, and plans for discharge or transfer to a care home. Much of the recorded contact appears to have been through nursing staff, and the detail is often limited. Because of this, we are not able to say the communication during this period was in line with Good Medical Practice.

28. The GMC guidance explains that when a patient lacks capacity, or their capacity fluctuates, it is reasonable to assume they would want those close to them to be kept informed about their condition and plans for their care, unless they have said otherwise. In Ms O’s case, we know she was confused at times, based on the information provided by Mrs N and evidence within the clinical records. In that context, our physician adviser told us it would have been in keeping with the GMC guidance for the Trust to have explained the reasons for important decisions (such as prescribing Pregabalin, continuing her heart medication, and recommending a move to a care home) to her family, within reason.

29. Our physician adviser also explained Pregabalin is a medication that can contribute to confusion. Given Ms O was experiencing confusion during her admission, it would have been appropriate to involve the family in discussions about why this medicine was being used, what side effects it might cause, and whether there were any suitable alternatives if it did not appear to be helping her or was making her more confused.

30. We understand Mrs N also had concerns about her mother being recorded as diabetic. From the records, we can see there was some question about whether Ms O had type 2 diabetes. Our physician adviser explained this appears to have arisen because upon admission, clinicians noted Ms O had been prescribed a medication that is often used for diabetes but is also used for other conditions, such as heart failure. The clinicians appear to have been checking whether the medicine had been prescribed for diabetes or for another reason. We would like to reassure Mrs N, on review, there is no evidence that a diagnosis of type 2 diabetes was confirmed, nor that her mother was started on diabetes‑specific medication during this admission.

31. Taking all the above into account, we can say there is evidence the Trust communicated with the family on a fairly regular basis, even if on some occasions this communication was initiated by the family, and later on during Ms O’s admission appears to be in line with the GMC guidance. However, the Trust did not always act in line with the guidance in terms of explaining its rationale for important decisions relating to Ms O’s care, treatment, and discharge to Ms O’s family.

32. We have thought carefully about the impact this caused. We have not seen anything to suggest the Trust’s communication caused Ms O to lose her independence or prevented her from returning home. In our view, the instances of poor communication likely caused Ms O and her family to feel confused and distressed.

33. Based on this, we considered what actions the Trust has taken to put things right following the complaint it received from Mrs N. We can see in its final response the Trust acknowledged its communication failings and apologised to Mrs N. It also set out several improvements it had taken forward with regards to communication, including:

• Reminding staff of appropriate communication style and delivery, especially in more complex and sensitive cases • Instructing one particular member of staff to undertake a customer care course for additional communication training • Sharing the anonymised complaint with the wider multidisciplinary team to ensure shared learning

34. We discussed these improvements with our physician adviser. Having done so, we are satisfied these actions are reasonable, given the issues Mrs N described. They focus on improving staff skills, raising awareness of how information is given in sensitive situations, and ensuring that learning is shared so that similar issues are less likely to arise in future.

35. We are glad to see the Trust has considered the concerns raised, apologised and shown how it will learn from Mrs N’s experience. Considering our Principles for Remedy, which sets out organisations should take those steps when they receive complaints, we can see the Trust has taken appropriate action to put things right. Therefore, we will take no further action.

36. We recognise this must have been a distressing and frustrating period for Ms O and her family. We hope our consideration provides Mrs N with clarity on some of her unanswered questions and reassurance the Trust has implemented positive changes.

Physiotherapy and rehabilitation

37. We looked at whether the Trust provided physiotherapy and rehabilitation suitable for Ms O’s needs, and whether this was in line with the relevant clinical guidelines and standards.

38. We reviewed Ms O’s clinical records, and considered these concerns, with the assistance of our physiotherapy adviser. NICE Quality Standard QS16 on hip fracture says adults with hip fracture should start with rehabilitation at least once a day, and no later than the day after surgery. It also says that they should be offered support with rehabilitation every day whilst in hospital, including by other members of the multidisciplinary team when a physiotherapist is not present. The NICE guidance explains daily rehabilitation can help improve mobility and independence and reduce the need for long-term care.

39. We can see from the evidence submitted by Mrs N and the Trust, including Ms O’s clinical records, Ms O did receive physiotherapy and wider rehabilitation input after she was transferred to the Trust on 7 October. The records and Trust complaint response indicate there was a physiotherapy assessment on 8 October, occupational therapy assessment on 9 October, further joint physiotherapy and occupational therapy sessions, mobility practice, personal care assessment, bathroom-based tasks, kitchen assessment, and identification of equipment including a perching stool, shower chair and kitchen trolley. The Trust response also indicates Ms O was mobilising with a frame under supervision and ward staff supported her mobility outside formal physiotherapy sessions.

40. However, our physiotherapy adviser noted the records do not show rehabilitation was provided with the consistency, frequency and structure recommended in the NICE guidance for people with hip fracture. Our adviser explained, although Ms O’s fracture was managed without surgery, the overall principles of this guidance are still relevant.

41. NICE guideline CG124 on hip fracture management stresses the importance of coordinated multidisciplinary care and early mobilisation to help people recover faster and regain mobility. Our physiotherapy adviser told us, given Ms O had been living independently and there was a marked difference between her previous level of function and her abilities in hospital, it would have been in line with the guidance for the Trust to have provided a clearly structured, goal-based rehabilitation plan. This is not evident within the records.

42. Our adviser noted, whilst rehabilitation was started, the evidence does not show it was maintained consistently throughout Ms O’s admission. Though the records include descriptions of assessment and some functional ability, there is limited evidence of a clear rehabilitation plan with measurable goals, frequency of physiotherapy contact, goals and progress, or rationale behind any reduction or termination of therapy.

43. CSP quality assurance standards set out physiotherapy services should deliver safe and effective care, work in partnership with patients and carers, keep appropriate records, communicate effectively, provide appropriate physiotherapy management and treatment, and evaluate clinical care and service delivery. In Ms O’s case, whilst we can see evidence of multidisciplinary involvement (contribution from multiple clinical teams), the records do not adequately show the intensity, continuity or evaluation of rehabilitation expected for a patient whose previous level of independence was a goal for recovery.

44. We also considered the NICE guidance on delirium. This guidance identifies various risk factors for delirium (including older age, cognitive impairment, hip fracture, etc) and advises clinicians to observe patients for changes such as confusion, reduced mobility and movement, restlessness and agitation, sleep disturbance, and altered social behaviour. The NICE guidance explains delirium in hospital and long-term care is common in older patients and can lead to a longer hospital stay, complications and new admissions to long-term care.

45. Our physiotherapy adviser explained the available evidence shows Ms O’s confusion, distress and loss of independence likely had many different causes. These included the trauma of her fall and fracture, pain, hospital admission and transfer between wards, infection, possible delirium, dehydration, raised calcium levels, low vitamin D, visual and hearing impairment, an unfamiliar environment, night-time disturbance and possible underlying cognitive decline.

46. We can see Ms O had a variety of significant complicating factors. These include her cognitive impairment, fall risk, agitation, reduced confidence, and the need for supervision. Our adviser recognised these factors may have limited the pace and scope of rehabilitation. However, even with that in mind, those factors would not remove the need for daily functional activity, reassurance, supervised movement, and goal-oriented rehabilitation adapted to Ms O’s cognitive state and in line with NICE guidance on hip fractures in adults, as set out in paragraph 38.

47. The HCPC standards set out that physiotherapists should practise safely and effectively, manage workloads and resources, protect the interests of patients, respect their dignity and autonomy, obtain valid consent (taking capacity into account), maintain good records and uphold high standards of care.

48. The available evidence suggests an initial physiotherapy assessment took place and safety issues (such as falls risk and supervision) were considered. This is in line with the HCPC standards. However, we understand from our physiotherapy adviser the records do not provide assurance that rehabilitation was delivered with the consistency, clarity and measurable progression expected for a patient transferred specifically for the purposes of rehabilitation.

49. To summarise, it is evident the Trust provided rehabilitation, including physiotherapy and occupational therapy assessments, supervised mobility practice, and discharge planning. This is all in line with applicable guidance. However, the records do not clearly demonstrate rehabilitation was adequate in terms of frequency, intensity, progression, and documentation. Whilst rehabilitation was provided, the evidence indicates failings in respect of the consistency, planning and review.

50. When considering all the available evidence, we have not seen that on the balance of probabilities that any indications of failings in rehabilitation planning and delivery and documentation are likely to have caused Ms O’s confusion or loss of independence. However, they likely meant she did not have the best possible opportunity to regain her previous level of mobility and confidence, or of going straight home from hospital or to her preferred environment. Not knowing what might have been different if she had been given that opportunity will cause the family distress.

51. With this in mind, we have considered what the Trust has done to put right that distress. Following discussions with the Trust, it has since reviewed its practice and confirmed it will apologise to Mrs N for the errors we have identified. The Trust has also told us it is willing to implement service improvements to avoid these issues happening again.

52. Having considered our Principles for Remedy, alongside the outcomes Mrs N was looking for, we can see the Trust has committed to taking appropriate steps to put things right. For this reason, we will take no further action.

53. We understand these events have been distressing for Mrs N, and we appreciate her taking the time to raise her concerns and speak with us. We hope our review and explanations have been helpful and provide some clarity. For the reasons set out above, we now conclude our consideration of this complaint.