Northern Ireland Public Services Ombudsman: Investigation of a complaint against the Belfast Health and Social Care Trust (July 2020)

Summary

Investigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.

Content

The investigation found a significant number of failures in the care and treatment of the patient overall and in the following areas:

Nutrition and Feeding the patient – contrary to guidance which highlights the importance of high quality nutritional care based on individual assessment of needs with appropriate planning and monitoring, this investigation found the following failings:

• The feeding of porridge contrary to Speech and Language Therapy advice on 3 and 4 December 2016 and offering other foods contrary to advice.
• The recording who fed the patient porridge.
• The identification that the recommended diet was not provided and the taking of appropriate action.
• The recording of foodstuffs in a consistent manner.
• The reporting and recording of adverse incidents in relation to the feeding of porridge on 3 and 4 December 2016.

Communication & Reasonable Adjustments – safe, person centred care is underpinned by effective communication. When caring for a patient with a learning disability communication must be timely and sensitive to the needs of the person and involve the family when appropriate. This is particularly essential in relation to pain management and when a patient is non-verbal. This investigation found the following significant failures:

• Failure to use any kind of pain tool to assess and record the patient’s possible pain or distress. This issue is of particular importance as the patient was unable to verbalise his pain levels.
• Failure to ensure the care of the patient was consistently tailored for a person with dementia and learning disabilities in accordance with GAIN Guidelines.

The investigation also established further failings in relation to:

• A failure to ensure there was a coordinated approach between the Palliative Care and Care of the Elderly teams.
• A lack of coordinated communication between the family, Palliative Care and Care of the Elderly teams.
• The over prescribing of paracetamol to the patient on Ward 3 South due to the inaccurate estimation of the patient’s weight.

The investigation established maladministration in relation to:

• The failure of the Trust to show regard for the patient’s human rights by failing to appropriately support or record the assessment of the patient's possible pain or distress; and to ensure the care of the patient was not consistently tailored for a person with dementia and earning disabilities.
• The failure to report overprescribing of paracetamol in line with the Trust’s ‘Adverse Incident Reporting and Management Policy’, April 2014 and Guidelines for the administration of intravenous (IV) Paracetamol’, December 2014.
• The failure to inform the complainant and her family of the overprescribing of paracetamol in line with the Trust’s ‘Being Open Policy’, February 2015 and it’s ‘Guidelines for the administration of intravenous (IV) Paracetamol’, December 2014.
• The failure to inform the complainant and her family of the overprescribing of paracetamol in line with the Trust’s ‘Being Open Policy’, February 2015.

The poor management of complaints has been highlighted in many of the reports and inquiries that have examined the care of people with a learning disability in hospitals. Opportunities were missed in this complaints handling process to provide the family with empathetic and timely responses which may have helped resolve their concerns locally and prevented them having to use time and energy in approaching the Public Services Ombudsman.

The investigation established failings in the Trust’s handling of the complaint namely:

• The failure to meet with the family prior to completing any investigation.
• The failure to share minutes of the meeting, held on 21 September 2018, with the complainant for comment.
• The delay in issuing minutes of the meeting, held on 21 September 2018, to the complainant.
• The delay in providing a final response to the complainant.
• The failure to provide regular and informative updates to the complainant.
• The failure to ensure coordination between the complaints team and the service area.
• The failure to recognise the sensitivities around arranging a venue for the meeting with the complainant on 21 September 2018.

The investigation did not establish failings in the patient’s care and treatment in relation to:

• The decision to carry out the procedure of oral suctioning on the patient on the night before he died.
• The vitamin drip being administered after the patient was deemed End of Life on 6 December 2016.
• The reducing pain relief without consen.
• The anaesthetics care of the patient on 10 November 2016.

The investigation was unable to make a determination as to whether the vitamin drip was administered prior to the administration of paracetamol on 9 December 2016