Mental Health Trust failed in two aspects of basic nursing care

What happened

Mr C had a number of physical and mental health issues, including type 2 diabetes, congestive cardiac failure, heart disease and kidney disease.

Mr C had periodic contact with the Sussex Partnership NHS Foundation Trust's community mental health team (CMHT) from late 2008 onwards.

In winter 2011, Mr C collapsed at his home. Clinicians treated him for acute renal failure, a respiratory infection and gout. After a few weeks, he was transferred to the Trust's psychiatric hospital so staff could review his mental health. Mr C remained there for just over two months, until he had to be transferred to another acute hospital because his physical health was deteriorating. Mr C died five days later.

Mr C's daughter Ms F complained that the CMHT failed to adequately intervene in her father's case or do enough to help him get support for around two years. She also complained about communication and the quality of his nursing and medical care while he was in the psychiatric hospital. Ms F said her father's health did not improve during that period and all the problems greatly reduced his quality of life.

What we found

The Trust did not handle the complaint about Mr C's care reasonably. It did not provide sufficient detail about the two different periods of care. There was some lack of clinical evidence but most importantly, two basic failings in nursing care went unacknowledged and not put right: his weight gain and his personal hygiene.

Mr C's weight was not adequately monitored. Though his weight chart was incomplete, it shows that Mr C gained over 10kg in the two months after his admission. There is little to indicate that staff responded to that appropriately. They did not complete a food chart and there was no evidence of weekly weight monitoring, regular review of his care plan or a referral to a dietician.

In addition, staff did not review Mr C's hygiene care plan regularly. Staff should have updated this after every episode of care but there were no entries for over two months. This demonstrates poor record keeping and implies that Mr C did not receive sufficient support with his personal hygiene.

It is quite conceivable that these two failings reduced Mr C's quality of life. His weight gain would not have helped his physical health, particularly as it could have worsened his pre‑existing conditions. We did not find that Mr C's weight gain had a direct and specific impact on his chances of survival.

Putting it right

As a result of our investigation, the Trust agreed to apologise for its failings and their impact on Mr C and his family. It will also reflect on the learning it needs to take from this complaint. It will submit a written plan to ensure that record keeping, complaint handling, weight and hygiene monitoring and management failings do not happen again.