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Selected Investigations Completed April - September 1999 > Part II, Case no. E.1635/98-99
Complaint against:
Nottingham Healthcare Trust
Complaint as put by Mrs P
1. The account of the complaint provided by Mrs P was that her mother, Mrs C, was a patient of the Nottingham Healthcare NHS Trust (the Trust) from 18 November 1997 to 30 March 1998. During this time she received physiotherapy. On 30 March, she was discharged to a nursing home (not within the Ombudsman's jurisdiction). On 2 April 1998, Mrs C fell at the nursing home while under the supervision of a physiotherapist (the first physiotherapist) employed by the Trust. At the time of her fall she was using a gutter frame (a walking frame with four legs, two of which had wheels at the foot, and a rest for the patient's forearms, allowing the weight to be supported through the upper arms). Mrs C was admitted to hospital where, sadly, she died on 3 April.
2. Mrs P complained about the actions of the first physiotherapist and received a reply from the Trust's chief executive on 5 May 1998. Mrs P remained dissatisfied and requested an independent review of her complaint. On 25 June, the Trust's convener refused her request.
3. The matter investigated was the circumstances surrounding Mrs C's fall.
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Investigation
4. The statement of complaint for the investigation was issued on 11 November 1998. The Trust's comments were obtained and relevant papers examined. The Ombudsman's investigator took evidence from Mrs P and her friend, Trust staff, and staff of the nursing home (though their actions are outwith the Ombudsman's jurisdiction). Two independent professional assessors were appointed to advise on the clinical and professional issues in this case and their report is annexed.
The Trust's formal response
5. In giving the Trust's formal response at the outset of this investigation, the chief executive wrote:
'Mrs C fell while she was undertaking a walking frame test under the supervision of [the first physiotherapist]. .... Immediately subsequent to the testing of the [gutter frame] to which the patient's arms were secured by means of velcro straps, [the first physiotherapist] turned to call for a member of the nursing home staff to bring a wheelchair, steadying Mrs C with his hand as he did so. Unfortunately, Mrs C fell backwards to the floor bringing the frame down with her, as she was attached to it. [The first physiotherapist] was unable to prevent her from falling. ....
'.... We are satisfied that [the first physiotherapist] acted in accordance with established procedure at all times. .... Frames have to be checked for height and to ensure that they are of a suitable size to move within the patient's surroundings. [The first physiotherapist] was familiar with Mrs C's capabilities and problems, having walked her previously on a number of occasions .... .'
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Documentary evidence
Trust protocol
6. A Trust protocol entitled 'Therapeutic walking of patients', in force at the time of Mrs C's fall, includes, within a section about safety precautions: '1. Ensure all walking aids .... are in good order .... . 2. Keep patients under adequate supervision. 3. Know patients' capabilities and tolerance. 4. Check all floor surfaces for possible dangers. 5. Report any accidents.'
Physiotherapy records
7. The Trust's physiotherapy notes show that Mrs C arrived for rehabilitation, on 18 November 1997. She had undergone a decompressive discectomy (removal of the disc between two vertebrae to relieve pressure on a nerve) on 10 November at another Trust.
8. On 19 November, Mrs C needed four assistants and a lifting belt to get her from a sitting to a standing position. Her physiotherapy treatment over the next few days concentrated on improving her ability to stand from sitting, and to support herself in standing within a set of parallel bars. On 26 November, Mrs C took a few steps with a wheeled frame with the help of two people. On 2 December, Mrs C walked a distance of approximately five metres with a pulpit frame (a tall frame providing a high level of support). By 9 December, Mrs C was able to walk with either a wheeled frame or a pulpit frame.
9. Mrs C continued to mobilise with both frames and on 19 December her notes show that the plan was for her to try using a gutter frame 'as an inbetween to pulpit and wh[eeled] frame' (note: a gutter frame provides more support than a wheeled frame). In January, Mrs C twice walked a distance of three to five metres using a pulpit frame and, on 28 January, Mrs C used a gutter frame to make a circuit of the physiotherapy room. The frame was pulled from the front (not by Mrs C) and another person supervised her (ie no physical help was given). The frame used had small wheels and it was noted that it was difficult to move over the carpet.
10. Throughout February, Mrs C continued to walk with a gutter frame and on 12 February it was noted that she was mobile with the 'supervision of one' (ie one person keeping close to Mrs C but not providing her with any physical assistance). On 25 February, Mrs C walked a distance of three metres on her own using the gutter frame.
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11. Mrs C's physiotherapy treatment continued throughout March with increasing distances being covered. On 16 March, she walked for 12 metres using the gutter frame and on 27 March, she managed 15 metres. On 24 March, Mrs C had a chemical sympathectomy (an injection to destroy pain fibres) and when she was walked on 27 March, one person supervised while another walked behind her with a wheelchair (there is no indication in the notes that this was normal practice).
12. The first physiotherapist worked with Mrs C at the Trust from 23 March until her discharge on 30 March. During that time he walked her three times, twice over distances of 10 metres and once over a distance of 15 metres. On each occasion the amount of support she was given was reduced, until, on 27 March, she was supervised rather than assisted. There is no indication in the notes that the first physiotherapist pulled the gutter frame for Mrs C. The notes also show that on only one occasion when the first physiotherapist walked her did someone walk behind with a wheelchair.
13. The notes record that on 4 March nursing staff were shown how to walk Mrs C with the gutter frame and on 9 March there is a note that Mrs C's footwear was left on because nursing staff intended to try walking her at teatime.
14. Mrs C used four different kinds of walking frame with physiotherapists at the Trust. She was discharged to the nursing home on 30 March 1998.
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Nursing and medical records
15. The Trust nursing records indicate that on 4 March it was decided at a case conference that Mrs C could be walked with a gutter frame by two nurses (in the care of one with another walking behind with a wheelchair).
16. The Trust medical records show that on a ward round on 10 March it was recorded that Mrs C was 'now using a gutter frame with nurses to walk'.
Entry in the nursing home accident book
17. The entry in the accident book made by the first physiotherapist on 2 April 1998 states '[Mrs C] fell backwards and onto [right] side whilst standing [with gutter frame] and physiotherapist turned to retrieve [wheelchair] and [patient] fell.'
Trust accident form
18. A Trust accident form completed by the first physiotherapist on 2 April 1998 records that '[Mrs C] had mobilised [with gutter frame] and moderate aid of one approximately 10 metres. Physio (myself) turned to locate [wheel chair]. It being out of reach I turned to locate any nurses. As I did this the patient lost her balance and fell backwards and towards the [right] landing on the [right] side of her pelvis.'
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Mrs P's and her friend's evidence
19. Mrs P said when interviewed that her mother was a tall, well built woman who was fully alert. While Mrs C was a patient of the Trust Mrs P had quite often seen her being walked by the physiotherapists on the ward and a few times in the gymnasium. She was never walked by nursing staff on the ward. Mrs P said that Mrs C had only ever used a gutter frame, and was unable to walk with it on her own. Mrs C had splints on her legs up to her knees which were covered with bandages, and she had sandals which fastened with velcro.
20. On 24 March 1998, Mrs C was given a chemical sympathectomy (paragraph 11). On 27 March, Mrs P saw the first physiotherapist walk her mother. He walked backwards, moved the frame and then Mrs C took a step. They walked only in a straight line and after about 10 metres Mrs C said that she could go no further. Another member of staff who had been walking behind with a wheelchair put Mrs C into it.
21. Mrs C was discharged to the nursing home on 30 March 1998. A new gutter frame had been made for her to use while at the home. On 2 April, the first physiotherapist went to the home and walked Mrs C. Mrs P and a friend went to visit Mrs C that day and discovered that she had fallen. Mrs C was in bed when they arrived. Mrs P said that the account given by Mrs C to her friend, and later that evening to Mrs P's sister, was that the first physiotherapist had walked her into a bathroom opposite her room. He discovered that there was no room to manoeuvre the frame and Mrs C was unable to step backwards. This caused her to fall. The friend said that Mrs C was very upset and sobbing and her back was hurting. She mentioned that she had been walked to the bathroom; that she had walked too far; and that something had fallen on her and she had fallen flat on her back. She had not wanted to go because she had no one with her and did not feel safe. Mrs P said that, for the first time, her mother's hands had been taped to the gutter frame and that this had frightened her. The straps prevented Mrs C from putting out a hand to break her fall.
22. The matron at the home showed Mrs P where her mother had fallen and said that staff had told the first physiotherapist that no one was available to assist him because of a staff changeover. Mrs P said that she could not understand why he had not waited; Mrs C was new to the home and the first physiotherapist was also in unfamiliar surroundings.
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Evidence of Trust nursing staff
23. One of the nurses interviewed said that, although she could not be certain, she thought that nursing staff had walked Mrs C for short distances. Another nurse recalled that nursing staff did walk Mrs C for short distances shortly before she was discharged. They did this about four to six times a day to help with the care of pressure sores.
The second physiotherapist's evidence
24. The second physiotherapist said at interview that he had begun to work with Mrs C on 7 January 1998 with the main aim of her achieving as much independence as possible. He thought a pulpit frame would suit her because she was a tall, strong and very determined lady. She was unable to use her legs below the knee because of paralysis, and had two ankle splints attached to her ankles and lower legs, and plaster boots to keep her feet in position. Mrs C was able to walk quite a distance with two people accompanying her.
25. On two occasions the second physiotherapist pulled the frame from the front (note: this is recorded in the physiotherapy notes) so that Mrs C would be able to practice stepping rather than taking a step, moving the frame, and taking another. The second physiotherapist explained that the gutter frame used in the physiotherapy department did not have velcro straps.
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The first physiotherapist's evidence
26. The first physiotherapist said, when interviewed, that he had assumed responsibility for Mrs C's care from another physiotherapist when Mrs C was close to discharge. His aim was to work towards preparing her for discharge. Targets set for Mrs C were for her to do independent transfers (eg from wheelchair to chair) and to walk for short distances (for example, from her bed to the toilet, and to her cupboard) with the assistance of one person and with an appropriate walking aid. The term 'assistance of one person' meant that someone would stand by to help if needed; to help with standing; to steady her if she was becoming 'wobbly'; to assist if she needed a rest or to sit down; and to call for assistance in an emergency. The term 'supervision of one' meant a person walking at the side of the patient to give confidence and to help if problems occurred.
27. The first physiotherapist worked with Mrs C for the first time on 23 March 1998. He explained that he usually walked his patients in a straight line after first ensuring that the path was clear of obstacles. If the patient had to negotiate a door, he would make sure that it was safe to do so. Often a chair would be used as a target. He would, for example, walk Mrs C towards a chair where she would sit. Then, if she felt strong enough, she would be walked back; if not she would be brought back in a wheelchair. If a patient became tired before reaching the target, the first physiotherapist would ask a nearby member of staff to fetch a chair. Before walking a patient he would assess the likelihood that he or she would be able to reach the target. Turning depended on each patient's ability. The first physiotherapist would try to turn a patient in a forward motion with a gentle curve. He thought that Mrs C was at the stage where she could mobilise with one person and that that person need not necessarily be a physiotherapist.
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28. On 24 March, Mrs C had a chemical sympathectomy (paragraph 11) which would have had the effect of considerably decreasing her pain and would have allowed her to move more easily. The notes show that Mrs C was walked regularly for 10, 12 and 15 metres; but the first physiotherapist was probably more cautious with Mrs C after the operation. He said that there had been no problems when ward nursing staff walked Mrs C to the toilet using a gutter frame.
29. On 2 April 1998, the first physiotherapist visited the nursing home to ensure that the new gutter frame that had been delivered to the home was suitable for Mrs C to use. He had not been to the nursing home before. He checked that the frame was mechanically sound and then assessed the interaction between Mrs C and the new frame to ensure that she was comfortable with it. He believed at the time that it would be sufficient for him to supervise Mrs C. With the benefit of hindsight, if he was doing it again, he would probably ask for a member of staff to be present. However, Mrs C had walked with one person at the Trust and the first physiotherapist felt comfortable walking her a short distance with no other assistance. In his experience, Mrs C's standing tolerance with a frame was very good; she had never been 'wobbly'; and had always stood for about a minute before setting off on a walk. The physiotherapist felt, therefore, that Mrs C would be strong enough to stand while he got a chair if she became tired. He was also aware that two members of the nursing home staff were nearby, along the corridor. If they had not been close by, or if the physiotherapist had been alone in that area, he would have made sure that someone else was close at hand before walking Mrs C.
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30. The first physiotherapist put the velcro straps loosely on Mrs C. They were a safety device and he would not walk a patient without first fastening them. Mrs C needed a little physical help to get from a sitting to a standing position and the first physiotherapist helped her by putting a hand around her waist. She had been walked every day while at the Trust and was a little stiff and more anxious because of the time that had passed since her discharge. The plan was for Mrs C to go onto the square landing outside her room, turn round and return. The first physiotherapist was satisfied that the dimensions of the landing were sufficient to allow her to do so. Mrs C first walked out of her room through the door space, with the first physiotherapist behind her and probably, with both hands on her waist. He then went round to her side and, he thinks, put his arm around her waist to reassure her. Mrs C did well and seemed happy with the frame. When she had had enough the first physiotherapist turned to locate the wheelchair, which he found to be out of reach. He turned to locate a member of staff to fetch the wheelchair and Mrs C fell. The first physiotherapist called for assistance, helped return Mrs C to her bed and made an entry in the nursing home's accident book recording the incident (paragraph 17).
31. The first physiotherapist said that, when walking Mrs C at the home, he would never stand in front unless someone was standing behind her. The back is the most unsupported area. Similarly, he would never stand in front and walk backwards lifting the frame, unless there was another person behind the patient. Mrs C was anxious that day, so he decided that it would be appropriate for him to walk at the side rather than behind her. When the fall happened, the first physiotherapist had not turned Mrs C. She remained facing in the direction of her walk. The first physiotherapist said that he had not asked his patient to walk backwards and would never do so if he was the only person assisting a patient.
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The nursing home staff's evidence
32. The care assistant had not seen Mrs C fall as she was at the other end of the corridor, and around a corner. She heard a 'thump', somebody shouting for help and Mrs C screaming. The first physiotherapist was ringing the buzzer and calling out. The care assistant was the first to arrive on the scene. Mrs C was lying across a doorway next to the sluice room (where commodes are rinsed out). She was not near a bathroom (paragraph 21). The walking frame was in the open doorway of the sluice room with, the care assistant thought, the wheelchair behind Mrs C and near to her bedroom door. The care assistant ran to fetch the matron who checked Mrs C with the first physiotherapist. Mrs C was then moved to her bed.
Findings
33. In reaching my findings in this case I have taken account of the advice of the Ombudsman's independent professional assessors in addition to documentary and oral evidence obtained in the course of the investigation. The physiotherapy notes are well documented and show the progression of Mrs C's treatment as she became more mobile. The various types of walking frame used reflected her growing independence; she was walking with one person and a gutter frame prior to her discharge from the nursing home. The first physiotherapist was familiar with Mrs C's capabilities and the evidence shows that nurses had walked Mrs C before she left the Trust. I do not believe that Mrs P was aware of the totality of her mother's physiotherapy treatment and the progress she had made.
34. On 2 April 1998, the first physiotherapist visited the nursing home to ensure that Mrs C's gutter frame was suitable. He walked her as part of the checks he made. The Ombudsman's independent assessors advise that the physiotherapist was right to do so and that it was good practice to check the appropriateness of the aids and appliances provided for Mrs C, her surroundings and the rehabilitation arrangements made for her. The advisers are also of the view that the physiotherapist had assessed Mrs C's walking and standing ability during her time at the Trust and that the expectation was that, at the nursing home, she would be walked by care assistants and would not be entirely wheelchair dependent. He also knew that there had been no history of falls. The assessors have found no evidence to support the allegation that the physiotherapist positioned himself inappropriately when walking Mrs C.
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35. There is some confusion about the circumstances of Mrs C's fall. She told Mrs P's friend, and later Mrs P's sister that the physiotherapist had walked her into a bathroom opposite her room and discovered that there was no room to manoeuvre the walking frame. Mrs C had been unable to walk backwards and so fell. Mrs C also maintained that she had walked too far; that something had fallen on her; and that she had fallen flat on her back. It is clear, however, from the evidence I have obtained that the 'bathroom' was, in fact, a sluice room. The physiotherapist maintains that his plan for the walk did not involve Mrs C entering it. He intended to walk her onto the landing outside her room, turn her and bring her back to her room. Mrs C did not complete the walk as she became tired. She fell while the physiotherapist had turned away to ask a member of staff to fetch her chair. This account is consistent with the incident report forms examined in the course of this investigation.
36. In summary, I accept the advice of the independent assessors in this case. I find that the first physiotherapist's levels of skill and experience were sufficient for the clinical situation; and that he acted appropriately on 2 April and in accordance with his knowledge of Mrs C's capabilities, as is required by the Trust protocol to which I refer in paragraph 6. I find that the physiotherapist acted appropriately and that the evidence points to an unfortunate accident. I do not uphold the complaint.
Conclusion
37. I have set out my findings in paragraphs 33 - 36.
Back to top Annex to E.1635/98-99
Professional Assessors' Report
Introduction
1. In this matter we are asked by the Health Service Ombudsman for an opinion on whether:
a. The first physiotherapist used his professional skills and knowledge appropriately in planning and undertaking a walk with Mrs C;
and if
b. the degree of supervision provided was of a standard the patient could reasonably be entitled to expect.
2. Mrs P has claimed that on the 2nd April 1998 the first physiotherapist walked her mother, Mrs C, with no concern for her safety. She complains that he walked her mother into a bathroom opposite her bedroom, realised that there was no room to manoeuvre the frame and that her mother was unable to step backwards. Mrs P believes that this resulted in Mrs C sustaining a fall.
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3. In formulating our report we have perused a bundle of documents which has been kindly made available to us by the Office of the Health Service Ombudsman for England and which have included:
a) statement of complaint;
b) records of interviews with staff at the Trust and the nursing home;
c) correspondence relevant to the complaint.
4. The first professional assessor was present at interviews conducted by the investigator with the first and second physiotherapists. The second professional assessor was not present at any interviews.
5. The first and second professional assessors attended a case conference at the Office of the Health Service Ombudsman on 15 April 1999 prior to compiling this report.
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Discussion and Consideration
6. In considering this case we have taken into account the following points:
the first physiotherapist is a qualified state registered physiotherapist;
we consider that his levels of skill and experience were appropriate to the clinical situation;
the first physiotherapist knew Mrs C prior to her discharge to the nursing home. It is clear from the physiotherapy notes that he had walked her on three occasions at the Trust;
Mrs C was discharged to a nursing home with the expectation that she would walk with care assistants and not be totally wheelchair dependent.
7. In our view walking was important for Mrs C's ongoing rehabilitation, not only for its own sake but for other medical benefits such as her circulation, and kidney function.
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8. It is clear from the physiotherapy notes that Mrs C was walking with the supervision of one person and using the gutter frame prior to her transfer to the nursing home.
9. It is good practice to check not only the walking frame itself but also to see the patient walk with the frame to check that it is appropriate for the layout of the new surroundings.
10. We consider that the use of velcro straps when provided is normal practice. These are not used as a restraint but as a positioning aid for the forearm. The first physiotherapist could not think of any reason why he would not use such straps if provided. It is recorded in the physiotherapy notes made by the first physiotherapist on 2 April 1998 that the straps were used.
11. There is no evidence of a history of falls. The first physiotherapist states that in his experience Mrs C's standing tolerance with a frame was very good and that she had never been wobbly. He further stated that Mrs C always stood for about one minute before walking and that if she had had enough he felt that she was strong enough to stand while he got a chair. This all fits the treatment and progress made by Mrs C outlined in the physiotherapy notes. The notes of 2 April state that Mrs C's standing posture was good prior to setting off for the walk. This would indicate that she stood for a moment before starting to walk.
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12. We consider the distance walked by Mrs C on 2 April to be reasonable given her clinical history and her progress as documented in the physiotherapy, medical and nursing notes.
13. We can find no evidence to support the allegation that the first physiotherapist positioned himself inappropriately in front of the walking frame. The second physiotherapist did record in the notes that on two occasions he walked in front of Mrs C to assist with moving the frame. This was done at the time for gait re-education and a second person was always present behind Mrs C. The second physiotherapist recalls that Mrs P was present on one occasion when he was walking Mrs C and it seems likely that that is why Mrs P believes that her mother was normally walked in this way.
14. The physiotherapy notes detail the type of walking frame used on each occasion with Mrs C. It is clear that the frame used at the nursing home was the same type of frame used for the two weeks prior to Mrs C's discharge from the Trust.
15. The visit to the nursing home was in our opinion good practice in fulfilling the duty of care to check the appropriateness of aids, appliances, surroundings and ongoing rehabilitation arrangements.
16. We do not consider it to be helpful to try to distinguish between a visit made to check the walking frame and one made to provide treatment.
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Conclusion
17. In conclusion, having looked at all the evidence provided to us, it is our opinion that the first physiotherapist did act appropriately and to a standard to which the patient could reasonably be entitled. In the absence of any evidence as to the cause of the fall it would appear that what happened to Mrs C was an unfortunate accident.
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