"Appalling care of my mother on elderly ward"

These notes are based on the observations and experiences of my sister, my niece and myself whilst our mother was in hospital over four months in 2013. We were regular visitors. I have reckoned up at least 26 different days of visiting, sometime twice a day, and my sister and niece visited on most days when I didn’t.

Chronology

My mother was admitted to St Helier hospital in mid 2013 and spent three weeks on Care of the Elderly ward A6. The reason for admission was the rapid onset of a lack of mobility; she was also suffering from urinary incontinence and moderate dementia. Her lack of mobility led to her being doubly incontinent almost immediately.

As her mobility improved, she was released to home with increased care package.

She was readmitted via A&E after 10 days, again to ward A6 as she had again stopped walking. Her mobility and dementia commenced a rapid decline in hospital. After protracted negotiations with Sutton Social Services she was discharged to an excellent care home in September.

She passed away, in the care home, two weeks later from Alzheimer’s dementia and a urinary tract infection.

Mum’s treatment in hospital

We were asked about my mother’s eating preferences – she had never liked soup or yoghurt, so requested that she should have alternatives. In spite of continually repeating this, she was still being supplied with soup and yoghurt, which mostly remained unconsumed, until she was discharged.

The hospital wouldn’t syringe her ears – a procedure carried out by her GP regularly – hence her hearing became an issue and probably added to her increased withdrawal and isolation. The olive oil drops in evidence when she was first admitted had disappeared from view by the end of the third week (my sister tells me she found them her bedside cabinet, where they remained).

My niece cleaned and trimmed her fingernails on her visits – no attention seem to be paid to this or her toenails by the ward staff – they seemed to be happy to treat an ailment but not care for the patient. When it was confirmed that the hospital could not provide a chiropodist, it still took persistent questioning to find out if I could arrange an external chiropodist to visit. Her toothbrush remained in her bedside cabinet, apparently unused, throughout her stay. There is a lack of many of the support structures that would improve life for patients on the ward, except for hairdressing (paid for by the patient; but which strikes me as less important than some other aspects) but not general hair washing.

The tea lady told my sister that mum was quite chirpy in the morning when she was sitting up. However, on each of the few occasions she could visit at 2pm, the start of visiting, to try to see mum while still up she was already in bed and the notes said she was put back to bed at 2pm. This was also my experience – when arriving early for review meetings, mother was much brighter and sitting out of bed.

Visiting is discouraged outside the published hours, although I was never challenged when attending meetings outside these. Surely in Mum’s case it would have been beneficial for a relative to help at mealtimes?

Mother’s deterioration was constant, with apparently no adjustment to care/treatment even when it became obvious to all that she was rejecting the drugs (spitting out pills and throwing away liquids), not drinking or eating properly, therefore becoming malnourished and losing weight. Despite her obviously losing weight (she was never overweight) over a period of many weeks, it was only on the day that agreement was finally reached on her care home place she had been placed on a drip, which kept her in hospital for another 3 days.

Understanding the patient

My niece and her daughter witnessed mum’s transfer from A&E to the ward. In her own words:

“ We could hear grandmother screaming when we entered the ward. I could hear the nurses talking to her: the nurse said "don't kick me or I'll kick you and stop being such a baby" she also said don't bite or I'll bite you back". At this point I intervened and explained I was her granddaughter and advised I had heard what they had said and that I didn't think what they had said was very nice. The nurse the nurse said "well she was scratching biting and kicking". I said that still doesn't excuse the way your talking to her she has Alzheimer’s and is confused by what's going on and she has very thin delicate skin. I also explained that I had my daughter with me and we'd both found it very distressing the way that they were treating her.

I helped calm grandmother down and they put her into the bed without saying anything more.

I spoke to one of the nurses afterwards and said that it might have been useful to read her notes before they'd tried to transfer her. She said the notes hadn't yet come up from the previous ward. Considering she was being transferred to the elderly ward I would have thought they would be more used to dealing with Alzheimer’s, confused, elderly, scared patients.

I didn't make a formal complaint at the time as I could see from the faces of the nurses id confronted that I'd not made myself popular and I was worried that this may affect grandmother's ongoing care. ”

There appeared to be a general lack of understanding of the condition of most of the patients on the ward. The majority of patients, all elderly ladies, seemed to be suffering a degree of dementia, confusion and fright. A number of times staff were observed asking indirect questions of patients such as ‘are you experiencing any discomfort’ and ‘when did you last have a bowel movement’ – both of which were met with blank stares.

Much time of staff is spent writing in and reading the patients’ folders – one at the end of the bed and the other kept in a ‘locked’ filing trolley (rarely actually locked). On approaching a bed, it is not immediately obvious what the patient’s name or their state of health or mind is. This results in a blanket approach to all patients: as the staff and doctors seem to change rapidly they cannot quickly understand if the patient hasn’t heard, doesn’t understand or is ignoring questions or requests; all of which I observed with my mother.

In order for staff to quickly identify with patients’ condition, needs and communication abilities there should be a very clear and obvious statement their abilities and requirements at the bedside – presumably in the bedside folder – rather than the opaque tick lists (which I managed to find hidden amongst the many pages of records in the bed folder) or in many pages of handwritten script in remote folders. Why are patient’s names not in plain view at the bed?

Patients have a large orange call button to press if they need help. My mother didn’t understand what this was, could not physically press it herself and when I operated it (whilst in a separate bedroom for MRSA cleansing) it was 9 minutes before anyone came.

Patient Information Station

On the ward there is a large illuminated sign by a cell of desks with a ‘Patient Information Station’ sign. Often there doesn’t seem to be anyone there to ask questions – and even if there is, if you don’t interrupt someone you are ignored. Quite commonly you are asked to wait for someone else to (not) answer your questions or wait while the ‘secret folder’ is pored over for any useful information, usually with little success.

My sister reports: we never received a missing discharge letter from the first three week stay – it was requested by the GP and social services. I asked several times and I stood at the "station" for about 10 minutes one day while one of the nurses tried to find it, first in the secret files then on the computer, when eventually she said she had found it, between two of them they couldn't work out how to print me out a copy, eventually they agreed to sort it out later and post it to me and it never arrived.

When supplying information or making a request on the patient’s behalf it is written in the folder – my experience was that this is never actioned “Can you arrange for my chiropodist for my mother? ” was written in the book twice – eventually, when asked, the house doctor spent 10 minutes finding the sister to get the answer that the hospital can’t arrange that.

There seems to be no strategy for communication with relatives/carers. It was very difficult to find out anything about mum’s treatment, diagnosis or condition. There are no doctors available during evening visiting hours which is when working relatives can attend. It seems a different model of ward is required for those unable to communicate for themselves.

Ward Staff

In spite of printing out the uniforms section from the hospital website, it was nearly impossible to identify the level of nursing staff and identify a doctor. Many of the nursing staff in dark blue uniforms referred me to another in the same uniform when I requested information – even when at the ‘Information Station’.

I found the attitude of many of these nurses towards me to be intimidating, as if I were a nuisance getting in the way. In one instance when asking a question the answer was so grudgingly given as to be positively rude. Often they did not engage with the patients, not introducing themselves or even saying hello when approaching the patient, for whatever reason. Many had thick foreign accents which exacerbated understanding difficulties, adding to the issues most of the patients had in coping with their situation.

A quote from my niece “…on one occasion the bed smelt of faeces and there was some on her hands, sheets and in her nails. I asked the nurse to clean her up and she said she was dealing with another patient first. I was there for a good 20 minutes before she came to sort her out. She looked at Diddy and said ‘oh it's her I'll need to get some help with this one’. I had to leave at that point while the nurse went to find another nurse. I overhead the other nurse say I've got the medication to give out she'll have to wait.

It shocked me that often in the evening there would only be 2 nurses on ward for all the high dependent patients they needed to care for”

There was never a sense of business on the ward. Things were done slowly and intentionally: reading files, walking about with bits of paper, looking for someone, talking on the telephone. The atmosphere from these nurses generally was one of resentful tolerance of visitors and patients. The more junior staff on the ward had a more caring attitude and seemed to be the people doing all the real care work.

At, I assume, shift handover time (during evening visiting hours) a group of four or five nurses in dark blue uniforms would drift along the foot ends of beds and discuss, with reference to a single sheet of paper, presumably, the patient in the bed. The patient was rarely acknowledged and I certainly wasn’t. A thoroughly depressing experience (with all the writing and reading of the ‘secret’ folder, why is that not used at this point? )

Doctors are indistinguishable from visitors, making a meaningful interaction with them difficult. The patients appear to be attended to by a small team of unidentified doctors at any one time – the only name generally offered was that of the consultant, whom I managed to talk to on the phone but never saw on the ward. I did have a deep conversation with a doctor after she visited the bed, when I had offered some information on my mother. However, I only saw this lady once or twice again. My mother asked me on more than one occasion ‘who’s that’ when a doctor was trying to elicit information (or blood) from her.

Mood on the ward

There was generally a feeling of depression in the ward. Very few of the patients were capable of reading and were not encouraged to engage with each other in any way. The only entertainment provided was via the ‘pay to view’ TV system, which supplied free BBC radio stations and the hospital radio channel – which played a selection of mostly pop music. However, given the age and abilities of the patients, none of them were, as far as I could tell, capable of operating the system. Indeed I had to help one of the staff turn the radio on for a patient. The pay to view TV, apart from the appalling expense (£10 for 24 hours from when bought), was difficult for my daughter, who is very IT literate, to operate.

This resulted in a very sterile social and sensory environment – further adding to the isolation, confusion and anxiety of the patients.

Patients would recover more quickly and be more cooperative if they could feel happy in their environment. A central entertainment system, with communal TV and music appropriate to the age group would help this, as would a form of social interaction between patients and staff.

Visitors, who could make a difference to the atmosphere, are not encouraged. There are no facilities on the ward – I could not find water tap or visitor toilet, I was never once offered a drink, even when they were being provided to the patients. The coffee bar is eight minutes and the shop six minutes walk from the ward, down and six floors. A long time away in a 2 hour visiting slot.

The hospital website states ‘Visiting is restricted to 2. 30pm - 5pm and 6pm - 8pm to allow time for patient care and meal times’, but patient care seems to carry on in visiting times and help at mealtimes could be useful (as above), so why be so restrictive?

With the feeling and approach of the staff on the ward, we were worried that complaining formally during her stay would further prejudice the staff attitude to my already very vulnerable mother. I did approach the PALS service at the very beginning of her first stay (about the sombre mood of the ward and the TV system) but could not structure my further comments in order to approach them further.

The contrast with the care home was stark and shocking: a happy, vibrant atmosphere, with music, chatting and many caring staff - I only managed to visit twice (no restriction on visiting hours and happy to let me help with meals) – both times I was asked if I’d like a drink and it was bought to me.

Other points

I witnessed some records, notably those pertaining to meals and position in/out of bed, being updated after the event. Two days’ records missing one day and filled in the next.

The ‘patient information’/nurses station was extremely cluttered with signs/notes/posters stuck on the walls and windows – some of which were two years out of date. Many of these were reminding staff of tasks which would appear to be a normal part of their responsibilities. This added to the gloomy and unstructured feeling of the ward.