Trust made 'Do Not Attempt Resuscitation' decision without telling patient's family

What happened

Mrs G was admitted to hospital following a stroke. She had a chest infection and respiratory failure, which meant she required a mask to help her breathe. Mrs G was agitated at times and attempted to remove the mask. Mr and Mrs R gave their permission for the Trust to put mittens or gloves on Mrs G's hands to prevent her removing the mask. But the mittens were not available and so the Trust restrained Mrs G with bandages round her hands. The following morning Mrs G became distressed and the mask was removed but the staff did not remove the bandages. Mr and Mrs R received a phone call the same day advising them to attend hospital urgently. When they arrived Mrs G had already died.

Mr and Mrs R complained that when Mrs G was restrained with bandages, she was not checked frequently. They said the Trust made a 'Do Not Attempt Resuscitation' decision without informing them. They also said the timing of Mrs G's death was unclear. Mr and Mrs R said that the lack of communication with them meant they were denied the opportunity to be with Mrs G when she died. They explained that what happened had a great emotional and physical impact on Mrs R.

What we found

It was reasonable for staff to use bandaging as a restraint in the absence of an alternative, but there was a failure to document why they were being used or to review the need for these over time. There was also a failure to remove the bandages following Mrs G's death, which meant that Mrs R had been left with a lasting memory of Mrs G's hands being restrained by bandages.

The nursing staff failed to refer Mrs G to a doctor when her health deteriorated. This meant that the Trust missed the opportunity to treat Mrs G's symptoms or consider palliative care at the very end of her life. The Trust failed to tell Mr and Mrs R about Mrs G's obvious deterioration and did not discuss the 'Do Not Attempt Resuscitation' decision with them.

Putting it right

The Trust acknowledged and apologised to Mr and Mrs R for the failings we found. It paid them £1,000 in recognition of the overall impact of these failings. The Trust also produced an action plan to address the failings we had identified.