Patient left without appropriate treatment for over 11 hours

What happened

Mr W who was in his sixties suffered from chronic obstructive pulmonary disease. An ambulance took Mr W into hospital after his mother had found him collapsed and cyanotic (blue skin colour as a result of low levels of oxygen). When he arrived in A&E, the Trust inserted a tube into his trachea to help him breathe. The plan was to remove the breathing tube when his blood carbon dioxide (CO2) level had returned to normal.

The Trust removed the tube and admitted Mr W to the hospital's acute assessment unit (AAU). Mr W's family was told that he was being left to pass away peacefully.

Mr W was then given a tight-fitting mask to help with breathing and his condition improved to the extent that he was discharged home four days later. Sadly Mr W died of a heart attack just over one month after his discharge from hospital.

Mr W's sister complained that her brother was treated with a lack of dignity which was very distressing for the family.

What we found

We upheld this complaint. The Trusts' decision to remove Mr W's breathing tube was wrong, as his blood CO2 level had not recovered to a sufficient extent. We also found that he should have been admitted to the intensive treatment unit rather than the AAU at that time. We found that the decision to remove the breathing tube led to an 11-hour period during which Mr W was in a state of considerable agitation and distress because he was left without the appropriate treatment. This in turn caused distress to Mr W's sister and other members of the family who were present.

However, we found that Mr W's death could not be attributed to the poor care that he received from the Trust.

Putting it right

The Trust acknowledged and apologised for the failings in the treatment given to Mr W. It paid his sister £500 in recognition of the distress she experienced as a result of these failings. The Trust also prepared an action plan to show what it had learned from the complaints.