Poor nursing care for elderly man and poor communication with his family

Mr E was an elderly man with a number of medical conditions including diabetes and vascular disease. Towards the end of the year, Mr E had a colonoscopy after which he was discharged home. A few weeks later he had a heart attack and was in hospital for several weeks. He underwent a coronary artery bypass and was discharged home in the spring following rehabilitation. A week later Mr E was readmitted to hospital with vomiting, diarrhoea and dehydration. He was reviewed and discharged home again. A few days later he had a severe haemorrhage and was taken to hospital where he was diagnosed with bowel cancer. A decision was made that no active treatment would be given for the cancer because Mr E was so unwell.

Mr E's existing foot problems got worse in hospital and his family raised concerns about his foot pain, given his diabetes.

Mr E was discharged home with a referral to palliative support and therapy. He was seen at a foot clinic and by his GP with increasing foot pain. Mr E fell at home the next month and was taken to hospital. His leg was amputated to the knee because of severe infection. Mr E developed fluid on his lungs and was vomiting and finding it hard to breath. He was given antibiotics and oxygen. His condition continued to deteriorate and he died the following month.

What we found

We upheld some parts of Mrs G's complaint. There were no failings in Mr E's clinical care and treatment, including the care and treatment of his foot and amputation, and his end of life care.

There were, however, instances of poor basic nursing care around hygiene, fluids, nutrition and community nursing foot care, some of which the Trust had already acknowledged. The Trust had also acknowledged that it had communicated poorly with the family about what was happening with Mr E's care and about his deterioration. Mr E was deaf on his right side. Although this fact was noted in numerous clinical records, we saw no evidence of any care planning in response to this.

It is highly unlikely that the outcome for Mr E would have been any different had these failings not occurred, but clearly they still caused considerable distress.

Putting it right

The Trust wrote to Mrs G to acknowledge its failings, apologised for the distress caused, and paid her £500. It also produced an action plan which described how it would prevent the same issues happening again.