Trust failed to undertake thorough observations

What happened

Mrs L was admitted to hospital for surgery to remove part of her lung. She was transferred to a 'step-down' area for her postoperative care but two days later she was found collapsed, and died. Her husband complained to the Trust, which accepted that it had not performed all of the necessary observations before Mrs L died. However, the Trust said that the recorded cause of death in the post mortem showed that the lack of observations had not contributed to her death. Mr L remained unhappy and asked us to investigate.

What we found

The Trust failed to perform two sets of standard observations and did not wake Mrs L to properly carry out the observations for the pain relief given to her. This was a failing. Despite this, the cause of death recorded in the post mortem report was unlikely to have caused any obvious symptoms, meaning that it was unlikely Mrs L's deterioration would have been spotted even if the observations had been performed correctly. However, we could not say for certain that this was the case. While the Trust had rightly acknowledged the missing observations, it had not given Mr L a clear apology for this.

Putting it right

We asked the Trust to apologise to Mr L and to share with him information about the changes put in place to make sure that it performed and documented all observations correctly.