Trust did not give older patient adequate care

What happened

Mr J was in his late seventies and was the sole carer for his disabled wife. He had a history of heart disease and stroke. Mr J collapsed at home and was taken to hospital where doctors diagnosed that he had probably fainted. Doctors discharged him the following morning with outpatient follow up for his fainting episode.

Mr J became unwell about two weeks later. He went to hospital where doctors diagnosed that he had a chest infection. They gave him antibiotics and intravenous (into a vein) fluids. His condition deteriorated. Mr J developed pressure sores at the base of his spine, became unable to eat and drink, and required help to clear his airways. Staff were unable to insert a feeding tube to help feed Mr J. They inserted a central catheter, which ward staff were not trained to use. Mr J was moved to a different hospital shortly afterward. He sadly died several months later.

The Trust carried out a safeguarding investigation and found serious failings in the lack of food provided for Mr J during his second admission to hospital. The Trust did not find any other failings.

What we found

Several doctors saw Mr J during his first admission to hospital and carried out appropriate examinations of him. Their diagnosis, and the decision to discharge him, were reasonable and in line with established good practice. In terms of the second admission, there were no failings in Mr J's mouth care. However, the Trust did not give him adequate pressure area care, early physiotherapy intervention or adequate nutrition during his stay in hospital. While these failings were serious, we did not find that they led to Mr J's death. Finally, although ward staff did not know how to use the central catheter, the Trust promptly recognised this and tried to address it.

Putting it right

The Trust had already identified a number of improvements as part of the safeguarding investigation. We therefore recommended that it provide an update on the actions it has already agreed to undertake as part of the safeguarding investigation.