Patient's family let down by nurse's actions

What happened

Mr P was suffering from a terminal brain tumour. He was admitted to hospital via A&E late in 2012 with difficulty breathing. During a transfer from a ward to one with a single room, there was a disagreement between a nurse and Mr P's family because the family were concerned that Mr P was not getting sufficient oxygen. Mr P was transferred and died later the same day. Mr P's family complained about the clinical and nursing care given to him. They also raised specific concerns about a particular nurse, including her attitude towards Mr P and his family, and that she did not provide Mr P with enough oxygen during a transfer from one ward to another.

What we found

The clinical care was of a high standard, but there were serious concerns about the actions of one of the nurses. When Mr P was to be transferred to another ward, there was insufficient oxygen in the cylinder and the nurse decided to reduce the oxygen flow rather than get another cylinder. As a consequence, Mr P struggled to breathe and when his family raised concerns with the nurse she refused to listen and dismissed their concerns. The records showed Mr P's oxygen levels dropped during this time, supporting the family's view that the reduced oxygen flow was causing him distress. Fortunately Mr P's oxygen saturation levels recovered once he was settled on the new ward and although he died shortly after, we did not find that the poor standard of nursing care was a contributory factor. The incident caused both Mr P and his family a considerable amount of unnecessary distress at an already very difficult time, given that Mr P was approaching the end of his life.

Putting it right

The Trust acknowledged the failings in nursing care and apologised to Mr P's family. It paid £1,000 in recognition of the distress and anxiety caused by the nurse's actions.