Clinical care of older woman was reasonable but there were some failures

What happened

Mrs H was in her early nineties when she was admitted to hospital with pain in her hip after a fall at home. She had a history of cardiovascular problems. Investigations revealed a slow heartbeat but no fracture.

Staff noted a new diagnosis of anaemia, along with fluid overloading, a failing heart and low sodium. Ongoing care included a combination of medication adjustment to control blood pressure and heart failure, physiotherapy, and treatment for anaemia.

Just over a month after her admission to hospital, Mrs H collapsed on a hospital ward and sadly died two days later. The post mortem showed that she had died from a spontaneous intracerebral bleed, severe hypertension, myocardial infarction, congestive heart failure and anaemia.

What we found

Mrs H's clinical care and treatment were reasonable but the Trust had not reviewed its medicine reconciliation process, and had failed to discuss a do not attempt resuscitation (DNAR) order with Mr or Mrs H. There were some failings in the Trust's communication with Mr H and how it handled Mr H's complaint.

While the Trust had apologised for this, we felt that there was more that could be done.

Putting it right

The Trust paid Mr H £250 in recognition of the stress and upset he suffered as a result of poor complaint handling.

We recommended that the Trust review its complaint handling in accordance with the Ombudsman's Principles of Good Complaint Handling and good practice. The Trust should pay particular attention to the Principle that organisations should deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate.

The Trust created an action plan that explained what it intended to do to minimise the risk of a failure to discuss resuscitation plans.

We recommended that the Trust review the efficiency of its medicine reconciliation processes to ensure the robust sharing of correct information about medication usage. The Trust accepted our recommendations.