Failings by hospital meant a patient became dehydrated

What happened

Investigations had identified that Mrs D possibly had cancer. Her consultant at Sherwood Forest Hospitals NHS Foundation Trust (the first Trust) decided not to admit her to hospital but did not immediately write to Mrs D's GP while further investigations were performed. Mrs D remained unwell and was admitted to Nottingham University Hospitals NHS Trust (the second Trust) before all of the test results from the first Trust were known.

The tests later confirmed that Mrs D had a type of abdominal cancer. While she was in hospital, she became dehydrated, and Mrs W complained about this and other aspects of her mother's care. Mrs D died in hospital six weeks later.

The first Trust apologised for delays in reporting on some of Mrs D's scan results. The second Trust apologised for allowing Mrs D to become dehydrated but said that the rest of her management had been appropriate. Mrs W remained unhappy and contacted us.

What we found

The first Trust: Mrs D should have been admitted to hospital when she was first seen or, at the very least, the Trust should have contacted her GP so that he had adequate information if Mrs D deteriorated. Mrs D's admission was delayed by ten days and while this had no bearing on the eventual outcome, investigations and treatment could have started sooner, avoiding additional distress for Mrs W and her family.

The second Trust: while much of Mrs D's management was reasonable, as the Trust said, it was a significant failing that she became dehydrated and needed dialysis. Although we found no evidence that this contributed to Mrs D's death or reduced her chances of undergoing surgery and/or chemotherapy, it undoubtedly caused a great deal of unnecessary distress to Mrs W and her family.

Putting it right

The first Trust apologised to Mrs W, reviewed its procedure for sharing significant information with GPs and paid her compensation of £500.

The second Trust paid Mrs W compensation of £1,000. Additionally, it created an action plan addressing the failings we identified and shared this with us, Mrs W, the Care Quality Commission and the local clinical commissioning group.