Mrs A's son, Mr A, was concerned about the care and treatment of his mother during her two–day admission to the Trust. He thought her care and treatment were inadequate and may have led to her premature death.
What happened
Mrs A arrived at the hospital's A&E in an ambulance. The Trust admitted her with abdominal pain and shortness of breath. Staff noted that she was confused. She had fallen at home the previous day but had not wanted to go to hospital. The hospital kept Mrs A under review but her health declined very quickly on the second day of her admission and she died.
When her family raised concerns about the unexpectedness of her death and questioned the Trust about Mrs A's care, the Trust investigated the complaint and responded with an explanation of the treatment provided. It concluded that she had received appropriate care. However, it acknowledged that staff failed to communicate just how unwell Mrs A was and that staff did not discuss the plan for a do not attempt resuscitation order (DNAR) with her family.
What we found
There were no failings in the hospital's care and treatment of Mrs A. Medical and nursing staff recognised that she was seriously unwell. Sadly, despite treatment, she deteriorated and died relatively suddenly. We found that her medical management had been appropriate and that her death was not preventable.
We agreed with the Trust that there had been failings because staff did not discuss Mrs A's poor condition or the plan for the DNAR order with her family. While the Trust acknowledged the failings and had apologised, we saw no evidence that the Trust planned to take action to prevent this occurring again.
Putting it right
We recommended that the Trust take action to improve its communication with families.
Royal Berkshire NHS Foundation Trust
Reading
Replied with inaccurate or incomplete information
Recommendation to change policy or procedure