Hospital changed patient's medication without informing GP, and failed to provide appropriate nutrition

What happened

Mr R was admitted to hospital via A&E in spring 2013. He had a number of medical conditions including Parkinson's disease, dementia, heart failure and pulmonary hypertension (raised blood pressure in the blood vessels that supply the lungs). Mr R was diagnosed as being in urinary retention (inability to empty the bladder), and staff fitted a catheter. His diuretic medication (to treat his cardiac failure) was stopped, but the hospital did not tell Mr R's GP about this.

The speech and language therapy team advised that Mr R should be supervised when eating and drinking, and that he should be given a special diet of soft and mashed foods. Mr R's specialist medication to treat his pulmonary hypertension ran out while in hospital. After a stay of 15 days, the hospital discharged Mr R. After his discharge, he developed fluid retention and had to be readmitted to hospital eight days later.

What we found

The Trust failed to tell Mr R's GP that his diuretic medication had been stopped, and failed to appropriately communicate with Mrs F when she tried to find out what had happened. The Trust failed to make sure that Mr R received food and fluids in accordance with the speech and language therapy team's instructions, and did not properly monitor his fluid intake.

Mr R's specialist medication for pulmonary hypertension ran out while he was in hospital. The Trust should have monitored what he had left so that it could order additional medication.

Putting it right

The Trust apologised to Mrs F for the failings in her father's care and its communication with her. The Trust agreed to produce plans to prevent this happening again.