Patient should have been prescribed stronger antibiotics and transferred to an acute hospital sooner

What happened

Mr A underwent heart surgery. After the surgery, Mr A was slow to wake up, and when he did, he was essentially bed–bound and unable to talk. The Trust transferred him to a general ward at the acute hospital where his improvement was very slow. He was then transferred to a rehabilitation ward in a different hospital where he had a temperature and was breathless with poor oxygen saturation levels. After this, he was moved back to the acute hospital, where he died of bronchopneumonia.

His family complained that staff did not give antibiotics soon enough and that a delay in transfer back to the acute hospital caused Mr A's death.

What we found

There were failings in the choice of antibiotics and in how staff completed charts and acted on them. Staff did not recognise early enough that Mr A would have benefited from transfer to an acute hospital.

However, we did not conclude that these failings caused Mr A's death. We saw that Mr A was very unwell and concluded that different treatment or earlier transfer would, unfortunately, not have made any difference. Mr A had a severe and multiresistant pneumonia which did not respond to powerful antibiotics. His immune system was also impaired. This combination was very likely to have proved fatal, whatever treatment was provided.

Putting it right

The Trust apologised to Ms A for the failings identified and produced plans to improve antibiotic treatment and to make sure staff recognised situations when a transfer to an acute setting was required.