Failure in care and treatment at end of 84–year–old's life

What happened

Mr F had advanced liver cancer and dementia, and lived with his son Mr E. After he became agitated and failed to recognise Mr E, Mr F was admitted to hospital. When Mr E visited him the following day, he found that some of Mr F's property was missing (clothes, a large amount of cash, and a pair of crutches). The hospital made no record of Mr F's property on his arrival, or when he was moved to different locations in the hospital. Some of the property was later found, but some remained missing. (Mr E said this included some of the cash.)

Mr F was discharged but was readmitted to hospital later the same month, just before a bank holiday. He was confused and agitated, and over the next few days nurses gave him medication to try to calm him. However, he was not seen by a doctor during the bank holiday weekend. After the bank holiday weekend, Mr F appeared over–sedated.

Family members were concerned about the sedatives he had been given, and asked nurses and doctors about Mr F's condition and treatment. However, they were not satisfied with the information given. Mr F's condition deteriorated further and he sadly died.

What we found

The Trust did not follow its own property policy, and did not properly investigate or follow up the lost property or Mr E's complaint. This led to remaining uncertainty about what had happened, and Mr E could not be reassured that action had been taken to prevent it happening again or that hospital staff were not stealing from patients.

Because of poor documentation, we were unable to find out whether Mr F had arrived at the hospital with all of the property Mr E said he had.

End–of–life care specialists should have been involved in Mr F's care very quickly when he went back to hospital, but this did not happen. Mr F's sedative medication should have been given using a syringe driver (a syringe attached to a motor, which delivers medication slowly and steadily over the course of a day) rather than by single doses given irregularly. Overall, Mr F should have had more sedatives than he did. If that had happened, his symptoms of confusion, agitation and breathing difficulties might have been eased in the last few days of his life. However, the medication he was given did not hasten his death.

Doctors and nurses did not communicate clearly to Mr E that the end of Mr F's life was near, or about the care and treatment being provided. This caused unnecessary distress to Mr E as he could not understand what was happening, or why. It also worsened his grief following his father's death.

Putting it right

The Trust apologised to Mr E for its failings and paid him £1,300 compensation. It also developed a plan to learn lessons from the complaint.