Miss A complained that her mother, Mrs A, was not monitored for eight hours and was found unresponsive after suffering a cardiac arrest. Miss A also had some specific concerns about aspects of her mother's care and about the way in which a consultant cardiologist approached the discussion of a do not attempt resuscitation order (DNAR).
What happened
Mrs A was admitted to hospital as she was more short of breath than usual. Staff gave her medication for heart failure and carried out two ECGs (to measure the activities of her heart). After further tests, the Trust started to treat Mrs A for a suspected heart attack and carried out a third ECG. Mrs A was transferred to a ward and nearly seven hours later was found unresponsive, having suffered a cardiac arrest (when the heart stops working). Cardiopulmonary resuscitation was successful and she was transferred to the intensive care unit. Eight days later she was transferred to a ward under the care of the consultant cardiologist. The consultant cardiologist spoke to Mrs A and Miss A about whether or not Mrs A should be resuscitated if she suffered a further cardiac arrest. Mrs A continued to receive treatment on this ward and another, before being moved the Trust's neurological centre. She later developed pneumonia and died.
What we found
Doctors did not realise that Mrs A was a high–risk patient and did not put in place a plan for continuous cardiac monitoring as they should have. After transfer to the ward, staff did not carry out any observations until after Mrs A's cardiac arrest. Although the decision to move Mrs A to a side room was reasonable, there is no evidence staff considered whether she needed one–to–one nursing during her periods of agitation; and relevant staff were not informed that Mrs A was nil by mouth when she had the scan. The consultant cardiologist did not explain that he did not feel that Mrs A should be resuscitated in the event of a further cardiac arrest in a sensitive manner to Mrs A and her daughter (although the decision itself was reasonable). Neither did he record his assessment of her capacity to contribute to the decision as he should have done. There was no evidence of a delay between when Mrs A was found unresponsive and the time of the cardiac arrest call.
How the Trust handled Miss A's complaint was maladministrative. These failings led to distress to Mrs A and her daughter.
Putting it right
The Trust apologised to Miss A for the failings and the injustice they caused. It agreed to put in place an action plan to address the failings it had not already addressed.
Sheffield Teaching Hospitals NHS Foundation Trust
South Yorkshire
Did not apologise properly or do enough to put things right
Did not take sufficient steps to improve service
Replied with inaccurate or incomplete information
Apology
Recommendation to learn lessons or draw up an action plan