NHS trust failed to provide adequate care for an older person

What happened

In early 2011 Mrs L (then in her nineties) became increasingly frail. Her doctor referred her to the hospital because of an impacted bowel. Doctors assessed her and treated her for constipation. Mrs L transferred to a ward soon after admission. In the next few weeks, her condition fluctuated. Later in the month, nurses found Mrs L to be unresponsive. Staff attempted to resuscitate her but she had died. Her son, Mr L, complained to us.

What we found

There were fundamental failings in Mrs L's care and treatment, especially around her situation as a frail, older person. There was some good nursing care; however, there was an overwhelming failure to provide 'person- centred care'. Assessment, review, monitoring and treatment of Mrs L's eating and drinking and constipation were consistently poor.

Doctors and nurses did not act in line with the applicable standards. Further, communication with the family was not in accordance with the relevant standard. Taken together, these failings meant the care and treatment Mrs L received fell so far below the applicable standards that it was service failure.

Putting it right

Following our report, the Trust acknowledged the failings we identified and apologised for the injustice these caused. The Trust agreed to pay £1,250 compensation to Mr L and to prepare an action plan to make sure it learnt lessons from the complaint.