Family denied opportunity to spend time with patient before he died

What happened

Mr B was admitted to A&E at the Trust after he developed breathing difficulties during dialysis treatment at another trust. Although his family stayed with him overnight, staff advised them to go home early in the morning. Mr B had a cardiac arrest later that morning, and did not regain consciousness. His family were called but Mr B died before they arrived. 

Mr B's daughter, Ms P, complained about the care that her father received from the Trust. She was concerned about whether there was enough senior staff involvement in her father's care, and whether staff considered other conditions. In particular, she felt that medical staff did not consider sepsis. Ms P also complained about the lack of discussion with the family about the do not attempt resuscitation (DNAR) decision and that they were not given an indication of how serious Mr B's condition was.

Ms P felt that the failings led to her father's death. She said that because the Trust had not fully addressed her concerns, she and her family did not know if her father would have survived if the Trust had given him appropriate treatment. She also said that her family felt guilty that her father died alone.

What we found

There was fault in the lack of senior involvement in the early stages of Mr B's admission, and in the differential diagnosis. However, Mr B did not meet the criteria for a diagnosis of sepsis and, despite the failings we found, it was clear that Mr B was very ill and different treatment would probably not have altered the outcome. There was therefore no injustice linked to this fault.

However, the failings in communication with Mr B's family caused a considerable injustice to them. Because the Trust gave them poor information about Mr B's condition, the family were denied the opportunity to make an informed decision about whether to stay with him shortly before he suffered his cardiac arrest. This was understandably very distressing for the family.

Putting it right

We upheld Ms P's complaint. The Trust acknowledged the faults we found and apologised for these. It also paid Mr B's family £1,000 to recognise their distress. In addition, it drew up an action plan to stop the mistakes happening again.