Trust did not properly consider rights of person with disabilities

What happened

B had diabetes, learning disabilities and was registered blind. In the five years before her death in summer 2009, she developed a number of other conditions. Because of these conditions and a fall in winter 2008, B had more than a dozen admissions to the Trust's hospital in 2008. In early 2009, Trust staff admitted B to hospital again. She stayed in hospital until summer 2009, when she died.

What we found

Mr A complained about a number of aspects of his daughter's care and treatment between early 2008 and mid-2009. There were no failings in some of those areas.

Mr A complained that when his daughter was transferred to another trust's hospital for an eye procedure in early 2009, the other hospital was not told that his daughter had MRSA. He complained that when his daughter returned to the Trust's hospital, she was placed in an open ward, even though she had tested positive for MRSA (a bacterial infection that is resistant to a number of widely used antibiotics). There were no failings in the Trust's screening of B for MRSA before she was transferred to the other trust's hospital. But the Trust's staff did not 'get it right' when B was transferred back to the Trust's hospital, because they did not screen B for MRSA at this time, as the Trust's own MRSA policy said they should have done. This meant that staff did not start a process to remove or reduce the bacteria as soon as they could have done.

Furthermore, staff did not tell B, her family or her carer about her MRSA status, as established good practice said they should have done. We recognised that it would have been distressing for B's family and carer to find out that she had tested positive for MRSA and that they were not told to take additional precautions.

Mr A also complained that he had asked the Trust for information about his daughter's eye procedure and the Trust had told him that it could not answer his questions. Had the Trust contacted the other trust (or even suggested that Mr A contact the other trust), as we did, it was likely that it could have answered Mr A's questions. However, although we recognised that Mr A would have been frustrated by the Trust's inability to give him the information he sought, we noted that the Trust had apologised for this.

Mr A said that the Trust did not consider his daughter's needs as a person with learning disabilities and a visual impairment. The advice we received told us that B's nursing assessment should have established how her learning disabilities and visual impairment affected her daily activities, her thought processes and her mental well-being.

It would have been good practice for staff to have identified how to improve communication with B at the outset. However, although there was evidence of the care given to B, there was little evidence of assessment and care planning.

This meant that B's nurses could not be sure that the care they gave B met her individual needs. Furthermore, B's doctors did not give proper consideration to her learning disabilities. This meant that they could not be sure that she understood what they told her or that she had the mental capacity to make decisions about her care and treatment for herself.

There was also maladministration in the time it took the Trust to investigate Mr A's complaint and in the way it provided answers to some of his key questions.

Putting it right

The Trust acknowledged and apologised for its failings. It agreed to put together an action plan that showed how it had learnt from its mistakes so that they would not happen again.

It also paid Mr A £1,250 to acknowledge the impact these failings had on his daughter, himself, his ex-wife and his daughter's carer.