Failings in care did not lead to patient's death

What happened

Mrs R, then in her eighties, had surgery to repair a fractured hip. She had a stroke in hospital shortly afterwards. She was transferred to a community hospital for rehabilitation, where she was found to have MRSA (a bacterial infection) in her surgical wound. She was very agitated and distressed during her admission and doctors gave her a drug to try to help with these symptoms.

Mrs R became extremely unwell and was transferred to an acute hospital. She developed a swallowing difficulty and died from aspiration pneumonia after she was transferred.

What we found

Doctors at the community hospital did not see Mrs R often enough or communicate well with Mrs S. This was a failing. She was too unwell for rehabilitation and should have been cared for in an acute hospital, where she would have had access to 24-hour care and treatment. She

would have had better treatment for her MRSA had she been in an acute hospital, although

her infection eventually cleared up with less intensive treatment.

Nurses did not properly monitor Mrs R's eating and drinking, although this might not have made much difference for Mrs R, who was very unwell. It was upsetting for Mrs S to see that her mother did not get the standard of care she was entitled to.

There were failings in the care provided to Mrs R, and missed opportunities to provide her with better care and treatment. However, it is more than likely that the course of events would have been no different had the failings not happened. Mrs R was very ill, with several health problems (such as the stroke, which contributed to her death) and there was little,

if anything, that could have been done to make these better.

Putting it right

The Trust acknowledged the failings we identified and apologised for the injustice that resulted from them. It also paid Mrs S £750 compensation in recognition of the injustice she suffered.

The Trust is producing an action plan to show that it has addressed the failings identified during our investigation.