Stroke patient received poor care

What happened

Mr R had a stroke at home and went into his local stroke unit. Trust staff carried out a scan and an assessment. Later that evening, nurses were worried that Mr R was deteriorating and called a doctor to see him. The doctor felt Mr R's condition had not changed but told nurses to check on him more frequently. During the night, Mr R fell out of bed, but a doctor checked him and found him unharmed.

Most of Mr R's clinical records for the next day are missing, and there is no evidence to suggest that a doctor saw him during the day, although nurses monitored him. A doctor saw Mr R during the night shift and his condition at that time was unchanged.

The next morning, doctors found that Mr R's condition had severely deteriorated. He had an urgent scan and was referred to neurosurgery. Staff transferred him to a specialist centre at another trust, but he died a few days later.

What we found

Generally, Mr R received good care from night shift staff but the care he received during the first day was not good enough.

A junior doctor failed to identify that Mr R was deteriorating during his first night on the unit. If the junior doctor had noted the deterioration, staff would have carried out a second scan sooner. However, even if Mr R had had another scan, it was unlikely that he would have survived his stroke.

There were also significant failings in the Trust's record keeping as some records were missing and record keeping was not good overall.

Putting it right

The Trust apologised to Mr H and paid him £1,000 in recognition of the distress caused to him and his father.

It also prepared an action plan that addressed the failings we identified to prevent others having similar experiences.