Mrs A died unexpectedly, only a few minutes before her husband arrived

What happened

Mrs A had late-stage metastatic lung cancer and had lived for longer than had been expected. However, she was admitted to hospital in summer 2012 with shortness of breath. Staff treated her initially in the Trust's acute medical unit before they transferred her to a ward the following evening. Staff did not think she was at any risk at this stage.

Mrs A was distressed because of previous bad experiences when she had moved wards. She asked staff to contact her husband to ask him to visit. Soon afterwards, nursing staff noticed a change in Mrs A's breathing and asked for the on-call doctor to review her. The doctor was delayed in attending as he had been called to treat another patient.

Sadly, only a few minutes before her husband arrived at the hospital, Mrs A died. This was approximately two hours after staff noticed the change in her breathing and was not long before midnight. When Mr A arrived, the doctor met him to discuss the events of the evening and confirmed Mrs A's death.

Mr A subsequently complained to the hospital about a number of issues, including the move to a ward and the date and time of death recorded on his wife's medical certificate of confirmation of death.

What we found

Mrs A's deterioration and death were sudden and relatively unexpected. Before her change in breathing, there were no clinical indications of Mrs A's imminent deterioration.

Ward staff had failed to recognise the significance of the change in Mrs A's breathing. Although staff had requested medical review, they did not escalate this when the doctor was delayed in arriving. Although we could not say that Mrs A's death could have been avoided, we considered an earlier medical review might have led to the prescription of medication for the build-up of secretions. This might have helped Mrs A's distress and could have allowed some additional time for her husband to arrive on the ward to be with her.

The checks staff carried out to verify death were appropriate. There was not enough evidence for us to query the details of the time of confirmation of death recorded in Mrs A's notes by the doctor. However, we reassured Mr A that the date recorded on the medical certificate of confirmation of death was appropriate because it was carried out after midnight.

Putting it right

The Trust acknowledged and apologised for the failings we found. It created and implemented an action plan to ensure that appropriate plans are in place for end-of-life stage patients, should their condition deteriorate unexpectedly. The action plan also ensured that staff on non-palliative care wards are trained to recognise the signs and symptoms of sudden, and unexpected, deterioration in end-of-life stage patients.

The Trust also agreed to Mr A's request to create and put in place a policy and guidance for the provision of care and respect in death.