Failings by Trust meant that a patient was denied his wish to die at home

What happened

Mr M's previous experiences of admissions had left him with a deep concern about dying in hospital and he had asked his family to honour his wish that he should die at home.

When his family realised that Mr M was very close to death, they asked the hospital to arrange to send him home. Mrs M said that the senior sister was not supportive of this plan and repeatedly raised concerns that the family would not be able to cope.

By midday on the day of his death, everything was ready for Mr M to be at home. The senior sister made arrangements via the ward clerk for an ambulance to take Mr M home at 6pm that evening. Unfortunately, the ambulance did not arrive until after Mr M's death at 8.20pm.

Mrs M complained that the senior sister had obstructed Mr M's dying wishes. The Trust denied that the senior sister hindered Mr M's discharge but it accepted miscommunication over the ambulance.

What we found

There was no evidence that the senior sister had put barriers in the way of Mr M's discharge.

Although the Trust had apologised for miscommunication in connection with the ambulance booking, it had, in a meeting with Mrs M, moved away from accepting responsibility.

The Trust said that it was not possible to arrange urgent transport in these circumstances, but we discovered that this was not true. We felt that it was probable that, had greater urgency been given to the ambulance request, Mr M would have been transferred in time to die at home. This was an injustice that could not be remedied.

Mrs M also explained that she and her children had suffered a great deal of distress because they could not honour Mr M's wishes. They were waiting at home and so were not able to be at his bedside when he died. They had all planned to say goodbye and to spend special time with him. This caused deep distress to the family, which could have been avoided if greater urgency had been placed on the transport request.

We did not feel that the Trust went far enough in acknowledging responsibility for what happened or the injustice that arose as a result. In the circumstances, an apology alone was insufficient remedy.

Putting it right

The Trust apologised to Mrs M for its failure to make urgent arrangements for Mr M's transfer home, and acknowledged the injustice caused by this failure.

It paid Mrs M £1,000 for the distress caused to her.