Failings in care at the end of an older patient's life

What happened

Mr B had advanced Parkinson's disease, which caused him to have problems swallowing. He ate a special diet to reduce the risk of choking on his food.

Mr B was admitted to hospital three times towards the end of his life. The first time, his denture went missing. The second time, he had pneumonia caused by inhaling food and he gradually recovered. Mr B was readmitted for a third time a few days later, again with pneumonia. He deteriorated and died soon after.

What we found

The Trust did not deal with Mr B's son's compensation claim for the missing denture properly or arrange for a replacement denture. Mr B could still eat without his denture, but his dignity was compromised. During the second hospital admission, Mr B was not given several doses of his essential medication for Parkinson's disease. This caused him stiffness and soreness, and made his swallowing problems worse. During the second and third hospital admissions, doctors and nurses did not tell Mr B's son (or other family members) clearly that Mr B was likely to die soon, even if he temporarily recovered from each bout of pneumonia.

While the decisions about food and drink were complex and difficult in this case, doctors and nurses did not make sure that Mr B was given enough food and drink. In particular, he was left without nutrition over a bank holiday weekend. The lack of food and drink did not reduce Mr B's chances of survival or hasten his death, but it caused him unnecessary discomfort in his final few weeks and days, and distressed his family.

The Trust did not explain the clinical team's caring plan for Mr B to Mr B's son, and this caused him more anxiety and distress.

Putting it right

The Trust apologised to Mr B's son for its failings and paid him £1,500 compensation. It also agreed to prepare an action plan to stop the same mistakes happening again.