Could more have been done to ease man's final days?

What happened

Mr T was in his 90s and had a history of bowel cancer and heart disease. He had had two heart attacks in the last few years.

Mr T was admitted to the Trust for observation because he had fallen and was complaining of lower back pain. After he had been in the hospital for 48 hours, Mr T began to vomit. Doctors put this down to a drug he had been given and changed his medication. However, the next day an X‑ray showed that his small bowel and stomach were distended and doctors suspected that he had a bowel obstruction.

In the following days, doctors continued to review Mr T and to treat him, but his condition deteriorated. He was diagnosed with an irregular heart rate, hospital‑acquired pneumonia and an excess of fluid in the lungs, in addition to the bowel obstruction. Later, Mr T choked on his tea and doctors suspected that he had accidentally inhaled tea into his lungs.

About ten days after Mr T was admitted, he developed shortness of breath and his abdomen became more distended. The doctors' plan included treatment for heart conditions, a CT scan and a senior surgical review. But Mr T died before this could happen.

What we found

There were no failings in doctors' medical management of Mr T.

However, there were failings in recording Mr T's levels of pain, which the Trust has already acknowledged. Nurses did not consider another way of giving him pain relief when he could not, or would not, take medication orally.

At a point when Mr T's condition had deteriorated, there was too much fluid in his blood (as he had become overloaded with fluids), and nurses did not refer Mr T to the Trust's critical care outreach team or to a senior doctor.

While the amount of fluid Mr T had received might have contributed to his heart problems, it was clear by that stage that his heart problems had caused the excess fluid on his lungs and that had led to his death. The fluids in his blood had no significant impact on the outcome for Mr T.

We could not say that, on the balance of probabilities, Mr T would have survived if the failings we had identified had not happened. However, it would have been distressing for his family to see Mr T in pain because nurses did not consider other ways of giving him his pain relief and to see him deteriorate knowing staff were doing nothing to increase his care.

Putting it right

The Trust acknowledged its failings, apologised to Mr T's son and paid him £500. It also agreed to put together an action plan that showed learning from its mistakes so that they would not happen again.