Poor end of life care

What happened

Mrs V was terminally ill with non‑curable cancer. She went into hospital when she became seriously unwell. The Trust carried out appropriate tests and investigations into her overall condition. The tests showed that the cancer in her liver could not be seen and had shrunk in her lungs. Staff shared this information with Mrs V's family. Mrs V's prognosis had not changed, however, and her condition deteriorated quickly. She died before a priest could see her.

Mrs V's family were understandably distressed. They thought that Mrs V had not been given the right treatment just before she died and that a shortage of staff meant she had not been cared for as well as she should have been.

What we found

Mrs V received good care and treatment even though her hospital ward was not staffed as it should have been. We noted that the Trust had not acknowledged the understaffing on the ward. Mrs V's medical records were not up to standard because there was no clear written plan of what clinical observations should be recorded, and therefore there was no full written record of her observations.

The Trust was wrong not to have discussed the DNAR order with her family, but in general, communication with them about Mrs V's condition was acceptable.

The staff had tried to arrange for a priest to see Mrs V, but we found that she deteriorated so quickly that there was not time. This was not due to any fault of the Trust.

Putting it right

The Trust apologised to Mrs V's family. It agreed to draw up a policy to improve communication about DNAR orders, to explain how it will improve staffing levels, and to make sure that written records meet the relevant guidelines.