Failure to communicate with a woman's relatives about end–of–life care

What happened

Mrs B was terminally ill in hospital. Trust staff made plans with Mr B for his wife to return home for her end‑of‑life care, but on the day she was due to be discharged, her condition worsened. The Trust decided to place Mrs B on the Liverpool care pathway, and she died three days later in hospital.

Following media publicity about the Liverpool care pathway, Mr B complained to the Trust. He said that his wife was put on the Liverpool care pathway without consultation with him or their son, and staff did not explain the plans for her treatment.

What we found

Staff did not complete sections of Mrs B's Liverpool care pathway assessment, including the section about communicating the plan for end‑of‑life care with the patient or their family. While there was some evidence that staff had mentioned the decision to put Mrs B on the Liverpool care pathway to her family, this was not sufficient to make sure that Mr B and her family understood the plans for her end‑of‑life care.

This led to the injustice that Mr B felt he had let his wife down by not asking more questions or being more involved in decisions about her care at the end of her life.

Putting it right

The Trust wrote to Mr B to acknowledge and apologise for the failure to communicate the decision to place his wife on the Liverpool care pathway adequately. It created an action plan to make sure that clinical staff discuss decisions about end‑of‑life care adequately with patients and their relatives in future.