Older patient died in hospital when his wish was to die at home

What happened

Mr C had terminal cancer complicated by heart problems, including heart failure. He went into hospital with breathing problems. Doctors diagnosed that he had fluid on his lungs and mild kidney problems. They arranged scans and continued to give Mr C diuretics. His condition deteriorated and he did not recover. He died in hospital.

What we found

Mrs C said that her husband's wish had been to die at home or in the care of a hospice. However, a breakdown in communication meant staff did not follow up this request. Doctors and nurses failed to escalate the deterioration in Mr C's condition to a suitably senior doctor. That said, earlier intervention would not have changed the outcome for Mr C.

We found shortcomings by the Trust, particularly in the lack of information it gave Mrs C about the seriousness of the downturn in her husband's condition. This meant she and her family lost the opportunity to be with Mr C when he died.

We found maladministration in the way the Trust handled Mrs C's complaint.

Putting it right

The Trust apologised to Mrs C and paid her £250 for the injustice caused by Mr C dying alone in hospital. It also agreed to prepare an action plan to make sure that lessons were learnt about complaint handling.