Family distressed by trust's poor record keeping and complaint handling

What happened

Mr F was extremely ill with cancer when he was admitted to hospital, where he died. It was unclear from the medical records if the Trust was giving palliative care or actively treating Mr F.

The Trust acknowledged it did not complete a treatment escalation plan or take the opportunity to discuss its approach with Mr F or Ms F. This would have given them the opportunity to discuss possible treatments Mr F may have benefited from.

Mr F's medical records indicated that staff did not treat his sodium and electrolyte levels. The Trust admitted that it had missed these when it treated him.

Ms F complained about the way the Trust handled her complaint. The Trust did not identify all of the shortcomings we found, and there were failings in documentation.

What we found

We partly upheld this complaint. While there were no failings in most of Mr F's care, it was unreasonable that Trust staff did not treat his sodium and electrolyte levels.

The documentation, including the failure to complete a treatment escalation plan, and the lack of discussion about palliative care, was also inappropriate. We concluded that the failings we identified were unlikely to have caused Mr F's death. However, as the failings were serious and needed to be addressed, we asked the Trust to take certain steps to put things right.

The Trust's responses to Mrs F's complaint did not acknowledge these failings. For that reason, we found failings in the way the Trust handled this complaint.

Putting it right

The Trust created action plans to address the failings in the care and treatment it gave Mr F. The failings included not completing a treatment escalation plan form, poor documentation and failings in complaint handling.