A hospital did not think about the needs of woman with learning disabilities and Down's syndrome

What happened

Ms G, an adult who lacked the capacity to make decisions about her own care and treatment, went into hospital with pneumonia. Staff found she could not swallow safely because of the high risk of fluid or food going into her lungs. Clinicians fed her through a tube in her nose but she repeatedly pulled this out. Staff tried another way of feeding Ms G, but this was unsuccessful.

Doctors made the decision that Ms G's condition was so poor that admitting her to intensive care and attempting resuscitation in the event of a cardiac arrest would be futile. Ms G continued to receive care and treatment on a ward but her condition did not significantly improve. Ms G's family disagreed with the decisions not to escalate Ms G's care and a meeting was held between them and the doctors but no agreement was reached. Following this meeting a third method of feeding (a radiologically inserted gastronomy) was attempted but Ms G suffered a recognised complication of this procedure (a perforated bowel) and died shortly after.

Ms G's family complained that the care and treatment the Trust provided was inadequate.

What we found

We found service failure in the management of Ms G's nutrition because the hospital missed opportunities to employ strategies that might have helped her accept the tube feeding, and took no proactive steps to make it work. We concluded that this caused her distress and discomfort that might otherwise have been reduced.

There was service failure in the Trust's assessment of Ms G's needs and its communication with her family and carers. The Trust did not develop a person–centred care plan and did not work in partnership with her family and carers. We decided that this led to her being unhappy and frightened to a greater extent than she might otherwise have been.

We also found that the Trust failed to follow the correct process when making decisions about Ms G's best interests. This did not mean that those decisions were wrong, that Ms G was treated less favourably because she had learning disabilities, or that the outcome is likely to have been different. However, because Trust staff did not follow the correct process, Ms G's family were excluded from the decision–making process and were denied the opportunity for an independent decision about her best interests while she was still alive.

Putting it right

The Trust acknowledged the failings we identified, and apologised for them. It paid Ms G's sister £2,500 to acknowledge the distress she and her family suffered.

It agreed to prepare an action plan that ensured that lessons have been learnt.