Patient received poor nutritional and pain care

What happened

Mr B was 79 years old and had multiple medical problems, including severe vascular dementia, a disease caused by reduced blood supply to the brain, and diabetes. Mr B developed gangrene in two of his toes, and went into hospital. Doctors prepared him for surgery, but later decided not to operate. They prescribed antibiotics and discharged him.

Mr B went back into the hospital a week later with the same problem. Doctors again prepared him for surgery, but again decided not to operate. They wanted to try to avoid surgery because Mr B was a high–risk surgical patient, and was likely to have a poor outcome. Over the following weeks, Mr B's condition worsened, and he appeared to be in pain. Doctors subsequently amputated Mr B's leg above the knee to try to control his pain. Mr B's condition deteriorated, and he died.

What we found

We partly upheld this complaint. There were failings in the nutritional care the Trust gave Mr B and also in the way it managed his pain and distress. This meant the Trust missed opportunities to plan and deliver appropriate care. We could not establish that the Trust met Mr B's nutritional needs during his first admission, and he may have suffered unnecessary pain and distress. This was upsetting and distressing for Ms C.

There were some significant shortcomings in the Trust's communication with Ms C about her uncle, and these made her feel extremely frustrated and upset.

The care and treatment the Trust provided for Mr B's foot were in line with established good practice.

We also identified some serious shortcomings in the Trust's complaint handling, but did not find that these amounted to maladministration.

Putting it right

Following our report, the Trust wrote to Ms C to acknowledge the failings in nutritional care, pain management, and communication, and to apologise for the impact of these. It also paid her £500 compensation, and agreed to update its action plan to make sure it had learnt lessons from these failings.