Mr F, who had severe mental and physical disabilities, became ill while living in a residential home. His condition deteriorated and he died following a hospital admission.
What happened
Mr F had very limited ability to communicate and lived in a residential home funded by the Trust and the local council. He became unwell in autumn 2011. His family were concerned and reported that he had a reduced appetite. His condition deteriorated and staff at the home sought specialist advice.
The next month, home staff called a GP to see Mr F. However, the GP was unable to attend immediately and Mr F's family insisted that an ambulance be called. Mr F was admitted to hospital for treatment but died in winter 2012.
What we found
The Trust failed to ensure that Mr F was admitted to hospital in a timely fashion when his condition began to deteriorate. While staff had acted in accordance with local policy, the incident highlighted a lack of appropriate training around what action should be taken to identify and respond to an emergency situation.
While Mr F's admission was delayed, this did not affect the outcome of his care and he initially responded well to treatment. An earlier admission would not have changed the sad outcome.
Putting it right
The Trust apologised for failing to arrange Mr F's timely admission to hospital, and produced an action plan to show how it would avoid a recurrence.
Lancashire Care NHS Foundation Trust
Lancashire
Did not apologise properly or do enough to put things right
Did not involve complainant adequately in the process
Apology
Recommendation to learn lessons or draw up an action plan