Significant failings in how Trust monitored patient

What happened

Mrs M went into hospital in 2011 with a provisional diagnosis of pneumonia, dehydration and low blood pressure. She died within 48 hours of admission. Mr M said that despite repeated concerns expressed by his wife and her family, nursing and medical staff did not provide the necessary support.

Mr M highlighted delays in his wife's medical assessment and shortcomings when staff gave her fluids and pain relief. He also complained about faults in how staff recorded Mrs M's deterioration. In particular, although Mrs M's condition visibly worsened, it was several hours before a doctor saw her.

Mr M also complained about the way the Trust handled his complaint, and that there were records of other patients in his wife's medical records.

What we found

There were shortcomings in: timely medical assessments when patients arrived at the Trust; how staff gave intravenous fluids; and nurses' record keeping, especially about pain relief. There were also failures in improvements the Trust had promised to make in its policy for referring patients to doctors, and in the management of junior doctors.

Putting it right

Following our report, the Trust acknowledged and apologised for its failings and put together action plans that showed learning from its mistakes so that they would not happen again.