Some poor care for woman with multiple sclerosis but this did not lead to her death

What happened

Mrs A had advanced multiple sclerosis. She went into hospital with aspiration pneumonia and her condition improved. Staff fitted a PEG tube (a tube through the stomach to help provide nutrition) and a urinary catheter.

During her time in hospital, Mr B said staff banged Mrs A on the head when they moved her from her wheelchair to her bed. He also said that staff administered a PEG feed while Mrs A was lying flat when she should have been upright. Mr B claims that Mrs A's catheter was blocked for several days and that staff did nothing to rectify this. He also said that Mrs A was not given adequate oral care, that is, her mouth was not kept moist and clean. Mrs A developed a further bout of aspiration pneumonia and died.

What we found

Staff did not take care when they moved Mrs A, but the Trust had taken action to address this. That staff did not properly administer Mrs A's PEG feed was a serious failing, but the Trust had taken steps to remedy this by raising the matter with staff, and introducing appropriate training. This did not lead to Mrs A aspirating and therefore we did not find that it led to her death.

There was no evidence that Mrs A's catheter was blocked or not properly managed. However staff did not give Mrs A oral care as they should have done, and the Trust had not taken adequate action to address this.

Putting it right

The Trust prepared an action plan that showed what it has done, or plans to do, to avoid a recurrence of the failings in oral care.