Poor communication affects family's chance to spend more time with their mother in her last days

What happened

Mrs K, a lady in her nineties, was admitted to hospital in summer 2012 because of concern about ulcers on her leg. The initial plan was to remove damaged tissue from the ulcer but this operation was delayed. Although the procedure, when it took place, initially seemed to have been successful, Mrs K began to deteriorate and her doctors decided that their only option was to amputate her leg.

Again, there was a delay before Mrs K was taken to theatre. Her daughter spent over two hours trying to find out how her mother was before being told she was 'OK'. Soon after, Mrs K's daughters were called to the hospital as Mrs K was critically ill. When they arrived, Mrs K was very distressed and there was a delay in getting her some sedation. She died soon after.

Mrs K's family complained about the delays of the two procedures and questioned whether it was appropriate to go ahead with the amputation given how ill Mrs K was.

They met with the Trust which accepted that there had been a number of shortcomings during Mrs K's admission and agreed that her family's experience on the morning of her death had been 'awful' and 'inappropriate'. The Trust said that the correct surgical decisions had been made and Mrs K's family then asked us to investigate their outstanding concerns.

What we found

The delay in both surgical procedures, while less than ideal, was reasonable under the circumstances. The decision to proceed with the amputation was appropriate as it was Mrs K's only realistic chance of survival.

There were a number of examples of service failure, in particular with Mrs K's monitoring and observations. However there was no evidence that these failings affected the decision to proceed with the amputation.

There were failings in communication with Mrs K's family. These were most apparent on the morning that Mrs K died and the evidence clearly showed she was not 'OK'. Clearer information should have been given to her family about her condition so they could have spent more time with her before she died. The family's distress was compounded by the delay in giving Mrs K sedation when she needed it.

Some, but not all of the failings had been acknowledged by the Trust, and we saw little evidence that any steps had been taken to address them.

Putting it right

The Trust apologised for the additional failings we found in our investigation and paid £500 to Mrs K's family in recognition of the avoidable distress they experienced on the morning she died.

The Trust agreed to create a comprehensive action plan to address the failings that it and we had identified.

We partly upheld the complaint.