Nurses did not alert medical staff quickly enough when older patient deteriorated

What happened

Mr S was taken to A&E after vomiting blood. He was also suffering with confusion. He was admitted to hospital with urinary sepsis and went on to develop aspiration pneumonia. Mrs S said the staff did not check on him enough.

He was transferred to the intensive care unit but continued to deteriorate. Mrs S said she thought her husband would not have died if he had received better care.

What we found

Nursing staff did not assess Mr S's ability to eat and drink when he was admitted, but this did not affect him.

Staff did not always keep simultaneous records of events, which meant that the timings of when Mr S deteriorated could not clearly be seen. They also did not sufficiently recheck Mr S's observations after he had a period of fast heartbeat. They did not alert medical staff as quickly as they should have done when he continued to deteriorate.

Although Mrs S believed that no one had checked on her husband, the records showed both doctors and nursing staff had checked him.

Although there were failings in Mr S's care, these did not lead to his death.

Putting it right

The Trust apologised to Mrs S and produced an action plan to ensure it learned from the complaint.