Mr R complained on behalf of his late father, Mr D, about the care and treatment he received from the Trust. Mr R was specifically unhappy that his father was moved from the A&E department, and ward staff were not prepared for his arrival.
What happened
Mr D was brought to A&E in early spring 2012 following a cardiac arrest. He lost consciousness but did not die. Staff tried to revive him but this was unsuccessful and they advised Mr D's family that his death was imminent.
Mr D went onto the Liverpool Care Pathway (LCP), although the documentation for this was not signed. The LCP was used (it is no longer used) to make sure the patient was comfortable and had dignity at the end of their life, after doctors had assessed that their illness was terminal.
Clinicians prescribed Mr D sedatives and pain relieving drugs which are often used as part of palliative care. Mr D was transferred from A&E to a ward with no transfer documentation, and the ward staff were not fully aware that he was due to arrive. He died early the next morning.
What we found
We partly upheld this complaint. Although it was appropriate to move Mr D from A&E, this was poorly communicated and would have only added to what was an already difficult and stressful situation for Mr D and his family.
The lack of signed LCP documentation did not prevent Mr D from receiving the correct medication. We are satisfied that staff had already given Mr D relevant and appropriate palliative medication, despite the fact that the paperwork had not been signed.
Had the nursing staff been aware that they were to receive a patient in the last few hours of his life, they would have been able to make sure a suitable environment was ready for him, as well as giving the family a more informed and compassionate welcome.
Putting it right
The Trust acknowledged and apologised for the failings in communication and for the time taken to address the complaint. It also produced an action plan showing what it had done or planned to do to reduce the likelihood of such events happening again, and what it had learnt from the failings identified.
The Trust also paid Mr R £500 to acknowledge the distress caused by the failings we identified.
Kettering General Hospital NHS Foundation Trust
Northamptonshire
Not applicable
Apology
Compensation for financial loss
Recommendation to learn lessons or draw up an action plan