Shortcomings in care and poor communication by Trust

What happened

Mr K, who was in his eighties, went into hospital at the Trust in early spring 2012 because his family thought he might have had a stroke. Doctors treated him for heart failure. Mr K had a heart attack two weeks later, for which he had further treatment. Trust staff discharged him two weeks after that.

Some two months later, Mr K was readmitted to the Trust because he was short of breath. Staff treated him and discharged him two days later. A few hours after he got home, Mr K went back into hospital because he was increasingly breathless. Over the next few days, Mr K's liver and kidney function deteriorated and he died ten days later.

Mrs L said staff did not monitor Mr K adequately or give him medication at the right time. She felt that staff did not always communicate well with Mr K's family.

What we found

We partly upheld this complaint. The Trust gave Mr K satisfactory medical care in early spring 2012, but doctors did not communicate adequately with other staff before Mr K was discharged. At times, doctors did not communicate enough with his family.

Although the decision to discharge Mr K in the summer was reasonable, he was left unmonitored for two and a half hours before he went home.

The Trust did not follow National Institute for Health and Care Excellence guidelines, a doctor did not assess Mr K in A&E when he went into hospital in the summer, and doctors did not provide medication or keep records in line with General Medical Council guidance.

The improvements the Trust had already made in nursing care addressed the issues that Mrs L complained about.

Putting it right

The Trust apologised to Mrs L. It agreed to give her information about the improvements it had already made and to prepare an action plan that described what it had done to make sure that it has learnt the lessons from the failings we highlighted.