Poor care and delays in transferring acutely ill older patient caused distress

What happened

Mrs H, who had dementia, went into the Trust's mental health unit for just over five weeks. During this time, her family raised concerns about the care provided. They said that a lack of appropriate observation and support by staff put Mrs H at risk from other patients on the unit. In the last few days of her admission, Mrs H's physical health deteriorated and she was eventually transferred to the neighbouring acute hospital, where she died some days later.

Mrs H's family continued to raise concerns about the care the Trust had given, including that a delay in transferring Mrs H to the acute hospital contributed to her death. Family members were concerned that a number of relevant records were missing, while other records were completed inaccurately. Delays and errors in the Trust's complaint handling further distressed the family.

What we found

We partly upheld this complaint. The Trust's communication with Mrs H's family was not always clear and effective, although we did not find that this was so significant that it amounted to a failing. However, there were a number of shortcomings in the care given to Mrs H, including in recording her general and vital sign observations; recording the medication given; and recording bruising, and investigations into what caused this. There was also an unreasonable delay in initiating Mrs H's transfer to the acute hospital. There were also failures in the Trust's complaint handling.

We could not say these failings caused, or contributed to, Mrs H's deterioration, or led to her death. However, they distressed her family and meant that family members were not reassured that Mrs H's care was appropriate. The family's distress was exacerbated by the poor complaint handling.

Putting it right

The Trust wrote to Mrs H's family to recognise, acknowledge and apologise for the failings we found in her care and in how it had handled the complaint. It paid Mrs H's family £750 to recognise the distress caused.

It created an action plan to demonstrate the learning it took from the complaint and the actions it would take to address its failings.