Trust put right its failings in care and treatment

What happened

Mrs W was in her nineties. She was admitted to hospital after she fell at home. A number of different doctors saw her and treated her for a urinary tract infection.

Just over two weeks later, Mrs W developed a clostridium difficile infection (inflammation of the large intestine) and Trust staff treated her for this. This was not successful, and after five days staff gave her a different treatment. Mrs W's condition deteriorated and staff tried to contact her family. However, there was no answer from Mrs W's son, the only telephone number that had been noted in the records by staff.

Staff contacted police, who went round to Mrs W's son address but discovered that he was away on holiday. Mrs W died during the night. The next morning staff found another telephone number and were able to get in touch with Mrs W's daughter.

What we found

We did not uphold this complaint.

Staff had made reasonable attempts to contact the family when Mrs W's condition deteriorated, although they could have contacted social services. But nurses had poorly completed the initial documentation and had not recorded two contact numbers for the family, as they should have done.

The assessment of Mrs W's needs when she was admitted was also inadequate; appropriate care plans were not put in place; and the risk assessment of her nutritional needs was wrong.

However, staff had completed other risk assessments and had monitored Mrs W as they should have. The care Mrs W received from doctors was also in accordance with established good practice.

The Trust had already apologised for the failings we had identified and had taken action to prevent similar failings from happening again. We did not therefore make any recommendations.