Avoidable death of a man with learning disabilities after failings in care and treatment

What happened

Mr P had a learning disability and lived in a nursing home. He had several medical problems and needed special bowel care. In summer 2012, Mr P went into hospital with abdominal pains and vomiting. Nurses noted the special bowel care he needed as a result of his disability.

Tests showed Mr P had kidney impairment and a blocked bowel. Mr P's treatment plan included no food and drink, intravenous fluids, a tube to drain his stomach contents, a urinary catheter to measure his urine output and surgery only if he did not improve. Two days later, his condition started to improve and doctors decided to let him have drinks but to continue with intravenous fluids until he was also eating. Later that evening, his blood pressure dropped and his heart rate increased, and there was evidence that his heart was not pumping blood properly, so doctors gave him medication.

The next day doctors noted that Mr P was probably well enough to go home in a day's time. However, later that morning he again had low blood pressure and a raised heart rate. A nurse recorded an instruction to give Mr P intravenous fluids and encourage drinks. The records also show that doctors prescribed fluids, but no one gave him these.

The following morning, a doctor noted that Mr P was eating and drinking. Staff gave Mr P fluids and he was not vomiting. His blood pressure was slightly low but stable, and he passed urine. However, blood tests showed signs of a kidney problem. During the afternoon, Mr P's blood pressure dropped, and he vomited a large amount. A house officer told the nurse to call the senior house officer.

The nurse did so, and was told that the senior house officer would review Mr P, but there is no evidence of such a review. Nurses also asked the outreach team (a specialist team of senior clinicians) to visit and they gave advice, including to keep giving fluids. That night Mr P's blood pressure remained low and he had a fast heart rate.

At 11pm the on-call doctor, who was less senior than a senior house officer, reviewed Mr P. Among other things, he advised further fluids. Early the following morning, Mr P was very ill and he died a few hours later. The cause of death was multiorgan failure caused by intestinal obstruction.

What we found

Doctors and nurses did not communicate adequately with Mr P's family about his needs and treatment, and therefore did not consider his rights as a disabled person.

Doctors' initial care and treatment of Mr P was appropriate, but they did not act in line with applicable guidance or established good practice when his condition deteriorated. In particular, they failed to arrange daily blood tests to monitor Mr P's response to treatment to see whether his kidney function was returning to normal.

Although Trust staff gave Mr P fluids, overall he lost a large amount of fluid. Doctors should have made sure that he got enough fluids, and not just prescribed them. Doctors should have taken further action, including giving him drugs or transferring him to the intensive care unit to filter Mr P's blood, if necessary.

Nurses did not act in line with guidance or established good practice. They overlooked information about Mr P's bowel care needs and did not carry out an adequate assessment. They failed to recognise Mr P's needs as a person with a learning disability and their assessment and care plans were inadequate. When Mr P's condition deteriorated, nurses appropriately gave him fluids and contacted the senior house officer and the outreach team. However, they failed to make sure that senior medical staff saw Mr P in good time.

There was no indication that Mr P's condition was irreversible, and if he had received appropriate medical and nursing care, it was more likely than not that he would have lived. On the balance of probabilities, his death was avoidable.

Putting it right

Following our investigation, the Trust acknowledged and apologised for its failings and agreed to put together an action plan that showed learning from its mistakes so that they would not happen again. It also paid Mrs H and Mrs M £10,000 between them, to acknowledge the impact its failings had had on them.