Serious failings in nursing care resulted in a missed opportunity to prevent a man's death

What happened

Miss D's father Mr F was admitted to hospital for a routine bladder operation. He developed an infection and died around a week later. Miss D complained to the Trust about the care her father received after his operation. It responded to say there had been problems with the nursing staffing levels at the time but it now had a new system to monitor staffing.

Miss D was not satisfied with this response and pursued her complaint. There were serious delays in responding to her. In a meeting with Miss D, the Trust acknowledged that the nursing care had been poor, leading to a missed opportunity to recognise the deterioration in her father's condition sooner. The Trust explained that it had made improvements to its care and complaint handling since.

Miss D brought her complaint to us because she was not satisfied that the Trust had done enough to put right the failings in the care or the complaint handling.

What we found

The Trust failed to monitor Mr F's condition and did not give him the nursing care he needed. It could have identified the deterioration in his condition sooner and treated his infection sooner. Because the infection was very severe, there was a 70% to 80% probability that Mr F would have died even if the care had been provided as it should have been. But an opportunity was missed to save his life.

The Trust also missed the opportunity to learn lessons from Miss D's complaint. However, it had made substantial improvements to both the care and the complaint handling since, which should prevent the same thing from happening to other people.

Putting it right

The Trust wrote to Miss D to acknowledge the failings we found and apologise for them. It also explained how it would make sure that it learnt lessons from complaints. The backlog of customer complaints has now been resolved and changes have been made to ensure the complaints process is better managed, and complaints are resolved faster

The Trust also paid her £1,500 in recognition of the effect of its failings on her.