Son was unhappy about his mother's care and medicines management on hospital ward

What happened

Mrs P suffered from lung cancer and was diabetic. After she fell one evening in early spring 2013, Mrs P went to A&E at the Trust's hospital. She had a head injury.

A doctor saw Mrs P and carried out various tests and a scan. The scan showed a large abnormal area in the brain, which clinicians thought was likely to be metastases from her lung cancer.

In the early hours of the next morning, staff admitted Mrs P to the acute medical unit at the hospital. She had suspected brain metastases and a possible sepsis infection. Staff put in place a treatment plan of rehydration and intravenous antibiotics. Mrs P stayed in hospital for 11 days. She died soon after from lung and brain cancer.

Mr K made a formal complaint to the Trust on behalf of his mother. He said that staff did not assess Mrs P's mental capacity after she went to A&E and the acute medical unit. He felt that this led to her refusing her medication; that she fell twice when she was in hospital, and the rails on her bed were not always raised; that there were shortcomings in recording her medication so her diabetes was not managed well and there was confusion about the medication she needed. In addition, he said that staff did not record nursing handover information properly; that there was a delay in treating Mrs P with steroids; that Mrs P was not cleaned after a meal, and that doctors made inappropriate comments, which Mr K overheard.

What we found

We partly upheld this complaint. There were failings in the Trust's care of Mrs P during her stay in hospital. We were satisfied that the Trust had acknowledged several of these failings and had taken the appropriate steps to minimise the risks of such incidents happening again. However, there were additional failings that it had not adequately addressed.

We concluded that the failure to prescribe Mrs P's insulin affected her blood glucose readings. High readings were probably caused by staff failing to give Mrs P her usual short– and long–acting insulin one evening and the following morning. However, this failure did not have any long–term effect on Mrs P's condition. We concluded that the Trust did not make sure that the medicines staff prescribed for Mrs P when she was in A&E corresponded to those that she was taking before admission. The Trust failed to carry out a nursing assessment and develop a nursing care plan for Mrs P. Her nursing care was not planned properly and staff did not evaluate it frequently. When caring for Mrs P, Trust staff did not give care in line with guidance from the Nursing and Midwifery Council.

Putting it right

The Trust reviewed its medicines reconciliation policy and reminded all A&E staff to consider the policy when admitting patients to hospital. It also reviewed its practice of conducting nursing assessments and developing nursing care plans and agreed to give extra staff training where necessary.