Trust failed to check patient's medication, causing her to miss three doses

What happened

Mrs K was admitted to the Trust in summer 2013 suffering from shortness of breath. Mrs K's daughter, Miss M, complained that the Trust failed to administer one of her mother's medications when she was admitted to hospital.ÿ Mrs K missed three doses which caused Miss M to worry.

Miss M also said that once its error had been recognised, the Trust reinstated the medication, but failed to monitor her mother sufficiently. Miss M also complained that the Trust failed to make sure that her mother had appropriate support when she was discharged, or make suitable transport arrangements when taking her mother home.

Miss M told us that as a result of the care at the Trust, her mother had an emergency admission to another hospital within 48 hours of discharge, and died of a heart attack within 24 hours of that admission.

What we found

We partly upheld this complaint because the Trust failed to properly follow its own policy for checking a patient's medication when they were admitted. This caused Mrs K to miss three doses. While this did not have a detrimental impact on her health, it caused worry to her daughter. The Trust's response to this aspect of the complaint was also contradictory and not based on the records, which caused Miss M further distress.

However, the Trust acted appropriately in reinstating Mrs K's medication when the error was spotted, and also in deciding to discharge her when it did. The Trust's response to Miss M's concern about her mother's transport home was reasonable.

Putting it right

The Trust apologised to Miss M for the distress caused to her, and prepared plans to make sure it adhered to its policy in future.