Patient transferred from acute hospital without adequate assessment

What happened

Mrs S was in her nineties and fell at home. She was admitted to the Acute Trust. Doctors assessed her and decided to transfer her to a nurse led community hospital (part of a different trust).

While she was there she had another fall and had to be readmitted to the Acute Trust. She was found to have a large and incurable subdural haematoma (a serious brain condition that is caused when blood collects between the skull and the surface of the brain) and she died a few days later.

Mrs S's daughter, Mrs T, said her mother's care and treatment at both hospitals was inadequate and that doctors at the Acute Trust inappropriately transferred her mother to the Community Hospital.

What we found

Doctors at the Acute Trust did not adequately assess Mrs S or give sufficient consideration to arranging further medical care for her before transferring her to the Community Hospital. We also found the handover to the Community Hospital was inadequate. Care that nurses at the Community Hospital gave to Mrs S fell below the relevant standards.

We were unable to say whether the outcome for Mrs S would have been any different if the failings we had found had not happened. But opportunities to provide further medical care were missed. Mrs T will never know whether her mother would have survived if she had received the care and treatment she should have. The not knowing, together with distress stemming from the poor way her complaints were handled by the Acute Trust, were injustices to her.

Putting it right

Both Trusts acknowledged their failings and apologised. The Community Trust had already demonstrated that it had learnt from the complaint. However, at our request the Acute Trust completed an action plan to demonstrate what it had done to avoid a recurrence of the failings.