Failings in the care of an older patient did not lead to her death

What happened

Mrs J, who had dementia, was admitted to hospital via A&E on the advice of an out–of–hours doctor because of concerns about her heart rhythm. While in hospital Mrs J had a stroke. She was transferred to the stroke unit but continued to deteriorate, and died in hospital three weeks after being admitted.

Mrs F complained that ward staff did not notice her mother had had a stroke. She also was unhappy about how the medical team managed her mother, about a number of nursing issues, and about poor communication. When the Trust responded to Mrs F's complaint, its responses were incomplete and were not sent by the chief executive. Mrs F told us she was shocked by the tone of the responses.

What we found

We partly upheld this complaint. Although the doctors took appropriate steps to identify the cause of Mrs J's symptoms and gave her suitable treatment, they did not monitor her condition as closely as they should have done. Also we saw that although Mrs J's stroke was probably related to the problem with her heart rhythm, there was nothing further that could have been done to prevent her having a stroke.

There were failings in hygiene; the attitude of nursing staff; communication with the family; awareness of dementia; the time taken to diagnose Mrs J's stroke; monitoring by nursing staff; and the Trust's complaint handling. Although the Trust had already acknowledged failings in Mrs J's care, apologised and taken some action to address this, we concluded it had not gone far enough.

We found no failings in Mrs J's end of life care, and no evidence her death could have been prevented if these failings had not happened.

Putting it right

The Trust expanded on the work it had already done in order to improve its services and apologised to Mrs F.