Opportunities missed to improve patient's chances of survival

What happened

Mrs C, in her nineties, was admitted to hospital in winter 2011. Doctors diagnosed her with an infection and gave her a course of antibiotics. Staff attempted to discharge her near the end of the year but eventually she remained in hospital for another two weeks over the Christmas period. She deteriorated during this time and doctors believed she had developed sepsis. They gave her a different course of antibiotics for this but stopped the treatment when they saw the medication was not appropriate for her. Shortly afterwards, doctors decided to stop treating her as they believed she was near the end of her life and treatment would not have any benefit. Around the same time, she moved ward. Doctors then decided to start treating her again as they considered treatment may still have some benefit for her. However, Mrs C died shortly afterwards.

Mrs C's granddaughter complained that the care Mrs C received was inadequate, and she believed that reduced staffing levels over the Christmas holidays were responsible for this. She said there were delays in tests being completed; periods of time when her grandmother was not given antibiotics; a delay in providing treatment for suspected sepsis; a lack of review by doctors; and delays in handling her complaint about this. She said this caused her grandmother and the wider Family distress.

What we found

We partly upheld this complaint. We did not find failings in Mrs C's initial assessment and treatment when she first went into hospital. However, we did find failings in the staff's understanding of Mrs C's condition, and therefore her care and treatment during her admission. There were delays in tests being completed, periods of time where she was not given antibiotics, a delay in giving her treatment for suspected sepsis, a lack of review by doctors, and delays in handling her granddaughter's complaint.

While we did not believe that appropriate care would have prevented Mrs C's death, opportunities were missed to improve her chances of survival and to make her more comfortable.

Putting it right

The Trust apologised to Mrs C's Family for the distress caused by the missed opportunities to improve her care and her reduced chances of survival. It also completed a clinical review of care to identify improvements to prevent this happening again. It also paid £1,500 compensation to Mrs C's Family for the additional distress caused to them and to Mrs C.