Failure to put in place a clear plan for a man coming to the end of his life caused avoidable distress

What happened

Mr F had kidney disease and, in late 2011, it was determined his condition had deteriorated and was irreversible. Mr F decided not to proceed with dialysis and chose to follow a conservative management course.

In early 2012 Mr F was living at home. He saw district nurses regularly. When he became unwell, Ms F telephoned his GP and, after a discussion about what might be needed, Mr F went to A&E by ambulance. He was admitted to hospital and, two days later, was discharged to a care home for a short–term respite stay.

Mr F became acutely unwell and had to go back to hospital less than a week later. He went onto a general medical ward over the weekend and was then discharged to a hospice, where he died.

Ms F complained because she said her father was left distressed and exhausted at an already difficult time, and his last days were neither peaceful nor dignified.

Ms F said it was very distressing to witness this sequence of events and she had been left with a feeling of guilt as she tried to reassure her father that she would sort everything out.

What we found

We partly upheld this complaint. We investigated this complaint jointly with the Local Government Ombudsman because it concerned the actions of a local authority as well as an NHS organisation.

There was fault in the actions of Mr F's GP Practice and in the actions of the Care Trust responsible for the district nursing service. An opportunity was missed to put in place an agreed care plan for Mr F when it was known he was coming to the end of his life. Had these faults not occurred, the final weeks of Mr F's life could have been more thoughtfully and appropriately managed. As such, he was caused avoidable distress, as was Ms F, who witnessed these events.

There was also fault on the part of the GP for the care home (the Medical Centre) because a lack of communication about a possible GP visit caused additional avoidable stress and anxiety.

In addition, there was evidence of avoidable delays in how the Trust handled Ms F's complaint. An Area Team handled the complaint in the later stages, and also caused delay. This created further stress and anxiety. We did not find fault in the actions of the local authority or the Trust Mr F was admitted to.

Putting it right

The Medical Centre, the Practice, the Care Trust and the Area Team all wrote to Ms F to apologise for their failings and for the injustice caused.