Hospital staff made multiple failings in assessing, investigating and monitoring a woman's condition

What happened

Mrs J was in her eighties and lived independently in her own home with support from her two daughters. She required regular anti–clotting medication and also pain relief because of a long–standing medical condition in her hip that affected her mobility. Her local GP Practice gave her treatment.

Mrs J started to experience episodes of confusion and her mobility deteriorated. At the request of Mrs J's family, doctors from the Practice often carried out home visits. However, at no point did the doctors feel that Mrs J lacked capacity to make decisions about her care. Carers were arranged to help Mrs J move around her home but unfortunately, her condition continued to deteriorate and doctors from the Practice along with Mrs J's care manager, strongly encouraged her to consider going into hospital. Mrs J was admitted to a community hospital (the Trust).

During Mrs J's stay at the Trust, nurses failed to carry out appropriate nutritional risk assessments or refer her to a dietician. Even though staff made some effort to monitor Mrs J's fluid intake, these records were poorly completed. The bowel care provided for Mrs J was also poor. There was poor communication between nurses, physiotherapists and occupational therapists regarding Mrs J's care, particularly in relation to her mobility.

Although staff noted that Mrs J's recent medical history included episodes of confusion, they did not arrange a scan of Mrs J's head to investigate whether her confusion could be the result of bleeding in her brain. After Mrs J's Family raised concerns that their mother might have had a stroke, doctors agreed to arrange a scan of her head. But, at that point, Mrs J's condition had deteriorated to the point that she was too unwell to undergo the scan. Mrs J's condition continued to deteriorate and she died with her Family by her side.

What we found

We partly upheld this complaint. The care given to Mrs J by the Practice was entirely appropriate as was the Practice's response to the complaint. However, in relation to the Trust, we concluded that the failure to carry out a scan of Mrs J's head at an early stage meant that she missed any opportunity for treatment that there might have been and she also missed having a definite diagnosis that might have informed a decision to go back home. In addition, we concluded that Mrs J's Family had not had the benefit of a diagnosis and we agreed with her Family that doctors did not listen to them as they should have done.

There were failings in the way that nurses, physiotherapists and occupational therapists communicated with each other regarding Mrs J's mobility. This was compounded by a poor assessment of her condition by occupational therapy staff. As a result, nurses, physiotherapists and occupational therapists did not fully establish what support should be provided to help her mobilise. This meant that Mrs J experienced unnecessary suffering and distress when moving and being moved. We acknowledged that witnessing this also caused her Family distress. This could have been avoided if those providing care for Mrs J had communicated appropriately with each other. We concluded that these failures caused both Mrs J and her Family unnecessary suffering and distress during her final admission.

Putting it right

The Trust acknowledged and apologised for its failings and put together an action plan explaining how it would ensure that the same situation would not happen again. It also paid Mrs J's Family £1,500 compensation for the distress and suffering they experienced as a result of the poor care given to their mother.