Mr and Mrs B complained to us about the care given to Mrs B’s sister, Mrs A, who had Alzheimer’s disease. They didn’t want an apology – simply an acknowledgement of the Trust’s failings and the injustice caused. Our investigation secured that and also led to a 16-point action plan by the Trust which will improve the care of future patients and benefit the wider community.

Mrs A was living with Mr and Mrs B when she was admitted to hospital with a chest infection. She was fed by a tube through her nose and into the stomach, but she sometimes pulled this out. Twice after doing this Mrs A went without food while staff waited for X-ray results. On one occasion she vomited constantly and it was five hours before staff intervened. This was undignified and threatened her life. On another occasion, when a scan was abandoned because Mrs A could not lie still, nobody reassured her, or spoke to her in her native language.

When the decision to stop actively treating Mrs A, who by then was dying, was taken nobody from Croydon Health Services NHS Trust discussed that with Mr and Mrs B. Mr and Mrs B chose to care for Mrs A at home but were given no support or information about how to do this.

Following our investigation, the Trust drew up an action plan to prevent a repeat of the failures we had identified, including the monitoring of staffing levels for all inpatient areas to prevent delays in providing care. They also planned ways to improve nursing staff support and communications with patients and carers. These ranged from giving patients adequate information about the drugs they take home with them to ensuring that there is a clear point of contact for families. Also, the Trust took action to improve the care given to patients, through training and reminders about the standards nurses are expected to meet.