The story

Mr D was first admitted to the Royal Bolton Hospital NHS Foundation Trust with a suspected heart attack and discharged a week later with further tests planned on an outpatient basis. Four weeks later, Mr D was readmitted with severe back and stomach pain. He was described by clinicians and nurses at the hospital as a quiet man, well-liked, who never complained or made a fuss. He did not like to bother the nursing staff.

Mr D was diagnosed with advanced stomach cancer. His discharge, originally planned for Tuesday 30 August, was brought forward to 27 August, the Saturday of a bank holiday weekend. On the day of discharge, which his daughter described as a ‘shambles’, the family arrived to find Mr D in a distressed condition behind drawn curtains in a chair. He had been waiting for several hours to go home. He was in pain, desperate to go to the toilet and unable to ask for help because he was so dehydrated he could not speak properly or swallow. His daughter told us that ‘his tongue was like a piece of dried leather’. The emergency button had been placed beyond his reach. His drip had been removed and the bag of fluid had fallen and had leaked all over the floor making his feet wet. When the family asked for help to put Mr D on the commode he had ‘squealed like a piglet’ with pain. An ambulance booked to take him home in the morning had not arrived and at 2.30pm the family decided to take him home in their car. This was achieved with great difficulty and discomfort for Mr D.

On arriving home, his family found that Mr D had not been given enough painkillers for the bank holiday weekend. He had been given two bottles of Oramorph (morphine in an oral solution), insufficient for three days, and not suitable as by this time he was unable to swallow. Consequently, the family spent much of the weekend driving round trying to get prescription forms signed, and permission for District Nurses to administer morphine in injectable form. Mr D died, three days after he was discharged, on the following Tuesday. His daughter described her extreme distress and the stress of trying to get his medication, fearing that he might die before she returned home. She also lost time she had hoped to spend with him over those last few days.

Mr D’s daughter complained to the Trust and the Healthcare Commission about very poor care while in hospital. When she still felt her concerns had not been understood she came to the Ombudsman. She described to us several incidents that had occurred during her father’s admissions. She said:

• he was not helped to use a commode and fainted, soiling himself in the process
• he was not properly cleaned and his clothes were not changed until she requested this the following day
• the ward was dirty, including a squashed insect on the wall throughout his stay and nail clippings under the bed
• he was left without access to drinking water or a clean glass
• his pain was not controlled and medication was delayed by up to one and a half hours
• pressure sores were allowed to develop
• no check was made on his nutrition
• his medical condition was not properly explained to his family
• he was told of his diagnosis of terminal cancer on an open ward, overheard by other patients.

What our investigation found

We found that Mr D’s care and treatment fell below reasonable standards in a number of ways. Those failings in care and treatment, and also in discharge planning and complaint handling, caused distress and suffering for Mr D and his family.

We found no service failure in the time taken to diagnose Mr D’s cancer, nor in the way the Trust communicated the diagnosis to his family. However, there were a number of service failures during both of his admissions. There was no care plan for his malaena (blood in his stools), and no risk assessments relating to pressure ulcers or falls were carried out. Mr D’s nutritional status was not properly assessed, while a lack of records meant that it was impossible to assess his fluid or food intake. Even as Mr D’s condition deteriorated and his needs increased, no further detailed nursing assessments were undertaken, nor was an appropriate care plan drawn up. Pain relief for Mr D was not always effective, yet no formal pain assessments were completed. In his daughter’s own words, she was ‘disgusted that a dying man was left in a chair for almost a month, with no-one ever trying to make him comfortable in bed, no-one relieving his pain adequately, checking for pressure sores or ensuring he ate or drank’.

Considerable guidance existed at the time of Mr D’s discharge relating to discharge and care for terminally ill patients, and in some respects the Trust’s discharge planning was good. For example, they contacted Macmillan and District Nurses and social services. But other aspects of the discharge planning were not good. In particular, the change of Mr D’s discharge date should have prompted a complete review of his condition, needs and discharge arrangements. That did not happen; the palliative care team were unaware of Mr D’s changing medication needs, and the medication prescribed on discharge did not meet his needs. His daughter graphically described to us the family’s experiences on the day of discharge and the frantic efforts they made to obtain pain relief for Mr D. The uncertainty about whether he would still be alive on their return from their trips, or how much pain they would find him in, must have been harrowing.

The Trust’s response to Mr D’s daughter’s first complaint contained inaccuracies, and a later response did not address all of the new concerns she had raised. The Trust apologised to her for the shortcomings in Mr D’s care, but did not give her evidence that they had fully implemented improvements recommended by the Healthcare Commission.

We upheld this complaint.

What happened next

The Trust apologised to Mr D’s daughter and paid her compensation of £2,000. They also told us what they would do to prevent a repeat of their failings. Their plans included a review of all nursing documentation; the introduction of a five-day pain management course available to all Trust staff; and the introduction of an ‘holistic assessment tool’ to be used by the palliative care team to make sure that a person’s care needs are met and their discharge is properly planned.