Mr & Mrs J's story - Care and Compassion

Case studies

Mr & Mrs J's story

Hospital staff at Ealing Hospital NHS Trust left Mr J forgotten in a waiting room, denying him the chance to be with his wife as she died.
Mr D’s story

Royal Bolton Hospital NHS Foundation Trust discharged Mr D with inadequate pain relief, leaving his family to find someone to dispense and administer morphine over a bank holiday weekend.
Mrs R's story

Mrs R’s family were concerned that she would not receive food and drink while in Southampton University Hospitals NHS Trust unless they themselves helped her to eat and drink.
Mrs Y's story

Mrs Y died from peritonitis and a perforated stomach ulcer after her GP Surgery missed opportunities to diagnose that she had an ulcer.
Mrs H’s story

When Mrs H was transferred from Heart of England NHS Foundation Trust to a care home, she arrived bruised, soaked in urine, dishevelled and wearing someone else’s clothes.
Mr C's story

Staff at Oxford Radcliffe Hospitals NHS Trust turned off Mr C’s life support, despite his family’s request that they delay doing so for a short time.
Mr W's story

Mr W’s life was put at risk when Ashford and St Peter's Hospitals NHS Foundation Trust stopped treating him and then discharged him when he was not medically fit.
Mrs G’s story

Mrs G’s doctors at her local surgery failed to review her medication after she left hospital, with serious consequences for her health.
Mr L’s story

The care and treatment that Surrey and Borders Partnership NHS Foundation Trust gave Mr L contributed to a loss of his dignity and compromised his ability to survive pneumonia.
Mrs N’s story

While doctors at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust diagnosed Mrs N’s lung cancer, they neglected to address the severe pain that she was suffering.

The Story
What our investigation found
What happened next

The story

Mrs J was 82 years old. She had Alzheimer’s disease and lived in a nursing home. Her husband visited her daily and they enjoyed each other’s company. Mr J told us ‘She had been like that for nine years. And I was happy being with her’. One evening, Mr J arrived at the home and found that his wife had breathing difficulties. An ambulance was called and Mrs J was taken to Ealing Hospital NHS Trust at about 10.30pm, accompanied by her husband. She was admitted to A&E and assessed on arrival by a Senior House Officer who asked Mr J to wait in a waiting room.

Mrs J was very ill. She was taken to the resuscitation area, but was moved later when two patients arrived who required emergency treatment. Mrs J was then seen by a Specialist Registrar as she was vomiting and had become unresponsive. It was decided not to resuscitate her. She died shortly after 1.00am. At around 1.40am the nursing staff telephoned the nursing home and were told that Mr J had accompanied his wife to hospital. The Senior House Officer found him in the waiting room and informed him that his wife had died.

In the three hours or so that Mr J had been in the waiting room, nobody spoke to him or told him what was happening to his wife. As a result he came to believe that her care had been inadequate. He thought that he had been deliberately separated from her because hospital staff had decided to stop treating her. ‘They let her slip away under the cloak of “quality of life” without stopping to think of any other involved party.’ He felt the hospital had denied them the chance to be together in the last moments of Mrs J’s life and he did not know what had happened to her.

Mr J complained to the Trust. Their response was timely, and he met with staff in an attempt to address his concerns. The Trust apologised that staff had forgotten that Mrs J had been accompanied to hospital by her husband, describing that as ‘a serious breakdown in communication’, but then took no appropriate steps to tackle this failing.

What our investigation found

We investigated the circumstances surrounding Mrs J’s death and the Trust’s response to Mr J’s complaint. Our investigation found that Mrs J was not monitored properly after she arrived at the hospital. No observation chart was started, no further assessments were documented after the first assessment and she waited for a medical review which did not take place. No attempt was made to contact the nursing home or a family member until after she had died. The Trust’s care fell below the level set out in national guidance.

We sought expert advice on the decision not to resuscitate Mrs J. Our Clinical Adviser’s opinion was that attempts to resuscitate a patient as ill as she was would have been ‘futile and undignified’. The hospital failed, however, to involve Mr J in the decision-making process and nobody told Mr J what was happening to his wife until she had died. It was crucial that Mr J was involved in the decision-making and the move to compassionate and supportive care in his wife’s last moments. Mrs J was denied the right to a dignified death with her husband by her side. In Mr J’s own words, ‘They decided that enough was enough without bothering to include me in'.

Aspects of Mrs J’s care and treatment and the Trust’s failure to involve Mr J in decisions about them, fell below the level set out in national guidance and established best practice. The impact of these failings on Mr and Mrs J was that Mrs J did not receive the appropriate level of care and did not have her husband with her when she died. Mr J was understandably distressed that he was not told what was happening; not involved in his wife’s care; and was unable to be with her at the end of her life. In addition to this, the Trust’s failure to address the issues in Mr J’s complaint unnecessarily prolonged the complaints process. ‘It was a shabby, sad end to my poor wife’s life.’

We upheld Mr J’s complaint about the Trust.

What happened next

The Trust apologised to Mr J for their failings and paid him £2,000 in recognition of the distress he had suffered. The Trust’s Chief Executive met with Mr J and explained the procedural changes they had made, which included asking patients attending A&E if they are accompanied, recording the response and ensuring that staff keep the accompanying person informed about what is happening to the patient.

At the conclusion of the investigation, Mr J thanked the Ombudsman’s staff for ‘pursuing his case so faithfully and with such dedication’.