Mrs R'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 R lived with her husband in a warden‐assisted flat. She had limited mobility and was very dependent on him for support to walk. In March 2007 Mrs R was admitted to Southampton University Hospitals NHS Trust with worsening mobility, recurrent falling and confusion. She was diagnosed with dementia the following month. Her health deteriorated and she was given palliative care. She died in July 2007.

Her daughter complained to the Trust and then to the Ombudsman about various failings in nursing care during her mother’s time in hospital before she died. She said that staff had not offered Mrs R a bath or shower during her 13‐week admission. She told us that when she and her sister had tried to bath Mrs R themselves, they were left in a bathroom on another ward, without support from staff or instructions on how to use the hoist. They felt unable to risk using the equipment and so Mrs R went without her bath. Her hair was unwashed and her scalp became so itchy that, at the family’s request, nurses checked her hair for lice.

Mrs R’s daughter complained that staff had to be asked on four consecutive days to dress an open wound on Mrs R’s leg, which she said was ‘weeping and sticky’. She said that when she raised concerns about this with staff on the ward she was told there was no complaints department. Mrs R’s daughter said that her mother was not helped to eat, even though she was unable to do it herself. She said this had once happened when several nurses were ‘chatting’ at the nurses’ station. Nurses left food trays and hot drinks out of reach of patients and Mrs R’s family felt she would not receive food or drink unless they gave it to her. Her daughter felt the fact that staff did not give her mother food or drinks was effectively ‘euthanasia’.

Mrs R’s daughter also said Mrs R had suffered four falls in hospital, including two in 24 hours (she was unaware that her mother had actually suffered nine falls), and that the family’s requests for cot sides to be used had been declined on the grounds that their use might compromise her mother’s rights. One fall led to Mrs R sustaining a large facial haematoma with bruising, which greatly distressed her family when they viewed her body before the funeral. Mrs R’s daughter described her father as a robust man but he was in tears seeing the bruises. He died shortly afterwards and she felt he had ‘died of a broken heart’.

Overall, Mrs R’s daughter was left feeling that ‘there was a lack of concern and sympathy towards patients/deceased and [the] family’.

What our investigation found

We found that Mrs R had nine falls while in hospital, yet only one fall was noted in the nursing records; the Identification of Risks of Falls and Intervention Tool was completed just twice; and both entries were reviewed only once. There was no evidence that Mrs R’s risk of falling was kept under review, no detailed care plans, or any incident forms following her falls. No advice or support was sought from a specialist falls practitioner.

We found that no consideration was given to offering Mrs R help to bath or shower, although she was washed in bed. There was no further assessment of her nutritional needs, and no evidence in the nursing records that she was offered frequent fluids to prevent dehydration or encouraged to drink. Nurses failed to co-operate with medical recommendations and requests to provide hip protectors for Mrs R, to place a mattress next to her bed and to encourage her to drink. Dressings were applied to Mrs R’s leg wound but we could not judge from the nursing records if the wound was appropriately treated.

In response to her daughter’s complaint, the Trust apologised for the lack of bathing facilities and acknowledged the need to support families wishing to use facilities on other wards. The Trust said they had introduced protected meal times (times when patients can eat without interruption) and a system to identify patients who may need help. Volunteers were being recruited to help with this. The Trust apologised that Mrs R’s family were told that cot sides could not be used as they would compromise her rights, when it would have been better to say it was her safety that might be compromised. The Trust also acknowledged Mrs R’s daughter’s concern about repeatedly having to ask for the leg wound to be dressed.

However, the Trust did not identify failings in meeting Mrs R’s nutritional needs and in relation to her falls, and they did not discuss the issue of cot sides at their falls group, as they had told Mrs R’s daughter they would. Her complaint about the leg dressing was not addressed.

We found that the nursing care provided for Mrs R by the Trust fell significantly below the relevant standards, causing her and her family considerable and unnecessary distress. The Trust’s handling of the subsequent complaint left her without full explanations or assurances that they had learnt lessons. She was understandably dissatisfied with the Trust’s responses and she had to come to the Ombudsman for further answers.

We upheld this complaint.

What happened next

The Trust apologised to Mrs R’s daughter and put together an action plan to address their failings in nursing care and complaint handling. Their plans include ensuring that patients and their carers are offered a choice in how their personal hygiene needs are met; changing the way patient meals are delivered so that staff are able to help with eating; centralised complaint handling so that all complaints are dealt with consistently and best practice is shared; and removing the distinction between complaints made informally, formally, orally or in writing.