Mrs Y'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 Y lived on her own. Her relative described her as always being in good health, and having ‘excellent energy and vitality for her age’. In May 2008 Mrs Y had a fall at home which she did not report at the time; her relative said she was of a generation who ‘tended to put up with things’. A week later Mrs Y’s family persuaded her to attend the A&E department at Epsom and St Helier University Hospitals NHS Trust, as she was obviously in some discomfort. Mrs Y was diagnosed with a fracture of part of her pelvis. She was kept in overnight, and discharged the next day with painkilling medication that included ibuprofen.

No follow-up care was arranged for Mrs Y and it was only five days later on 2 June that the hospital faxed a discharge summary to Mrs Y’s GP. The summary did not contain details of the medication which had been prescribed.

Mrs Y began to feel sick after returning home and she developed severe constipation. Her relative said she was not her usual lively self and was ‘unusually low’. She was eating little and losing weight. Eventually, Mrs Y’s neighbour telephoned the GP on 10 June to ask her to carry out a home visit. The GP telephoned Mrs Y but did not visit. She recorded that Mrs Y was constipated and had a poor appetite and advised her to phone again the next day if she remained concerned.

The following day another neighbour drove to the surgery to say that Mrs Y seemed confused. The GP telephoned Mrs Y again, offering to visit that afternoon. Mrs Y said that would not be convenient: a visit was arranged for two days later, which was the day after her 88^th birthday. During the visit the GP assessed her mental condition and prescribed paracetamol. She told Mrs Y that arrangements would be made for a carer to visit.

Sadly, Mrs Y was found dead on the upstairs landing of her home the next day, by a neighbour who had become very concerned that she was not answering her telephone. A post-mortem established that Mrs Y had died from peritonitis and a perforated stomach ulcer.

Her relative and his wife complained to the Trust that the hospital had not arranged follow-up care for Mrs Y after her discharge, and did not inform the GP promptly about her attendance at the A&E department. They also complained that the GP did not see Mrs Y until three days after a home visit had been requested and that the GP’s assessment of Mrs Y had not been sufficiently thorough.

As her relative put it, ‘I am concerned that an otherwise healthy elderly lady was allowed to deteriorate so quickly following her self-admission, in circumstances known to be potentially serious’.

What our investigation found

Although Mrs Y’s hospital discharge was appropriate, planning for the discharge should have started earlier. There should have been an earlier referral to the GP and Mrs Y should also have been referred to a specialist falls service. The discharge summary gave no details of the medication prescribed for Mrs Y. This was significant, because it is quite likely that her ulcer developed as a result of taking ibuprofen.

The likelihood is that Mrs Y was showing significant symptoms related to her ulcer when the GP examined her, and we concluded that the GP’s assessment of her was not thorough enough. We could not say that Mrs Y’s death definitely resulted from the failure to identify the symptoms from the ulcer, but the opportunity to treat it was missed.

We concluded that the GP had not met the General Medical Council standard that good clinical care must include adequately assessing a patient’s condition taking account of their history. While a telephone assessment might initially have been appropriate, the GP should have arranged to visit when she received a message of further concern from the neighbour the following day.

We upheld the complaints about both the Trust and the GP Surgery.

What happened next

The Trust and the GP Surgery both apologised to Mrs Y’s relatives and drew up plans to prevent recurrences of their failings. Among the actions taken or planned were new procedures for ensuring that discharge summaries were completed promptly; a matron-led review of the nurse’s role in the A&E observation bay; and regular teaching sessions for A&E doctors about prescribing and monitoring medication. The Trust also said that they would share the lessons learnt from the complaint to reduce the risk of others suffering the same experience.

For their part, the GP Surgery drew up a protocol for the care of elderly people living alone, who have problems after their discharge from hospital.