Mrs H’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 H was a feisty and independent woman of high intelligence who loved literature and crosswords. She was a dignified woman whose clothes were important to her. She lived in her own home until the age of 88, needing relatively little support. Mrs H was deaf and partially sighted and communicated through British Sign Language and deaf-blind manual although she could still read large print. She was an active member of her local deaf community and one of the founder members of the local Institute for the Deaf. Her only relative, her niece, lived in New Zealand but maintained close contact and held power of attorney for her.

Following a fall at home, Mrs H moved to an intermediate care centre for treatment. From there she was admitted to the Elderly Care Assessment Unit of Birmingham Heartlands Hospital (part of Heart of England NHS Foundation Trust) with acute confusion. She remained there for about four months. Social workers identified a care home for residents with dementia, which Mrs H’s niece declined because it had no facilities for residents with sensory impairment. This led to a longer stay in hospital. Her niece eventually found a place at a care home in Tyneside and arranged for Mrs H to move there. While Mrs H was in hospital:

she had a number of falls, one of which broke her collar bone, but her niece was not informed. Several injuries and falls were not included on her discharge summary
poor nursing records were kept and no personalised plans for her non-medical needs were developed
although at low risk of malnutrition at admission, Mrs H lost about 11 lbs during her first three months in hospital
communication with Mrs H was difficult and her specific needs were not met. No activities or stimulation were provided for her
her valuables and clothing were brought to the ward but there was no record of their receipt
communications around the discharge arrangements were poor with no handover to the home
despite her niece’s requests, no arrangements were made with social services for Mrs H’s clothes to be laundered.

During a lengthy journey to the home, Mrs H was strapped onto a stretcher in the back of an ambulance for her safety. (The Trust told us that this was because the potential consequences of her becoming more distressed and confused on the journey could have been very serious.) Mrs H was accompanied by a male nurse who had nursed her on the ward. She was agitated and distressed but was not given any medication despite it being available. (The Trust told us that this was because it could have increased her confusion.) When Mrs H arrived at the care home, the Manager noted that she had numerous injuries, was soaked with urine and was dressed in clothing that did not belong to her which was held up with large paper clips. She had with her several bags of dirty clothing, much of which did not belong to her, and few possessions of her own. Mrs H was bruised, dishevelled and confused. She was highly distressed and agitated and the following day was admitted to a local hospital due to concerns about her mental state and her physical condition.

Sadly, Mrs H died in August 2010 shortly before the conclusion of our investigation.

Mrs H’s niece complained that Mrs H’s right to dignity was not respected and that she had been treated with contempt and disdain. She complained that Mrs H’s property and clothing had not been taken care of whilst in hospital, and that no arrangements had been made to launder her clothes. She said that her aunt suffered distress and indignity, her mental health had suffered premature deterioration and she needed to be admitted to another hospital on her arrival at Tyneside. She also complained that some of Mrs H’s property and clothing had been lost.

Mrs H’s niece complained that Mrs H sustained unexplained injuries in hospital and that she was not informed of these. She believed the discharge and transfer arrangements for Mrs H were wholly inadequate and inappropriate.

What our investigation found

We found evidence that the care given to Mrs H fell significantly below the applicable standard in relation to meeting her cultural and linguistic needs, maintaining her comfort and wellbeing and safeguarding her property and clothing. We also found serious shortcomings in the Trust’s communication with her niece. Underpinning these serious shortcomings were failures to carry out appropriate assessments and to develop personalised care plans, failures to understand Mrs H’s relationship with her niece and failure to follow local and national policy and guidance. Taken together, this amounted to service failure.

As a result of this we found that Mrs H suffered additional unnecessary distress which could have been minimised by care tailored to her needs, which allowed her to exercise choice and control and have her preferences met. The failure to personalise her care meant that her dignity and individuality were compromised. She suffered financial loss through the Trust’s failure to safeguard her property.

Mrs H’s niece also suffered unnecessary distress as a result of the Trust’s failure to keep her informed about Mrs H’s falls and condition.

We upheld these complaints.

What happened next

The Trust apologised to Mrs H’s niece for the distress and indignity that Mrs H had suffered and for losing her property. The Trust also paid her niece compensation totalling £1,500 and reimbursed her £300 for the loss of her aunt’s belongings.

The Trust also drew up plans to prevent the same failings from happening again. The actions taken or planned include the development of study days to determine staff’s attitude, knowledge and beliefs surrounding dementia; the introduction of a password‐protected system to enable staff to give confidential information to family members over the telephone; reminders to staff about how to access interpreting services for patients with impaired hearing; and the appointment of an Admission and Discharge Co-ordinator.