Mr C'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

Mr C was described by his daughter, Miss C, as mentally active and creative – he was in the process of writing a book.

He became unwell and underwent heart surgery (a quadruple coronary artery bypass) at Oxford Radcliffe Hospitals NHS Trust, an operation which started at midday and was expected to last for three hours. Mr C’s wife and daughter remained alone in the waiting room for five hours. They told us that during that time they tried unsuccessfully and with increasing desperation to find someone to give them some information. They eventually found the Consultant, who indicated that the surgery had gone well.

Sadly, about two hours after the operation, Mr C’s condition deteriorated and he suffered a heart attack.

Mr C underwent open heart massage, while his wife and daughter waited nearby for news, occasionally ‘wander[ing] the corridors looking for someone to tell us what was happening’. A Registrar spoke to Miss C, but his English was ‘very poor and broken’. The exchange left Mr C’s wife and daughter unclear as to whether Mr C had died — ‘my question asking if he was alive kept getting sidestepped yet the question – is he dead — also got a no. The confusion was terribly distressing’. They asked to see Mr C and did so at around 9.30pm. At 9.15pm, unknown to Mr C’s family, a ‘Do not attempt resuscitation’ note was made in his medical records.

A nurse told Miss C that her father was only being kept alive by the ventilator and that he had ‘flatlined’ (meaning that there was no heart beat). His wife, who was totally distraught, wanted to telephone her sons.

Miss C told the nurse that they were going to make a phone call and stated expressly that the life support was not be switched off as she was coming back to sit with her father. She was still hopeful of a recovery. Miss C later told us that, had she known her father was going to have his life support switched off, she would have wanted to help him ‘go peacefully after being battered by so many medical procedures and surrounded by strangers’. However, she and her mother returned to find that Mr C’s ventilator had already been switched off. Miss C felt that ‘the staff decided that we had been given as much time as we were allowed’. Mr C was pronounced dead at 10.25pm.

Mr C’s daughter complained first to the Trust, and then to the Ombudsman that she had been left with no clear understanding of her father’s condition during his final hours, and why his life support had been turned off against her express wishes. As she observed in one letter to the Trust ‘This is just one of many such events in the working life of your staff but it has lifelong repercussions for us’.

What our investigation found

We found that the Trust’s communications with Mr C’s family were below standard. There were several examples of this.

Staff did not explain to Mr C’s family that his condition had worsened, nor tell them about the ‘Do not attempt resuscitation’ decision. This was counter to the Trust’s own policy which says that discussion with families should aim to secure an understanding of why the decision was reached. Although a nurse spoke to Mr C’s family after he had stopped responding to treatment, there was little information about what they were told. The use of the term ‘flatlined’ in a conversation with his daughter was inappropriate and insensitive and did not communicate the clinical significance of Mr C’s heart having stopped.

The Trust have no formal policy that indicates when it is appropriate for nurses to turn off a patient’s life support, but in practice the Trust allow senior nurses to do this, if the patient’s family is present and in agreement. If the family disagrees, nurses must seek a medical opinion. Here, by turning off Mr C’s life support against his family’s wishes, staff acted contrary to the Trust’s practice. Staff could reasonably have accommodated the family’s wishes and delayed switching off Mr C’s ventilator for a few minutes, even if he had already died and life support was no longer serving any purpose. As his daughter said later ‘We would have liked the opportunity to have the peace of mind of sitting with my father and of praying for him. I have the feeling that I failed my father’.

The records do not show if Mr C had died before or after his life support was turned off, and so we could not say for certain whether that action denied Miss C the opportunity to be with her father when he died. Nevertheless, the Trust’s actions caused her unnecessary distress. Indeed, his daughter has told us she is ‘very aware of how deeply this handling of my father’s death has affected me’.

We upheld Miss C’s complaint.

What happened next

The Trust apologised to Mr C’s daughter for the distress they had caused her and paid her compensation of £1,000. They also began to review some of their policies and arranged further training for staff in end of life care. The Trust also drew up plans to share the lessons they had learnt from Miss C’s complaint, and acknowledged the need to promote effective communication.