Mr W'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 W was 79 years old. He suffered from dementia and depression, was frail and had not long been widowed. He was admitted to St Peter’s Hospital (part of Ashford and St Peter’s Hospitals NHS Foundation Trust) with recurrent dehydration and pneumonia.

The hospital treated Mr W with intravenous fluids and antibiotics, which were stopped when his chest infection cleared up. A week later, his daughter, herself a former nurse, told a doctor caring for Mr W of her concerns that his general condition had deteriorated during his admission and that he would be better off receiving intravenous fluids. The doctor said he could not do this as it would ‘prevent his leaving hospital’ and that ‘he can meet his needs orally’. Mr W’s daughter disagreed as he frequently refused to eat and drink more than very small amounts. The doctor said that Mr W was medically fit for discharge, but that he was frail and prone to further infection and any further treatment should be palliative. He told Mr W’s daughter that Mr W was ‘probably as good as he is going to get’.

Over the next few days Mr W continued to eat and drink very little, refused most meals and drank only about one cup of fluids each day. Feeding him through a percutaneous endoscopic gastrostomy (PEG) tube was considered but ruled out because of the high risk of death associated with PEG feeding of patients with advanced dementia.

Despite his daughter’s concerns about Mr W’s condition, the hospital discharged him to a care home on Christmas Eve. He weighed just 6 st 7 lbs. They did not communicate with his family who therefore ‘could do nothing to stop it’. Mr W’s daughter said ‘Our Dad had this big move on his own even though I had made it clear to the ward that I wanted to be with him when he moved… upset[ting] us all greatly’.

Three days later, at 2.00am, Mr W was admitted to a different hospital with breathing difficulties. He was severely dehydrated and had pneumonia. That hospital treated Mr W’s pneumonia and fed him through a PEG tube. His daughter told us that once the tube had been inserted and Mr W received adequate nutrition and fluid, he had been ‘transformed’. She told us that following this treatment not only was Mr W still alive, but he had not needed to be hospitalised since, enjoyed life, and participated in the activities in the care home, including playing dominos.

After complaining first to the Trust and then to the Healthcare Commission, Mr W’s daughter came to the Ombudsman. She felt the Trust had put Mr W’s life in danger by discharging him when he was not medically fit. In one letter she wrote ‘As yet we haven’t even been able to mourn our mother as we have and are continuing to fight for any kind of quality care for our Dad’.

What our investigation found

In Mr W’s case, the Trust did not follow their own discharge policy or national guidance which state that patients should be fit for discharge. The Trust’s policy also notes that a patient’s fitness for discharge does not necessarily indicate that it is safe to go ahead. Indeed, taking account of Mr W’s very low weight, his inadequate nutrition and hydration and the development of suspected C.diff (a serious hospital-acquired infection), we concluded it had not been safe to discharge him.

Mr W’s nutritional and fluid intake needs were not being met, and this continued until his discharge. His medical fitness for discharge was not reviewed or addressed and no plan was made to increase his nutrition and fluid intake, other than by simple encouragement. This was wholly inadequate, yet the doctor saw no need for further consideration or intervention. His daughter’s repeatedly expressed concerns about her father’s deterioration were not taken seriously or acted upon. This lack of respect for her views caused her considerable unnecessary distress.

We uncovered very troubling possible explanations for the failure to review Mr W’s fitness for discharge. The doctor caring for him was no longer actively treating him; the implication being that he would develop another chest infection from which he would die. The tone of emails exchanged between a social worker and Trust staff suggested they regarded Mr W’s daughter’s concerns as a nuisance, and as potentially preventing a bed being freed over Christmas. This appeared to be their priority.

The lack of treatment given to Mr W put his life at risk. His discharge and subsequent treatment at a different hospital saved his life. His daughter had pushed to have Mr W admitted to St Peter’s Hospital because she was anxious about his condition and thought he would be safe there. The opposite was true.

We upheld this complaint.

What happened next

In line with the Ombudsman’s recommendations, the Trust apologised to Mr W’s daughter and paid her £1,000 compensation for the distress they had caused her. They also drew up plans to stop the same mistakes from happening again. The actions the Trust planned included a review of their discharge policy; more junior doctors working at weekends; advanced communication skills training for doctors; and the introduction of a Pledge, setting out the behaviours expected of all clinical and non-clinical staff.