The story

Mr L was 72 and suffered from Parkinson’s disease. His wife described him as a brilliant architect, and someone who had enjoyed keeping fit all his life. He was taking medication to manage his symptoms, but this disturbed his mental health and was stopped. Mr L experienced further episodes of hallucinations and paranoia, disturbed and aggressive behaviours which were sufficiently frightening for his daughters to administer diazepam and take him to A&E at Epsom General Hospital. From there, Mr L was transferred to the Trust’s West Park Hospital, which specialised in assessing elderly patients with mental health difficulties.

On arrival at West Park Hospital (part of Surrey and Borders Partnership NHS Foundation Trust), Mr L was moved to Bluebell Ward for assessment at around 3.00am and was said to be ‘in a calm and pleasant mood’. Nevertheless, he was given 10mg olanzapine, an antipsychotic drug. Mrs L visited her husband later the same day and was ‘devastated’ by what she saw. Before his admission, his wife said he had been able to eat, drink, talk coherently, see to his personal care and do some weight training, but now he had been ‘turned into a zombie, a ragdoll’.

Over the next few days, despite his family’s concerns, Mr L was given more antipsychotic and tranquillising medication, which his family say robbed him of his dignity. Mrs L said the ‘image of [Mr L] haunts us to this day’ – he had to be taken to the toilet, could not walk unaided, had to be fed and could not speak coherently.

Five days after his admission to West Park Hospital, Mr L was transferred back to Epsom General Hospital for a routine echocardiogram, but on arrival, he complained of shortness of breath and a cough. On examination, crackles were heard in both lungs and he was dehydrated. A chest X-ray indicated that Mr L had pneumonia and he was admitted. He did not recover from this and died two weeks later.

Mrs L and her family complained to the Trust that Mr L had been given antipsychotic drugs unnecessarily, which they said had led directly to his death. Dissatisfied with the Trust’s response, the family complained to the Healthcare Commission and then to the Ombudsman. Mrs L said that her husband should not have been given olanzapine, which had reduced him to a state in which he could not function, and that he had developed pneumonia which had not been recognised. These failings had ‘fast-tracked her husband to his death’ and the Trust ‘took away every last ounce of dignity my husband had left’. Mrs L wanted assurance that future patients would not be treated in a similar way.

What our investigation found

We found that although it had not been unreasonable to prescribe olanzapine to Mr L, the initial dose was incautious and too high for an elderly man with his symptoms. Once it was realised that Mr L was over‑sedated, the prescription was changed to a lower dose, to be given as required if he became very agitated or psychotic. However, this new instruction was not written up on the drugs chart and the nurses continued to give Mr L olanzapine on a regular basis, even though he did not meet the criteria for its administration.

Shortcomings in the nursing and medical care meant that Mr L’s deteriorating physical health was not noticed. There was no evidence that care plans were drawn up to meet Mr L’s physical needs. Fluid charts, poorly kept as they were, showed that he was at severe risk of dehydration. Nurses recorded that Mr L had passed very concentrated urine, yet did not draw the correct conclusions or act appropriately to address his developing dehydration. The nursing records, which fell short of the standards required by the Nursing and Midwifery Council, led to a failure to recognise the implications of the observations that were made, or to take appropriate action to tackle the problems that were developing.

Despite concerns and a specific request by doctors that Mr L should be monitored, there was no evidence that regular nursing observations were taken and none were recorded. This meant that while we found no evidence that Mr L showed signs of pneumonia during the time he was in Bluebell Ward, staff did not put themselves in a position to be able to state confidently that Mr L was well when he left them. (For their part, Mr L’s family are convinced that he had contracted pneumonia while in Bluebell Ward and that he was already seriously ill when he arrived at Epsom General Hospital. There is nothing to contradict this view.)

We concluded that the care and treatment given to Mr L fell significantly below the applicable standard and this was service failure. Although we could not be certain that Mr L’s death was avoidable, the service failures put him at greater risk, probably contributed to his decline in physical and mental health and loss of dignity, and compromised his ability to survive pneumonia. All of this was an injustice to Mr L. It also affected Mrs L and her family who found it ‘heartbreaking’ to see his condition deteriorate to the extent it had. The length of time taken to complete the complaint process, which included two separate reviews by the Healthcare Commission, meant the complaint was not concluded for more than four years.

We upheld this complaint.

What happened next

The Trust apologised to Mrs L for their failings and agreed to pay her £1,000 compensation for the distress and anxiety caused to the family.

Mr L’s family did not seek compensation and did not wish to accept the Trust’s compensation payment. They have told us that their complaint was never about compensation and that the award added insult to injury.

As Mrs L and her family were keen that the Trust should learn lessons from this complaint, we asked them to prepare plans aimed at ensuring that lessons were learnt and mistakes not repeated. The Trust told us about a number of actions they were taking, which included: wards carrying out their own monthly record keeping audits; identifying training needs around the Care Programme Approach and medication; and benchmarking themselves against the Essence of Care standards for privacy and dignity involving people who use their service and their carers.