Mrs K’s 85 year old father had recently had cancer surgery at Gloucestershire Hospitals NHS Foundation Trust (the Trust). He fell the day after he was discharged, and was admitted to the Trust’s Cheltenham General Hospital. A Do Not Attempt Resuscitation (DNAR) order was made and then Mrs K’s father was moved to a different hospital for palliative care. He developed pneumonia and was moved back to Cheltenham General Hospital, where another DNAR order was made. He died a few days later.

Mrs K complained to the Trust about the level of consultation over the DNAR orders. She was also upset that doctors had told her that her father’s condition was not immediately life threatening, when the death certificate showed that he had terminal bladder cancer. Mrs K said ‘the deeper the investigation went the more discrepancies became apparent’. She was ‘concerned that other elderly people might encounter similar experiences’ and that she ‘would like to prevent more serious outcomes for those who do not have relatives to advocate on their behalves’.

Our investigation highlighted the importance of good communication with patients and their families. We found that Mrs K’s father should have been informed about the severity and finality of his condition and asked if he wanted his family kept updated. Instead, his family were generally kept in the dark about his illness and his deteriorating condition. The level of communication with doctors about his condition did not meet the family’s needs, and the family were given limited information about the DNAR orders, which upset them greatly. Mrs K said ‘not consulting my father or I was both disempowering and insensitive’.

Following our recommendations, the Trust drew up plans to provide communication training for medical and nursing staff. The Trust also paid £1,000 to Mrs K and her family, which they donated to a hospice.