Part 12 - Complaint about Gloucestershire Hospitals NHS Foundation Trust (the Trust) and the Healthcare Commission
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Complaint about the care and treatment of an elderly patient who died during an in-patient admission, and complaint about the Commission’s subsequent review
Background to the complaint
Mr W, aged 74, was admitted to Gloucester Royal Infirmary as an emergency in August 2002 for treatment of an infective exacerbation (pneumonia) of chronic obstructive pulmonary disease. He was treated in the Intensive Treatment Unit until the end of August when he was transferred to a respiratory ward. Mr W then had episodes of confusion, difficulty with oxygen intake and some bleeding from a catheter site. He later contracted MRSA, developed diarrhoea and was found to be infected with C.difficile. Mr W was transferred to Standish Hospital at the start of October, where he suffered with recurrent C.difficile infection. Mr W died in November 2002, with the cause of death noted as respiratory failure.
The complaint to the Trust and the Commission
Mrs J, Mr W’s daughter, questioned whether the Trust’s actions had contributed towards his deterioration and death. She had specific concerns about the care and treatment that he had received, including: his transfer from the Intensive Treatment Unit; the timing of medical reviews following that transfer; the general standard of hygiene and nursing care (Mr W had been found by his family with bloodstained pyjamas and bedclothes and there was a delay in providing continence pads when he suffered from diarrhoea); effectiveness of communication (both between staff members and with the family); the management of MRSA and C.difficile and the accuracy of the death certificate. Mrs J believed that Mr W had been caused undue suffering and stress during his admission and that their family had been caused unnecessary distress.
Mrs J complained to the Trust in March 2003; they responded in July 2003. A local resolution meeting was held in August 2004. Mrs J was unhappy with the action taken by the Trust and complained to the Commission in October 2004.
In November 2005 the Commission referred some aspects of the complaint back to the Trust for action (requesting an update on improvements to record keeping and communications between staff and families) and asked them to look at the timing of Mr W’s transfer from the Intensive Treatment Unit. Mrs J complained, again, to the Commission in December 2005, which said, in May 2006, that it would take no further action as it was satisfied with the Trust’s actions and responses.
What we investigated
Mrs J asked us to investigate all aspects of her complaint against both the Trust and the Commission.
We considered all the available evidence and took clinical advice from an experienced General Physician (who is also a Consultant in Elderly Care Medicine) and an experienced Nurse. We also took account of the relevant standards and guidelines including the Department of Health’s National Service Framework for Older People (2001), the British Society of Geriatrics’ ‘Standards of Medical Care for Older People’ (revised 2003), the Nursing & Midwifery Council’s ‘Standards for Records and Record Keeping’, the NHS Modernisation Agency’s benchmarking tool ‘Essence of Care’ and the March 2001 guidance about resuscitation decisions published jointly by the British Medical Association, Royal College of Nursing and the Resuscitation Council.
What our investigation found
We found that the timing of Mr W’s discharge from the Intensive Treatment Unit was appropriate; that the medical care in late August/early September 2002 was generally reasonable; that there was no objective evidence of MRSA being implicated in Mr W’s death; that the medical management of C.difficile was appropriate; and that the Trust’s response on the accuracy of the death certificate was reasonable. However, when taken in the round, the evidence we saw pointed to serious failings in the Trust’s service to Mr W and his family which were:
- a lack of monitoring while Mr W waited to be transferred from the Intensive Treatment Unit;
- a delay in carrying out a medical review;
- extremely poor nursing care in relation to care planning, communication, pain management, infection management, patient privacy and dignity, and monitoring fluid intake/output;
- a lack of multi-professional working and senior medical review;
- poor record keeping; and
- poor end-of-life care (including lack of a care plan and no discussion with the family about resuscitation and the seriousness of Mr W’s prognosis).
We concluded that, irrespective of the poor practice identified, the final outcome for Mr W would not have been different, but that the failings identified would have significantly affected Mr W’s quality of life and the level of distress he suffered. We also found that Mr W’s family were caused undue distress due to the condition in which they sometimes found Mr W and because they had no opportunity to come to terms with the fact that his life was ending and to make suitable arrangements.
We acknowledged the time and effort the Trust took in attempting to resolve Mrs J’s concerns and that they readily acknowledged several failings and took action to address them. However, we concluded that Mrs J’s complaint should have prompted a wider review of nursing care which may have led to a more co-ordinated approach to implementing improvements and, in turn, provided reassurance for Mrs J that her complaint was being taken seriously.
We found maladministration in the Commission’s handling of Mrs J’s complaint (including failure
to seek clinical advice, not providing her with regular updates and failure to assess the priority of the case) which had exacerbated her worry and distress.
The investigation concluded in March 2008 and we upheld Mrs J’s complaints against both the Trust and the Commission.
Outcome
In this case we decided to involve Monitor, the body which authorises and regulates NHS Foundation Trusts, because we were highly critical of the nursing care at the Trust and were keen to ensure that there was an appropriate review of the Trust’s progress in learning lessons from the complaint.
The Trust agreed to:
- write to Mrs J and her family to acknowledge and apologise for the failings identified;
- review the areas where we had identified serious failings in order to ensure that their practices were in accordance with current guidance and standards;
- provide Monitor with information to demonstrate that their practices (in the areas where we had identified serious failings) are in line with current standards; and
- report back to Mrs J on the action taken in response to our recommendations.
The Commission agreed to write to Mrs J and her family with an apology and pay £250 compensation in recognition of the worry and distress caused by its poor complaint handling.
