Failings in nursing care of older patient

What happened

In early spring 2013 Mrs N was admitted to the Trust having become bed bound and suffering from a necrotic toe (death of most or all of the cells in an organ). One late morning, nursing staff were aware that Mrs N was drowsy, and they used the 'Patient at Risk' scoring system (used to recognise 'at risk' patients and to trigger early referral to doctors) to record their observations and had twice called a doctor but did not indicate it was urgent. As a result, nursing staff did not act on Mrs N's deteriorating symptoms and did not document their actions. In the afternoon Mrs N's visitor twice expressed concern about her condition, and nursing staff said they were still waiting for a doctor to arrive. However, nursing staff did not take any further observations until later that evening when the doctor came to see Mrs N.

Two days later, Mrs N's condition deteriorated and she died of hospital acquired pneumonia.

Mr N believed that his mother received poor care, which led to her death. He also expressed concerns about the Trust's complaint handling and a breach of confidentiality relating to the temporary loss of his mother's records.

What we found

Nursing staff failed to carry out adequate observations despite concerns raised by Mrs N's visitor. When nurses assessed Mrs N, they did not properly assess her condition, which in turn meant that a doctor was not called earlier that afternoon. This was followed by a failure to properly record events. In consequence there was a missed opportunity to treat Mrs N with antibiotic medication at an earlier stage.

We were unable to say whether this would have changed the outcome for Mrs N, but it is established clinical fact that early treatment is vital in these cases. Therefore, we upheld this part of the complaint about the Trust. We did not uphold concerns about complaint handling and patient confidentiality.

Putting it right

The Trust apologised to Mrs N's family and paid them £1,000 in recognition of the distress they experienced.

The Trust also put together an action plan to show it had learned from its mistakes so that they would not happen again.