Nursing home did not tell son about his mother's discharge from hospital

What happened

Mrs W was in her late eighties and had lived in the nursing home since spring 2010. She had severe vascular dementia and needed help with eating and drinking at all times. Doctors prescribed her a sedative to help with her agitated behaviour but this left her drowsy and unable to swallow. Mrs W's son, Mr W, said he raised concerns that staff did not supervise his mother properly at mealtimes, particularly given her drowsiness. He said staff did not listen or act on his concerns about this.

In spring 2012 Mrs W developed aspiration pneumonia (inflammation of the lungs that can be caused by breathing in particles of food) and was taken to hospital. She was discharged back to the nursing home five days later but it wasn't until four hours after she arrived that staff told Mr W this. Mrs W's condition deteriorated and she died about one hour later.

Mr W believed that his mother's death could have been avoided if the nursing home had listened and acted upon his concerns about her swallowing difficulties. He said that he was greatly upset and distressed by her death, and that staff did not tell him as soon as she returned from hospital, so that he could have been with her when she died.

What we found

We partly upheld this case. There was insufficient evidence that nursing home staff gave Mrs W sedatives inappropriately. We did not find that staff failed to act on Mr W's concerns about his mother's swallowing difficulties or to monitor Mrs W properly while she ate.

However, staff should have told Mr W that his mother had returned to the nursing home after her discharge from hospital. This failure meant Mr W suffered unnecessary distress.

Putting it right

The nursing home acknowledged its failing and apologised to

Mr W for the distress he experienced.