Case study 4: Failing to keep a family updated about their mother’s deteriorating health
What happened
Mrs G had difficulty swallowing when she was admitted to hospital. She was known to have a progressive lung disease that caused breathing difficulties. The Trust thought she might have a type of lung infection and she was treated with antibiotics and fluids intravenously (into a vein).
The Trust decided Mrs G could not safely eat or drink normally and needed a liquid diet. It inserted a nasogastric tube – a tube passed through the nose and down into the stomach. The Trust did an X-ray and found a pneumothorax (a collapsed lung, which happens when air is trapped between the lung and the chest wall). Mrs G’s condition deteriorated and she died in hospital the following morning. A coroner’s postmortem concluded that her death was due to natural causes.
What we found
We found that the Trust did not keep the family updated about Mrs G’s condition when it should have. The Trust only spoke with Mrs G’s family when she was admitted to hospital and again when her condition had significantly deteriorated.
An X-ray had shown a small pneumothorax, which the Trust said did not need treatment due to its size. The Trust did not tell Mrs G’s family about this at the time. This was not in line with relevant national guidance.
Following the consultant ward round that took place the day before Mrs G died, the medical and nursing team should have informed her family of the seriousness of her condition and her increasing frailty. There was no documented reason why Mrs G’s family were not informed.
We did not conclude that the failings we identified led to Mrs G’s death, but we did find that the poor communication contributed to her family’s distress and compounded their grief.