Case study 5: Unclear care plan due to poor communication between specialist teams
What happened
Mrs A was admitted to hospital after her GP referred her with symptoms including a chest infection and a low platelet count. She was also coughing up blood and had reported bruising. During her admission, the Trust arranged tests to find the cause of Mrs A’s symptoms. The results showed that Mrs A had oesophageal cancer.
About two weeks later, the Trust discussed Mrs A’s condition at a multidisciplinary team (MDT) meeting to consider whether she was suitable for a stent procedure - a palliative treatment to help with swallowing if her symptoms worsened. Mrs A died in hospital a few days later.
What we found
We found failings in communication by the Trust’s medical team on the ward and its specialist teams. The medical team waited for the MDT meeting outcome and input from the gastroenterology team before planning Mrs A’s care, including the stent procedure.
Following the MDT meeting, the plan was to carry out the stent procedure while Mrs A was an inpatient. When this was discussed the following day, Mrs A and her daughter decided they wanted to concentrate on symptom control, rather than an invasive treatment such as the stent.
Records showed there was little communication between the teams before this. Had the teams collaborated effectively in line with relevant guidance, they might have reached a plan for Mrs A’s care sooner, and the family would have had a clearer understanding of what a stent could offer. A more coordinated clinical approach would have enabled clearer communication with Mrs A and her family. It might also have reduced her family’s uncertainty about what treatment the Trust intended to provide.