Case study 6: Failing to provide critical information to a care centre about a patient’s condition and needs
What happened
Mrs R had ovarian and peritoneal cancer. She went to A&E with symptoms of nausea, vomiting and fever. She also reported abdominal swelling and constipation. She was later diagnosed with a subacute bowel obstruction.
Clinicians decided to fit Mrs R with a syringe driver to administer cyclizine, a medication used to treat nausea and vomiting. About two weeks later she was discharged from hospital to a care centre that provided rehabilitation to enable patients to return to their own homes. After several days, she was taken back to hospital as her condition deteriorated. Mrs R died in hospital the following week.
What we found
We found that the Trust failed to share critical information about Mrs R’s condition promptly. The referral contained no mention that Mrs R had been admitted with bowel obstruction caused by progressive cancer, or that she was likely approaching the end of life.
The referral also made no mention of the syringe driver that had been fitted. The care centre said this information was essential, as its staff were not prepared or equipped to manage patients with syringe drivers. On the day of admission, the care centre noted concerns about the appropriateness of the referral and raised a formal incident report about the syringe driver.
Although the discharge summary contained this information, it was only shared after Mrs R had arrived at the care centre, rather than when the referral decision was made. Had this been communicated earlier, it is likely the centre would have refused the referral. We also found that earlier communication may have avoided the second hospital admission, and Mrs R could have chosen to receive palliative care at home with minimal medical intervention.