Decision report 201004012

Summary
Mrs C’s husband (Mr C) was admitted to hospital with breathing problems and fever. He was diagnosed with pneumonia with a background of chronic lung disease, and given antibiotics. He continued to be treated over the next few days during which his condition slowly improved (although he continued to experience breathlessness) and he was being considered for discharge. However, Mr C suffered a cardiac arrest and collapsed in his room. Although staff tried to resuscitate him, unfortunately Mr C did not recover. One of the nursing staff contacted Mrs C, who lives in a remote location around 200 miles from the hospital, and advised her to come to the hospital quickly as her husband had ‘taken a turn for the worse'. Mrs C and her family immediately drove to the hospital, only to discover that Mr C had already died. When Mrs C was told the time of her husband’s death, she discovered that he had died before the telephone call was made.

Mrs C and her family had a number of complaints about Mr C’s care and treatment, and communication difficulties they had experienced with the staff. They were also concerned that the hospital had not taken sufficient action as a result of their experiences.

We did not uphold the complaint about Mr C’s care and treatment. We found that the management plan was comprehensive, that Mr C was regularly observed, and that the choice of antibiotics demonstrated good practice. Unfortunately, Mr C died due to a sudden and unpredictable cardiac arrest caused by underlying ischaemic heart disease. We did, however, uphold the complaint about communications. We found that the way staff dealt with Mrs C and her family was extremely unsatisfactory, from being advised to come to the hospital as quickly as possible to the way they were greeted there and told by the staff that Mr C had died. The family were made to wait some time, and the doctor who broke the bad news had not been present at the resuscitation efforts. We found this to be poor care of a family being advised of a bereavement. Given, however, that the hospital had made an unreserved apology, particularly on behalf of the individual staff involved, we had no recommendations to make. We did not uphold the complaint about the action taken because the hospital provided good evidence of the action plan that they implemented as a result of Mrs C’s complaint. This involved more staff training about communication and dealing with families in outlying areas, and ensuring that the learning outcomes from the complaint were implemented throughout the hospital.