Decision Report 201300450

Summary

Mr and Ms C complained about the care and treatment given to their late mother (Mrs A) while she was a patient in hospital. Mrs A had been admitted with a history of diverticular disease (disease of the colon) and schizophrenia (a long-term mental health condition that causes a range of different psychological symptoms) but her immediate symptoms included a possible gastro-intestinal bleed. After admission, Mrs A experienced increasing confusion and showed signs of dehydration. Mr and Ms C said that staff failed to address these growing problems, together with the problem with which she had originally presented, to the extent that Mrs A became dangerously ill and died. Mr and Ms C were shocked at their mother's swift deterioration and death. They said that no proper intervention had been made until the day she died and they believed staff paid more attention to Mrs A's mental health than to the physical problems she was experiencing. They complained to the board, who said that they were satisfied that the care and treatment given to Mrs A was appropriate to her needs.

We obtained independent advice from a medical adviser and nursing adviser, and gave careful consideration to Mrs A's medical records and the complaints correspondence. We upheld the complaint, as our investigation found that although the board had tried to address Mr and Ms C's concerns by holding a number of meetings and by writing, their initial letter failed to mention that intravenous fluids were not started when they had been suggested or that a deteriorating renal function was a key part of Mrs A's condition.

Recommendations

We recommended that the board:

• consider the use of cognitive function screening and assessment tools as routine in similar circumstances;
• ensure that nursing care plans are in place for patients; and
• review their initial letter to Mr and Ms C and consider what steps could be taken to improve the quality of future responses.