Decision Report 202001414

Summary

C's spouse (A) had advanced kidney cancer which had spread to their brain. A was admitted to hospital after they developed breathing problems. They were diagnosed with a pulmonary embolus (blood clot in the lung). A agreed for the pulmonary embolus to be treated in hospital, in the hope that they could be discharged once stable, but their condition deteriorated and they died in hospital.

There was a period during A's admission when their medication was stopped while clarification was sought as to their treatment plan. C complained about the clinical decision-making regarding A's care and treatment. C considered that failings in A's care and treatment led to their death in hospital, denying them of the right to be cared for at home. C also complained about the board's communication.

We took independent advice from a consultant physician. We noted how difficult this case was, in particular from the perspective of the family. Although we noted certain areas of care that could have been better, we considered that overall the standard of care and treatment was reasonable and that A was nearing the end of their life by the time of their admission. We did not consider that the outcome would have been different had there not been a period of time during which medication was withdrawn pending clarification of A's treatment plan. Therefore, we did not uphold this complaint.

We noted that a number of physicians were involved in A's care and treatment and that there had been a degree of uncertainty about A's treatment plan. Although some aspects of communication could have been better, we considered that the clinicians did their best to communicate to A's family how ill A was and to have appropriate discussions with them around resuscitation and escalation. Therefore, we did not uphold the complaint about communication.