Decision report 201201225

Summary

Mrs C complained about the care and treatment given to her late mother (Mrs A) in hospital over a two day period. Mrs A was elderly, had been unwell and was deteriorating. Mrs C said she had spoken to her mother by phone late on the afternoon of the first day, and she had sounded well. However, Mrs C received a call the next morning to say that Mrs A had deteriorated rapidly and that she should come to the hospital. Mrs C then spoke over the phone with an out-of-hours GP who was treating Mrs A. The GP advised Mrs A that he felt it would not be appropriate to transfer Mrs A to an acute unit, and that ensuring her comfort and dignity was the priority at that stage. Mrs C complained to us that she felt an opportunity to provide Mrs A with further treatment was missed. She said that though she understood Mrs A was nearing the end of her life, she was concerned that there was a lack of appropriate care and treatment over the two days.

We obtained independent medical, nursing and GP advice from our medical advisers in order to reach a decision on Mrs C's complaint. We found that, although it may have been reasonable to reduce the number of observations carried out on Mrs A due to the type of care she was receiving, this was not recorded in her care plan, nor was there evidence of this having been discussed with Mrs A or her family. We noted that clinical observations taken a couple of days before were inappropriately recorded as 'low', and there was then a

60-hour period during which no observations were made. We took the view that the Modified Early Warning Score (MEWS - a guide used to quickly determine the degree of illness of a patient) had not been used correctly and, although there was no suggestion that the eventual outcome for Mrs A would have been different, we found that her care in this regard was not reasonable.

We did find that the care provided by the GP following the discovery of Mrs A in an unresponsive state was appropriate, reasonable and patient-centred. Mrs C had felt it was inappropriate and distressing that he had discussed these matters over the phone, although the board said that they had phoned Mrs A earlier to advise her to attend the hospital immediately. Mrs C disputed this. We could not reach a definitive conclusion about this, although we noted that in the circumstances there did not appear to have been any alternative and that the GP handled a difficult situation well. On balance, however, giving regard to our findings in relation to the lack of observations, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C in writing for the failures identified in Mrs A's care; and
• consider adopting a weighted scoring system to identify patient deterioration in place of the 'as required' use of the MEWS system, as detailed in National Early Warning Score (NEWS): Standardising the assessment of acute illness severity in the NHS.