Decision report 201101313

Summary

Ms C complained about the care and treatment that her late father (Mr A) received in hospital before his death. She said that staff failed to recognise and manage her father's pain and to act on her concerns about this. During our investigation, we took independent advice from one of our medical advisers. We found that there was no evidence in Mr A's medical records to suggest that he was in pain, and there was evidence that staff had recognised and acted on Mr A's agitation.

Ms C also said that Mr A was left sitting in a chair that he could not get out of unaided. Although our investigation found that the times that Mr A was in the chair were not recorded, our adviser said that it was reasonable for staff to get him out of bed, as moving and being in an upright position would have helped to prevent complications such as chest infections and venous thrombosis (a blood clot forming in a vein).

Finally, Ms C complained that a junior doctor did not pass on or discuss her concerns with senior colleagues and that she had difficulty in being able to speak to senior doctors. We did not find any evidence that this was the case. However, we did find that staff did not make it sufficiently clear that Mr A was dying before he was discharged from the hospital. We also upheld Ms A's complaint that staff delayed in responding when Mr A's family and carer used the assistance buzzer.

Recommendations

We recommended that the board:

• consider whether they should provide training to staff on giving difficult messages / bad news to patients and families; and
• provide confirmation that the nurse call system is now set at a volume that nursing staff can clearly hear.