We investigated a complaint from Mr A about his grandmother, Mrs B’s, hospital care in January 2024. The investigation specifically focused on whether the accepted lack of observations following Mrs B’s admission to hospital significantly impacted her condition, and whether communication with Mr A, his father (Mr C) and his grandfather (Mr F) by staff at the Hospital was appropriate, prior to, and following, the death of Mrs B.
The investigation found that Mrs B received an appropriate level of clinical care given the challenges of treating her in light of the presence of multiple health conditions. However, there was a lack of action or escalation of care when her NEWS (a system to identify deterioration in a patient) was raised, which was contrary to expected practice. This was a service failure. However, the lack of observations/escalation did not significantly impact on Mrs B’s condition and did not contribute to her deterioration or death. This complaint was not upheld.
The investigation found that communication with Mr A, Mr C and Mr F during Mrs B’s admission fell short of expected standards. The standard of communication following Mrs B’s death was also of concern. Despite telling Mr A in its complaint response that Mrs B expressed a preference for her sister to be contacted as opposed to her husband (who was the documented next of kin) and son, there were no corresponding entries in Mrs B’s records to support this, which was contrary to expected practice. This lack of contemporaneous records was contrary to the requirements of expected nursing standards. This amounted to maladministration and meant there was an inappropriate delay in informing Mr A, Mr C and Mr F about her poor prognosis and death. As a result, it is likely that they missed an opportunity to see Mrs B before she died. This was an injustice and this complaint was upheld.
The Health Board agreed to apologise to the family for the serious communication shortcomings and to acknowledge the impact on them of the missed opportunity to see Mrs B before she died; discuss the report with relevant staff involved in Mrs B’s care to reflect on the communication shortcomings and reinforce the requirements of relevant guidance about family communication; review whether its nursing documentation clearly allows staff to record communication preferences and to review complaint handling practices.