Annual Report 2007-08 - the Parliamentary and Health Service ...

20Case StudySerious failings highlighted needfor review of careMr Z, aged 74, was admitted to Gloucester Royal Infirmary as anemergency in August 2002 with pneumonia. He was treated in theIntensive Treatment Unit until the end of August when he wastransferred to a respiratory ward. He later contracted MRSA,developed diarrhoea and was found to be infected with C.difficile.Mr Z was transferred to Standish Hospital at the start of October,where he suffered with recurrent C.difficile infection. Mr Z died inNovember 2002, with the cause of death noted as respiratory failure.Mrs A, Mr Z’s daughter, questioned whether the Trust’s actions hadcontributed towards his deterioration and death through failings inhis care and inadequate levels of hygiene. She also questioned theaccuracy of the death certificate. Mrs A believed that Mr Z had beencaused undue suffering and stress during his admission and that theirfamily had been caused unnecessary distress.Mrs A complained to Gloucestershire Hospitals NHS FoundationTrust (the Trust) in March 2003, which responded in July 2003.A local resolution meeting was held in August 2004. Mrs A wasunhappy with the action taken by the Trust and complained tothe Healthcare Commission in October 2004. After conductingits own investigation, the Commission said in May 2006 that itwould take no further action as it was satisfied with the Trust’sactions and responses. Mrs A asked us to investigate all aspectsof her complaint against both the Trust and the Commission.Although we did not uphold complaints about specific aspectsof Mr Z’s medical care, we found that, when taken in the round,the evidence we saw pointed to serious failings in the Trust’s serviceto Mr Z and his family. These included a lack of monitoring whileMr Z waited to be transferred from the Intensive Treatment Unitand a delay in carrying out a medical review. We also found therehad been extremely poor nursing care in relation to care planning,communication, pain management, infection management, patientprivacy and dignity, and monitoring of fluid intake/output.We concluded that Mrs A’s complaint should have prompteda wider review of nursing care which may have led to a moreco-ordinated approach to implementing improvements and, inturn, provided reassurance for Mrs A that her complaint was beingtaken seriously. We found maladministration in the Commission’shandling of Mrs A’s complaint, including failure to seek clinical advice,not providing her with regular updates and failure to assess thepriority of the case, which had exacerbated her worry and distress.The Trust agreed to write to Mrs A and her family to acknowledgeand apologise for the failings identified, and to review the areaswhere there had been serious failings. It agreed to provide Monitor(the body that authorises and regulates NHS Foundation Trusts) withinformation to demonstrate that its practices in the areas where wehad identified serious failings were in line with current standards, andto report back to Mrs A on the action taken in response to ourrecommendations. The Commission agreed to write to Mrs A and herfamily with an apology and pay £250 compensation in recognitionof the worry and distress caused by its poor complaint handling.44