A grandmother in her 90s died at University Hospital of Hartlepool without her family by her side following an administration error in recording loved ones’ contact details.
The woman, known only as Mrs W, was admitted to the hospital after suffering a fall at her home, but just one family phone number was added to her records.
Staff had made reasonable attempts to contact the family when the woman’s condition deteriorated, although they could have contacted Social Services.Parliamentary and Health Service Ombudsman report
A number of different doctors saw and treated her for a urinary tract infection, but just over two weeks later, the pensioner developed a clostridium difficile infection, an inflammation of the large intestine.
Treatment for the condition by staff was not successful, and after five days she was given a different course.
The woman’s condition then deteriorated and staff tried to contact her family.
However, there was no answer from the only telephone number that had been noted in the records by staff following an administration error.
Staff contacted police, who went round to the woman’s son’s house, only to find he was away on holiday at the time.
The woman died during the night.
Following her death, the woman’s family made a formal complaint about what happened.
A report into the complaint, detailed alongside hundreds of others against health trusts and compiled by the Health Service Ombudsman and released today, found that it was not upheld by the watchdog.
It said: “Staff had made reasonable attempts to contact the family when the woman’s condition deteriorated, although they could have contacted Social Services.
“But nurses had poorly completed the initial documentation and had not recorded two contact numbers for the family, as they should have done.
“The assessment of Mrs W’s needs when she was admitted was also inadequate; appropriate care plans were not put in place; and the risk assessment of her nutritional needs was wrong.
“However, staff had completed other risk assessments and had monitored Mrs W as they should have.
“The care Mrs W received from doctors was also in accordance with established good practice.
“Following our investigation the trust had already apologised for the failings we had identified and had taken action to prevent similar failings from happening again.
“We did not therefore make any recommendations.”
A spokeswoman for North Tees and Hartlepool NHS Foundation Trust said: “We take matters like this very seriously and have already made significant changes and improvements to ensure, as far as humanly possible, this type of situation does not happen again.”