Hospital criticised over care

A hospital trust in the Thames valley has been criticised over their care in a report

A Thames Valley man was left to die alone - after hospital staff ignored his family's request and turned his life support machine off.

Heart's found out Oxford John Radcliffe Hospitals is one of 10 trusts criticised in a report out today into the care of older people in the NHS.

The investigation by the Health Service Ombudsman found his machine was turned off when his family were out of the room calling relatives.

Health Service Ombudsman, Ann Abraham, says the NHS is failing to treat older people with care, compassion, dignity and respect. The report, Care and compassion?, is based on the findings of ten independent investigations into complaints about the NHS in England, including Oxford Radcliffe Hospitals NHS Trust.

The Case:

Mr C was admitted to Oxford Radcliffe Hospitals NHS Trust for heart surgery. The surgery took longer than anticipated and for five hours Mr C’s wife and daughter were alone in the waiting room desperately trying to get information on his condition. Two hours after the surgery Mr C had a heart attack and was placed on a ventilator. Unknown to the family a ‘Do not attempt resuscitation ’ note was made on his medical records. A nurse would later tell Mrs C and her daughter that he had ‘flatlined ’ and was only being kept alive by the life support machine. Distraught, Mrs C wanted to telephone her sons. She expressly asked for the machine not to be turned off while she and her daughter made the call. When they got back, the life support machine had been switched off. Mr C’s daughter said that she had wanted to sit and pray with her father.  Because she had not been able to do this, she felt that she had failed him.

The investigations covered in the report are not isolated cases. Of the nearly 9,000 properly made complaints to the Ombudsman about the NHS last year, 18 per cent were about the care of older people. The Ombudsman accepted more than twice as many cases for investigation about older people as for all other age groups put together.

The full report will be available from the Health Service Ombudsman’s website  from 00.01 on 15 February 2011

Elaine Strachan-Hall, Chief Nurse at the Oxford Radcliffe Hospitals NHS Trust told Heart: "It is always our intention to make sure that patients’ families are kept fully informed about the care of their loved one. The Trust’s practice in 2007, at the time of this case, was to make sure that any ‘do not resuscitate’ decisions were discussed with the family so that they could fully understand how a decision was reached. In this instance, it seems that this procedure was not followed and we are very sorry that this was the case.

 

“Since this case, the Trust has apologised to the family for the distress that was caused by the lack of communication. We have reviewed our practice and introduced a Trust-wide policy called the Liverpool Care Pathway to guide staff on end of life care. Further training has been introduced for both nursing staff and junior doctors in this area. The sorts of issues that were raised in this particular case about communication between the clinical team and relatives are now specifically included as part of our staff training.

“If patients or their relatives ever feel that our care has fallen short of our high standards, then we welcome their comments, because it is through their feedback that we are able to improve our services.

 

"I am sorry that we were not able to resolve the issues with the family in this case and that ultimately they felt they needed to raise them with the Health Ombudsman. We accept the comments made by the Ombudsman and have moved already to learn from this particular case.”

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