Decision report 201200974

Summary

Mrs C complained that the care and treatment provided to her late mother (Mrs A) was not reasonable. She particularly complained about lack of pain relief, inadequate palliative (end of life) care, and communication failures. Mrs A, who was 94, had been admitted to hospital after a fall at home. On examination she was found to have a tumour in her chest. She was treated for her pain and for urinary back-up (where urine passes back up into the kidneys) but otherwise her care was non-interventional. Mrs A's condition deteriorated and she died two days later.

During our investigation we took independent advice from two advisers, a medical and nursing adviser. Both advisers considered that the care and treatment provided to Mrs A was reasonable and that appropriate and timely actions had been taken to monitor, review and address her pain. Urinary back-up is a common symptom in elderly patients and Mrs A's treatment for her pain may also have contributed to this. The medical adviser was of the view that appropriate action was taken to address this problem, and we did not uphold Mrs C's complaints about care and treatment.

The board acknowledged and apologised for communication failures between staff and the family. They reviewed the provision of palliative care in their region and additional training, including communicating with patients and families, has either taken place or is on-going. In view of this, although we upheld this element of the complaint, we did not need to make a recommendation.