Decision Report 201903759

Summary

C held power of attorney for their parent (A) and complained about the management of A's medication during a hospital admission for treatment of a chest infection. A's medication Furosemide and Ramipril (both used to treat heart failure) were stopped for eight days. A was readmitted to hospital again having suffered a heart attack and died.

The board acknowledged it was not recorded who stopped A's medication and why they did so, and that there were failings in how A's medication was reviewed and managed prior to discharge.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly). After review of relevant medical records and statements, we found that while it may have been reasonable to stop A's medication at the time, there was a failure to record who made the decision and their rationale for the decision.

We also found the board did not give adequate consideration as to whether the cessation of A's medication may have had an impact on A's readmission, further heart problems and subsequent death.

We also found that A's discharge letter was not appropriately updated prior to discharge. We upheld three of C's complaints, however we concluded that the board's communication with C about the changes to A's medication was not unreasonable in the circumstances and this complaint was not upheld.

Recommendations

What we said should change to put things right in future:

• Individual staff, particularly the consultant responsible for A's care, should show they have included this complaint in their annual appraisal as part of reflective practice.
• That it has been considered whether the failures relating to the management of A's medication had an impact on A's need for readmission and ultimate death.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.