Payout to family after watchdog identifies failings over woman's care

Dudley Group NHS Foundation Trust has now been ordered to make the payout to relatives who went through the agony of watching their mother pass away.

NHS watchdog, The Local Government and Social Care Ombudsman, found there were failings in the woman’s care both in hospital and at different nursing homes.

It also criticised how formal complaints by the family were handled by the trust and also in a subsequent safeguarding investigation and review by Dudley Council which was only finally concluded in April 2019.

But the health watchdog ruled the hospital and its staff were not ultimately responsible for the death of the unidentified patient, known only as Mrs D, in March 2015.

Dudley Council will pay Mr D’s family £500 for the delays in its safeguarding investigations and another £500 will be paid by a care home for the family’s distress.

A further £250 will paid by the home’s local GP surgery for its fault in handling a complaint by Mr C.

A complaint into the death was raised by the woman’s son, known as Mr C, who claimed the NHS trust should not have discharged his mother and her subsequent treatment in the care homes caused her unnecessary pain and distress.

Mrs D was first admitted to hospital in October 2014 after suffering a stroke and over the next five months she was readmitted twice as her health deteriorated.

After a third admission she was finally discharged to a hospice where she later died.

Saying no one explained to her family that she was unlikely to survive, the ombudsman stated: “The trust missed the opportunity at all the admissions to have an open conversation with the family about Mrs D’s poor prognosis.

“I consider this caused confusion among Mr C’s family about Mrs D’s health and potential for recovery.

“This is linked to the trust’s missed opportunity to consider a palliative approach to manage Mrs D’s complex health needs in the second and third admissions.

"On the balance of probabilities, palliative care would have reduced some pain and distress Mrs D suffered."

He added: “Mr C and the family suffered distress at witnessing Mrs D’s pain and distress.”

In addition, he said the trust had also failed to provide detailed care plans to the nursing homes causing confusion and delays in her care.

Ordering Dudley Group NHS Foundation Trust to pay Mrs D’s family £1,000 for the distress they had suffered the ombudsman said it must also ensure it creates care plans in line with the Royal College of Physicians for patients when it discharges them to a community setting.

He also ordered it create an action plan to improve the way it communicates a patient’s poor prognosis with families.

Responding to the ombudsman’s report, Diane Wake, chief executive of the Dudley Group NHS  Foundation Trust, said: “This finding which related to a case from five years ago demonstrated problems across the whole care system but in which the Dudley Group had some important lessons to learn.

“We are committed to providing the best possible care for our patients and to learning from all and any occasions where we fall short.

“Our care plans and systems of communication have changed in the five years since this case and we have met with the complainant to apologise fully for the shortfalls identified at this trust and the distress caused to him and his family."

Dudley Council cabinet member, Councillor Nicolas Barlow, who oversees health and adult social care, said: “We accept the findings of the report and acknowledge that although our safeguarding process was lengthy and complex, it was found to be “thorough and robust” by the Ombudsman.

“It’s really important we ensure all our residents receive appropriate care and support and in this case, we believe we maintained an appropriate offer of care to the resident.

“We have since offered our condolences to the family and apologised for the length of time it took to complete our safeguarding investigations.

"We have put measure in place to improve the way we work to avoid similar instances in the future.”