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Trust to pay £750 to family of malnourished pensioner who died in ‘discomfort and distress’

Ombudsman finds evidence of failings including 'maladministration' after grieving daughter's complaint

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An 83-year-old woman suffered “discomfort and distress” in the last weeks of her life due to her care and treatment at Craigavon Area Hospital.

An investigation has found a number of failings by the Southern Health Trust in relation to the treatment of the pensioner.

They came to light after a complaint made by the woman’s daughter, who wrote to the Northern Ireland Public Service Ombudsman Marie Anderson.

Having carried out her investigation, the Ombudsman has submitted her findings in a detailed 41-page report.

And she ordered that the Trust issue an apology to the family of the pensioner, along with £750 in compensation “in respect of the injustice” experienced.

The pensioner’s daughter said she had sustained injustice as a result of “maladministration by the Trust and failings in its exercise of professional judgment in relation to the provision of health care to her late mother”.

In particular, she complained about the care and treatment received in Craigavon Area Hospital over a two month period – between April 6 and June 6, 2014, when she sadly passed away.

Her elderly mother had been transferred to Ward 1 South at Craigavon on April 10, 2014.

Her daughter said when her mother had been admitted to the ward she was on a diet of soft food and drinking normal liquids.

She complained that on April 9 – the day before she was transferred to Ward 1 South – the diet was modified by her medical team to thickened liquids without prior consultation with the speech and language therapist.

She complained about the poor nutritional care and treatment her mother received on the ward which she believes contributed to her significant weight loss and may have accelerated her death.

The woman also complained about the nursing care and treatment her mother received.

She claimed that nursing staff attempted to artificially feed her mother without sedation on one occasion, which was against the instructions of both her mother and her mother’s medical team.

Ombudsman Marie Anderspn upheld the complaint, saying she had carefully considered all of the issues, together with the Trust’s responses, the patient’s medical notes and records and the advice of a number of independent professional advisors.

She said she had considered the principles enshrined in the European Convention for the Protection of Human Rights and Fundamental Freedoms (ECHR) and the European Social Charter (ESC).

The Ombudsman found: “The ESC enshrines the right to the protection of health and contains specific provisions relating to older people. The right to health is intrinsic to the right to life (article 2 of the ECHR) and the right to private and family life (article 8 of the ECHR). This guarantees physical and psychological integrity and prohibits non-consensual medical treatment.

“I consider that in attempting to insert a NG tube without sedation against the patient’s stated wishes and in failing to address her nutritional needs in a more timely manner, the Trust did not have sufficient regard for her rights.”

She also said that while “earlier intervention may not have prevented” the death of the pensioner, whose health had been declining for a number of years, but it “may have alleviated her discomfort and distress in the last weeks of her life”.

Ombudsman Anderson continued: “I am mindful also of the distress of her family who witnessed their mother dying in a malnourished state. I note that the complainant seeks an improvement in patient care.

“I sincerely hope that, on reading my findings and recommendations, the complainant and her family will be reassured that their main issues of concern have been carefully and fully investigated, and further that the Trust will have learned important lessons from this complaint to the benefit of patient experience in the future.”

The Ombudsman, from her investigation, said she had found failures in care and treatment with regard to the triaging of the speech and language therapy referral, failure to provide adequate nutritional care and treatment to the patient, and failings with regard to some aspects of nursing care and treatment.

She continued: “I have also identified instances of inadequate record keeping which constitutes maladministration. I consider that the Trust had a number of opportunities to provide adequate and timely nutritional care and treatment to the patient. In this respect her medical team failed to supplement her nutrition at an earlier stage.

“I am satisfied that, as a result of these failings, she suffered the injustice of loss of opportunity, upset, distress and discomfort.

“I am also satisfied that the complainant and her family suffered the injustice of upset, distress, uncertainty and frustration in dealing with these issues.”

The Ombudsman recommended that the Trust provide herself with an action plan within three months specifying how the failings identified will be shared with the medical and nursing teams involved in the patient’s care.

She added: “The Trust should also ensure that the agreed plan of care is readily available to all medical and nursing staff and remind staff that they must consult the plan and adhere to its requirements before treating a patient.

“I have observed that the main dietetic notes are held separately from the clinical and nursing notes and that this may have been a factor which contributed to the failings I have identified in this case.

“I therefore ask the Trust to report to me on progress towards the goal of maintaining a single patient record for all patients in Northern Ireland.”

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