Buckinghamshire Healthcare NHS Trust

4. Ms T complains about aspects of the care and treatment provided to her partner Mr S by Buckinghamshire Healthcare NHS Trust (the Trust) at hospital A from 4 July to 17 August, when he died. Ms T raises a number of concerns regarding aspects of care while Mr S was on Ward X, and a lack of communication with her. Her specific concerns are that there was:

· a lack of encouragement for Mr S to mobilise · inconsistency with Mr S’s hydration and food intake · a lack of attention to Mr S’s personal hygiene needs · a lack of compassion to end of life care for Mr S, and his relatives · a discrepancy about the time of Mr S’s death

5. Ms T says Mr S did not receive appropriate care and treatment in the last weeks of his life, and she was distressed to witness that he was not treated with kindness and compassion. She says it was never communicated to her that he was near the end of his life, which added to her distress, as she fully expected him to return home. Ms T also says she was not informed that he had died when she attended the hospital on 17 August, resulting in her experiencing severe shock and distress when she found him dead in his bed.

6. Ms T says her grieving is intense and protracted due to not being informed of Mr S’s deteriorating health, not being prepared for, or notified of, his death and witnessing his poor end of life care.

7. As an outcome Ms T is seeking an acknowledgement of her concerns, service improvements, and a financial remedy.

8. On 4 July, Mr S was admitted to Ward Y at hospital A, following a fall at home on the previous day. Mr S had primary progressive Multiple Sclerosis (MS). This is a condition that affects a person’s movement and balance. The NHS website explains the nature of primary progressive MS means symptoms continuously get worse and are always present, although there are often periods where the condition appears to stabilise.

9. Upon his admission, a nurse saw Mr S alert in bed and gave him his prescribed medication. They washed him in bed and identified he should be repositioned regularly. They noted he had declined breakfast that morning but appeared comfortable. The same nurse checked on Mr S four hours later and recorded his blood pressure, and National Early Warning Score (NEWS). This is used for early identification of clinical problems. They helped him drink and encouraged him to continue drinking.

10. A neurology consultant also visited Mr S. They recorded he was confused and struggled to follow complex instructions. They referred him to a physiotherapist to help with his mobility.

11. Staff transferred Mr S to Ward X on 5 July. Ward X specialises in caring for people with long-term conditions and looks after patients who are recovering from falls. The admission nurse identified he needed some help eating and drinking and transferring to and from his bed. On 6 July, a nursing assistant checked on Mr S and recorded he was incontinent. They encouraged him to eat and drink and recorded that he was confused trying to get out of bed.

12. An occupational therapist (OT) visited Mr S later that day, and recorded he was likely to need a package of care and equipment at home before they could discharge him. An occupational therapist works with patients who have difficulty completing everyday tasks. They look at what activities are challenging and agree different approaches or adaptations to make them easier. The OT agreed to review Mr S in the future, along with a physiotherapist.

13. When the physiotherapist saw Mr S they assessed his mobility and established a ‘baseline’. His right leg was moderately strong, but his left leg was very weak. This meant Mr S was unable to stand or mobilise easily, so they prescribed him some exercises and equipment to help with this.

14. Nursing care continued throughout the following days and weeks. This included help with repositioning, and also eating and drinking. Nurses typically recorded he was ‘well in bed’ throughout this period.

15. When an OT visited Mr S again on 10 July, they found his mobility was below the baseline established days prior. They also identified his cognition had decreased and he needed help with his daily activities. The OT decided to liaise with social services and Ms T to agree to a package of care. They also spoke to a physiotherapist about Mr S’s mobility problems, and a physiotherapist reviewed him later that day. They referred Mr S to a neurologist for review.

16. A specialist MS nurse visited Mr S on 11 July and recorded in the notes that Mr S should be referred to a dietician for a nutritional assessment. At the ward round later that day the doctor planned to help Mr S mobilise more and continue with the input from occupational therapy and physiotherapy. This was with a view to sending Mr S home. The next day a neurological physiotherapist found Mr S could only stand for five seconds using a frame and needed staff to help him moving to and from his bed.

17. Visits from nurses, social services, and neurology consultants continued. They identified that Mr S needed help with all food and drink intake and did not initiate it himself. This meant he was at risk of dehydration and ongoing urinary tract infections. Despite this, he was typically sat upright in bed and comfortable. Notes from doctors show they still intended to send him home when the right package of care was arranged.

18. On 20 July, a doctor recorded that Mr S was ‘fed up of being in the hospital’. His physical health was getting worse in terms of his mobility, and his mental health was declining too.

19. On 23 July, a psychiatrist visited Mr S and performed a MoCA cognitive assessment. This is designed to help medical professionals diagnose and measure the difficulties a patient is having with their thoughts. Mr S struggled to complete the test and so the psychiatrist referred him to the hospital’s Psychiatric In Reach Liaison Service (PIRLS).

20. PIRLS visited Mr S the next day. They considered he may have delirium, and he was unsure of where he was and current events. They also formed the impression Mr S experienced a background level of depression due to his MS. Ms T disputes this diagnosis and says Mr S told her not to let him die in hospital.

21. Until now, nurses had been able to help Mr S eat and drink, albeit with encouragement. However, on 25 July he began refusing oral intake. They put measures in place to remedy this, such as giving drinks in a beaker rather than with a straw. His food intake fluctuated over the following days.

22. A physiotherapist visited Mr S on 31 July, and Mr S declined to take part in an assessment or to speak about his mobility. However, when PIRLS visited Mr S on 1 August they found him ‘brighter in mood’. He kept eye contact and tried to answer questions more than previously. They recorded his anti-depressant medication had been increased to 50mg, and no further input from PIRLS was required at that time.

23. A nurse and doctor visited Mr S early in the afternoon and set up a plan to encourage him to eat and drink more. A physiotherapist also visited and helped Mr S exercise, despite his difficulty engaging. They asked nursing staff to help transfer Mr S from his bed to the chair in the future, and there was a hoist available to do this.

24. Over the next week, nurses continued to help Mr S with his meals and give him the prescribed medication. He was often found comfortable in bed and so they attended to his pressure area care. Doctor notes record he was medically fit for discharge, but this did not happen because the package of care Mr S needed at home was not in place. This was because he was ineligible for Continuing Healthcare funding.

25. On 9 August, a doctor recorded that Mr S was having difficulty swallowing water. They decided to speak to Ms T about the options that were available to help Mr S and arranged to have a more detailed conversation about it the next day.

26. When the doctor spoke to Ms T they explained that Mr S’s condition was declining. Mr S was dehydrated but unwilling to receive artificial rehydration. The doctor explained the options available, and Ms T wanted to discuss these with her daughter.

27. Notes show that Mr S ate and drank small amounts over the next few days. Ms T visited Mr S on 12 August, and says he was very thirsty and told her he had not drank since the day before.

28. On 13 August, a doctor recorded that Mr S was unwilling to take food or drink orally. They escalated the care plan to keep Mr S comfortable but to cease observations. Mr S denied having any pain and staff still aimed to discharge him if possible.

29. On 14 August, a doctor visited Mr S who was asleep in bed, and his family were not present. The doctor signed a ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) form and arranged to alert a more senior doctor. A DNACPR form advises care staff they should not try to artificially resuscitate the patient using chest compressions, otherwise known as CPR. It is often put in place when CPR would be ineffective or cause long lasting injuries and a poor quality of life. A consultant signed off the DNACPR the next day.

30. Another doctor tried to speed up returning Mr S home. As such, they asked for an OT’s involvement, who arranged to speak with Ms T. On 16 August, a consultant telephoned Ms T at home and had a conversation about resuscitation. They explained the DNACPR decision and asked what she wanted staff to do if Mr S’s condition deteriorated. Ms T said that she wanted Mr S discharged home and the consultant advised her to speak to the discharge officer the following day.

31. On 17 August, a nurse telephoned Ms T to advise that Mr S’s breathing had deteriorated. Ms T offered to attend the hospital and the nurse agreed this was a good idea. Within an hour Ms T arrived at the hospital and entered the ward. She says that a member of staff led her to Mr S’s bay on the ward and drew back the curtains. She says they did not speak to her and left her with Mr S. Ms T sat with him and noticed he was not breathing or moving, she checked his pulse and realised he had died.

32. She was very shocked and upset. She sat with him and held his hand. A nurse came in later and gave her a leaflet explaining what to do next. Ms T says she was too shocked to take anything in, so she left the hospital in a very distressed state.

Encouragement to mobilise

36. Ms T complains staff on Ward X did not properly help Mr S to mobilise during his stay, between 5 July and 17 August. She says that whenever she visited the ward, she found Mr S sat on his chair or in his bed and was unhappy staff did not help him exercise as she believes they should have done.

37. Throughout this investigation we have used NICE guidance to inform our understanding of what should have happened. NICE is an organisation responsible for producing standards that doctors, nurses and other staff in care settings use. It is a nationally recognised organisation, and its guidance is widely adopted throughout the NHS. It publishes evidence-based guidance on a range of specialist topics, and for this reason we are satisfied it is appropriate.

38. NICE guidance Multiple Sclerosis in Adults sets out how staff should care for people with MS. It says that care staff should ensure people with MS and mobility problems have access to an assessment that establishes individual goals and ways to achieve them. These assessments usually involve rehabilitation specialists and physiotherapists with expertise in MS.

39. Nursing staff should also follow The Code. This is a set of broad guidelines published by NMC. Point 2.5 says nurses should ‘respect, support and document a person’s right to accept or refuse care and treatment’.

40. The medical notes show the physiotherapy team saw Mr S regularly during his stay in hospital. They assessed him several times between 6 July and 1 August, although he occasionally declined their involvement. The physiotherapists found he was independently mobile before admission, but by the time he arrived on Ward X he needed two people to help him sit, stand, and move between the bed and chair.

41. The physiotherapy team referred Mr S to different specialists, such as occupational therapists, to help find ways to overcome his mobility problems. The care team planned what support he needed in hospital and at home. Mr S had the support of nurses to help him move between his bed and the chair. This was in line with recommendations a physiotherapist made on 12 July.

42. On 1 August, a psychiatrist saw Mr S and assessed his mood. They found he struggled to follow basic commands and did not fully understand what the therapy staff offered. Throughout Mr S’s stay on Ward X, nursing care staff followed the advice of the physiotherapy team. They helped Mr S move between the bed and chair and did so using the appropriate techniques and equipment.

43. The Trust’s investigation set out that Mr S was chronically fatigued and in a low mood. It found this prevented him from fully engaging in the physiotherapist’s exercise plan. In the Trust’s complaint correspondence, it reflected on the care its staff gave to Mr S and recognised it could have spoken to Ms T about his reluctance to engage. The Trust acknowledged this may have improved the likelihood that Mr S continued to exercise and mobilise regularly.

44. Our expert adviser explained that that nursing staff had to reach a balance between mobilising Mr S, in line with his care plan, and respecting his wishes. Having considered the relevant evidence we have found that the nursing staff successfully reached the balance between mobilising Mr S in line with NICE guidance and respecting his wishes according to The Code.

45. We are pleased to see the Trust’s investigation acknowledged it could make improvements to aspects of physiotherapy care on Ward X. It therefore put several service improvements in place. The ward is now a therapy nurse led unit, and staff encourage patients to sit out and mobilise as much as they are able. Additionally, it has implemented a ‘Get Up, Get Dressed, Get Moving’ policy. This aims to encourage patients to get out of bed as soon as possible.

46. It has also put in place improvements that address the specific circumstances of Ms T’s complaint. Where patients do not engage with therapy or nursing staff, they will seek the support of next of kin as soon as possible. This aims to help the patient engage with their exercise regime sooner. This is a positive change brought about by Ms T’s complaint.

Hydration and food intake

47. Ms T complains that staff at the Trust did not properly manage Mr S’s food and fluid intake during his hospital stay between 4 July and 17 August.

48. NICE guidance Nutrition Support for Adults sets out how staff should identify and resolve any problems patients have with eating and drinking. To identify problems, all hospital inpatients on admission should be screened. Screening should be repeated weekly for inpatients.

49. Screening should assess body mass index and the amount of unintentional weight loss. It should take into account how long food and drink has been reduced, and the likelihood of impaired nutrient intake in the future. The Malnutrition Universal Screening Tool (MUST) can be used to do this. MUST quantifies how malnourished, or likely to become malnourished, someone is. A score of zero is low risk, one is medium risk, and two or more is high risk.

50. The guidance also sets out that staff should ensure they provide enough quality food and fluid. They should also provide the appropriate support to help patients eat and drink comfortably. This support should include eating aids as well as support from a multidisciplinary team, if appropriate.

51. We have also considered Essence of Care 2010 Benchmarks for the Fundamental Aspects of Care (Benchmarks for Food and Drink). Factor 7 says that staff should assess the level of assistance patients need when they are admitted to hospital. It says staff should provide this help and it specifies food and drink should be accessible for patients.

52. Ms T explained that when she visited Mr S on 12 August, he was so thirsty he drank two and a half beakers of orange squash with her help. When she visited the following evening, the drink from the previous day was still at his bedside. He explained he had not drunk since she left. Hospital notes show Mr S was reluctant to drink, but Ms T’s account demonstrates otherwise on this occasion.

53. She says that on nearly every visit she found his beaker was empty, and once saw it had fallen to the ground when he had unsuccessfully tried to give himself something to drink. She says on one occasion she found staff had given Mr S a straw to help him drink. However, a sign displayed above his bed said that he was unable to use them effectively. She believes he was malnourished, and says his appearance changed significantly during his stay in hospital, so he appeared to be just ‘skin and bones’.

54. Mr S’s records include the MUST tests that staff did. They also include daily food and fluid intake charts, as well as a fluid balance chart. These show what he ate and drank, and how much he managed to have.

55. We have identified several inconsistencies within the records. On 21, 22, and 30 July the notes record that fluids were within Mr S’s reach. Our adviser has explained having them within reach was irrelevant, as the neurophysiotherapist’s advice on 16 July says Mr S does not initiate independent fluid intake.

56. In corroboration with Ms T’s account of events, the notes show that on 25 July a nurse advised that Mr S cannot use straws, and all drinks should be in a beaker. Despite this, on 7 August, a doctor advised that staff should give Mr S straws to help him drink.

57. Additionally, there is no record that staff completed a nutritional needs assessment for Mr S in line with the Essence of Care 2010 Benchmarks. On 10 August, staff recognised that Mr S preferred sweet foods. After this date, staff offered more sweet food and Mr S’s nutrition intake increased.

58. Finally, on 11 August, the MS Specialist Nurse recorded that Mr S needed a referral to a dietician. They nurse did not complete this referral nor leave specific instructions for someone else to complete it. The Trust’s complaint investigation has acknowledged this should have happened and agreed that someone should have made the referral based on its internal policy.

59. We do acknowledge that on numerous other occasions staff did help Mr S to drink. Likewise, Mr S regularly declined food and drink and although the nursing staff encouraged him, they respected his right to refuse. They also completed the recommended MUST assessments properly.

60. However, the examples above demonstrate the overall nutritional care Mr S received at the Trust was below the appropriate level set out in the guidance despite individual nurses trying to meet his needs. Ms T says her experience of Mr S’s care meant that she worried about him frequently and this caused her distress.

61. The Trust’s investigation did not find it fell below the guidance set out in national standards but did acknowledge staff should have referred him to a dietician, in line with its internal policy. As this did not happen, the Trust upheld Ms T’s complaint and made some service improvements.

62. Specifically, Ward X has sought further training and support from the dietician, nutrition specialist nurse, and speech and language therapists since Mr S’s death in order to prevent similar problems happening again in the future. Its complaint response also explains the Trust now inspects nutrition compliance on an ad hoc basis. It also conducts teaching sessions on the ward to highlight the risks of malnutrition.

63. Further, the Ward now has a nutrition folder that records patients’ dietary requirements and the help they need with eating and drinking. All patients now have food charts to monitor their intake and they are weighed weekly to monitor any weight loss. The Trust has advised any concerns are escalated accordingly.

64. We welcome the service improvements to stop similar problems happening again in the future, but do not this consider that this resolves Ms T’s individual impact. For this reason, we have set out the recommendation we have made at the end of this report.

Attention to personal hygiene needs

65. Ms T complains that care staff on the ward did not properly attend to Mr S’s personal hygiene needs. She says they did not clean his teeth or shave him as she would expect. She says this demonstrates staff did not show enough compassion for Mr S when caring for him.

66. Point 1.1 of The Code says nurses should treat people with kindness, respect and compassion. Point 1.2 of The Code says nurses should deliver the fundamentals of care effectively. Assistance with someone’s personal hygiene is a central aspect of achieving this. Additionally, NICE has published guidance Patient Experience in Adult NHS Services: Improving the Experience of Care for People Using Adult NHS Services. This says staff should ask patients regularly if they need help with personal hygiene. It adds that care staff should provide this help when needed.

67. Ms T says on one occasion she visited Mr S on the ward and found him in a urine-soaked bed. She tried to find staff to help but changed the sheets alone. Ms T also says she cleaned his teeth and shaved him on almost every visit as she believed nurses and care assistants were not doing so.

68. Mr S was an inpatient at the Trust for 44 days. The care records show that staff washed him and met his general hygiene needs on 34 of those days. This includes things like shaving and cleaning his teeth. However, on 15 August a doctor on the ward round recorded that Mr S had poor oral hygiene and asked care staff to give this added attention.

69. Staff did not help Mr S with his personal hygiene needs on 10 days out of 44 and this does not meet the fundamental standards of care that Mr S deserved. It also left an opportunity to show more compassion when caring for him. We acknowledge how this affected Mr S’s dignity and made an already upsetting time worse for Ms T. We accept the level of care Ms T witnessed would have contributed to some of the distress she experienced.

70. Our adviser explained that dehydration caused by decreased fluid intake leads to lower saliva production. They explained that Mr S’s poor dietary intake could have contributed to this and made the problem worse. This means oral care was especially important to ensure Mr S maintained his comfort and dignity whilst in hospital.

71. While there is no mention in the notes about Ms T changing Mr S’s sheets, we consider her account is reliable and accurate, given the documented history of Mr S’s bladder incontinence. We recognise that staff are not always available to help immediately in these situations due to caring for other patients. We also acknowledge that it is impossible to say how long Mr S was sat in the wet sheets given that we do not know the exact date of events. Likewise, from Ms T’s account, this experience was a one-off. That said, it was no less distressing for her and undignified for Mr S.

72. The Trust’s investigation report apologised for the attention its staff gave to Mr S’s personal hygiene needs. It also made service improvements so that staff assess all patients on admission, tend to their needs, and communicate this with them and their families.

73. As before, this does not go far enough to remedy the upsetting and distressing experience Ms T had. We have therefore made a recommendation below.

Discussions with Ms T about end-of-life care

74. Ms T complains staff at the Trust did not explain that Mr S was near the end of his life and gave the impression he was going to return home. She says this has added to the distress she continues to experience.

75. GMC guidance Treatment and Care Towards the End of Life says doctors should acknowledge the role of people close to the patient, such as friends and family. It says these people may want or need information about the patient’s diagnosis and progression of their illness. When explaining this, doctors should discuss potentially distressing issues with care and sensitivity. Doctors should document discussions like these, as well as CPR considerations, and decisions about a patient’s care.

76. The medical notes record that throughout Mr S’s admission to hospital there was a continued effort to send him home. This included the involvement of occupational therapists and physiotherapists to make sure he had the necessary support upon discharge. Unfortunately, Mr S was ineligible for continuing healthcare funding, which is when the NHS pays for a patient’s healthcare in the community. He also had repeated infections, which meant it was unsuitable to send him home. Nevertheless, staff did try and accommodate Mr S and Ms T’s wishes until his final days.

77. On 9 August a doctor arranged to speak with Ms T about Mr S’s condition and how he was doing in hospital. They recorded that they discussed how Mr S’s health was declining and that he was dehydrated but refusing rehydration. Ms T wanted artificial rehydration for Mr S should it come to that point but wanted to discuss with her daughter before committing to any other plans. They also discussed whether to resuscitate Mr S should he pass away.

78. Ms T discussed the plan with her daughter and agreed not to resuscitate him because of his frailty. We understand how difficult it can be to make a decision like this and recognise it is not easy to do. On 16 August the doctor also recorded that Ms T agreed with the plan to stop taking blood tests. They encouraged Ms T to visit or call the ward if she wanted to discuss anything. Early in the morning on 17 August, Mr S’s condition deteriorated rapidly, and he passed away in hospital.

79. We recognise that Mr S had returned home from previous hospital admissions, and doctors were trying to achieve this during his time at the Trust. Nonetheless, we are satisfied care staff communicated with Ms T appropriately regarding Mr S’s medical condition. She was involved in planning for his care and staff gave her time to discuss this with other family members. This is what should have happened according to the guidelines.

Compassion for Ms T

80. Ms T also complains that on 17 August staff did not tell her that Mr S had died and was instead led to his bedside after his death without an explanation or any compassion. She says this deeply upset her at the time and continues to do so. She says it means she has been unable to heal from the trauma of Mr S’s death.

81. Point 1.1 of The Code says nurses should ‘treat people with kindness, respect and compassion’. How to Break Bad News: A Guide for Healthcare Professionals, says that staff should break bad news face-to-face in a private setting. They should establish how much the relatives already know and respond to their feelings. They should prepare the relatives of any steps they should take after the death of a loved one, including giving advice on practical matters.

82. Ms T says that a nurse called her at home early that morning and explained that Mr S’s breathing had got worse, and Ms T agreed to visit him. She arrived within the hour but unfortunately Mr S had already died by the time she got there. Ms T says a nurse led her to Mr S’s bedside and she sat next to him. At this point the nurse left the cubicle. Ms T then checked Mr S’s pulse and touched him to see if he was moving or breathing. Ms T then realised her partner was dead. She kissed his head and tried to close his eyes which were still partly open. She could not close them and became very upset. She held his hand under the sheet and started to cry.

83. The staff had packed Mr S’s belongings and placed them on a moveable tray. The nurse returned to the cubicle and gave Ms T a leaflet on what to do next. Ms T was too shocked and upset to take in the information and left the hospital soon after.

84. There are no nursing notes of what happened after Ms T arrived at hospital. The Trust’s investigation did not find any evidence that nursing staff spoke to Ms T about what had happened. It explained there was no permanent member of staff on the ward that night, and the nurses were working there through the NHS staff bank or an agency.

85. What happened was unacceptable. On balance, we found that staff did not explain what had happened or show any compassion toward Ms T during this time. Just giving her a leaflet was not adequate support, and while it gave practical tips it did not meet the guidelines set out above.

86. We recognise how upsetting Mr S’s death was for Ms T and understand how distressing it is to lose a loved one – especially in the circumstances that Ms T experienced. We also understand how distressing she found the staff’s behaviour following the death of Mr S.

87. Ms T says her grief is intense and protracted because of the actions of staff on 17 August. We cannot attribute this solely to the nurse’s actions after Mr S’s death. We consider this would have been deeply distressing regardless of how the staff behaved. The actions of staff contributed to the severity and length of the distress Ms T experiences because of her partner’s death.

88. The Trust’s complaint investigation made some recommendations to address what happened. It says the ward will ensure the nurse in charge is a staff nurse wherever possible, and not from the NHS bank or agency. It has also explained the ward will make use of the hospital’s palliative care services for future patients in similar circumstances to Mr S.

89. On a personal level, the nurse on the ward has apologised to Ms T for the level of care they provided and documented on 17 August. Nonetheless, we consider this does not properly resolve the impacts associated with what happened. As such, we have set out a recommendation below to put this right.

Records about the time of death

90. Ms T complains the Trust’s investigation report dated 26 April was unable to provide an accurate time of death for Mr S. She says the Trust originally said he died at 4.50am, but later explained his time of death was 5.15am.

91. NHS England’s Complaints Policy says that its complaint responses will provide an explanation of what happened based on facts. Our Principles of Good Complaint Handling also say that organisations should give clear, evidence-based explanations of what happened.

92. Ms T says that she met with the ward sister responsible for the Trust’s investigation on 28 March. Ms T told us that at this meeting the sister explained that Mr S died at 4.50am. Ms T also explained that the Trust’s investigation report dated 26 April lists Mr S’s time of death as 5.15am.

93. We asked the Trust for notes from the meeting on 28 March. However, the sister who participated explained they did not take notes as they used the meeting to offer their apologies face-to-face and to properly familiarise themselves Ms T’s complaint. For this reason, we have relied on Ms T’s account of the meeting to understand what they discussed.

94. We have also used Mr S’s medical records to understand what happened when Mr S died on 17 August and clear any confusion over the series of events. They record that at 4.50am the nurse attended Mr S and found his breathing had got worse. They told Ms T about this change over the phone, and she agreed to visit immediately. The nurse also asked a doctor to attend the ward. A note from 4.55am says Mr S was ‘in a poor condition, has stopped breathing – doctor is coming to certify’. At 5.15am the doctor recorded in the notes that Mr S had died.

95. Having looked at the record of events we understand why the Trust gave two different times of death in its explanations. Although there is evidence Mr S had passed away at 4.55am it could not be certain of this based on the information available. It therefore relied on the verified time of 5.15am. This decision was based on the available records and an evidence-based approach to explaining what happened. This was in line with the relevant guidance.

96. That said, we understand the confusion the Trust’s explanation caused Ms T. We acknowledge this made it difficult for her to find closure on what happened and that it left unanswered questions for her. We hope the series of events as recorded in the medical notes clarifies what happened. It is more likely than not that Mr E passed away at 4.55am.

1. We found that staff at Buckinghamshire Healthcare NHS Trust (the Trust) failed to properly help Mr S with his hydration and food intake, and with his personal hygiene needs. We also found they did not properly communicate with Ms T when Mr S had died. However, we consider staff at the Trust helped Mr S with his mobility, communicated Mr S’s end-of-life care with Ms T appropriately, and followed relevant guidelines when it explained his time of death.

2. These failings contributed to the severity and length of distress that Ms T has experienced. Although the Trust has made some service improvements and apologies, these do not properly put right what happened. For this reason, we have partly upheld the complaint.

3. We recommend the Trust pays Ms T £800. This appropriately recognises how the actions of staff contributed to the severity and length of distress Ms T experienced because of her partner’s death. These problems had a cumulative effect that contributed to the lasting grief she continues to experience, and we acknowledge this may never get better for her.

97. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

98. We have also looked at what the Trust has already done to resolve the problems Ms T complains about. The Trust told us that an expert on nutrition and an expert on speech and language have given further training to the nursing staff on Ward X. The ward is inspected regularly for how well it complies with the necessary nutritional standards, and it has implemented new methods to monitor patient nutrition.

99. Additionally, a policy has been introduced where nurses encourage patients to get up and move more. Nurses will also assess a patient’s personal hygiene needs on admission and communicate these with them and their families. Further, nurses on the ward will utilise palliative care services in the hospital to help them care for the families of patients. Notably, the Trust has acknowledged staff made mistakes and apologised for these.

100. Considering the Trust’s actions, we are satisfied it has taken Ms T’s complaint seriously and learned from what happened to stop similar problems reoccurring. That said, there is more the Trust can do to properly resolve the lasting upset and distress its actions caused Ms T.

101. Our principles say that public organisations should put things right and, if possible, return the person affected to the position they would have been in the poor service had not occurred. If that is not possible, they should compensate them appropriately.

102. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Following this review, we recommend that the Trust should pay Ms T £800 within ten working days of this report.

103. This payment is to recognise that the actions of staff contributed to the severity and length of distress Ms T feels following her partner’s sad death. The numerous problems identified in this report had a cumulative effect. We consider they contributed to the last grief she continues to experience, and we acknowledge this may never get better for her.