Gateshead Health NHS Foundation Trust

3. Mrs O complains between 10 and 12 April 2021 the Trust did not communicate the severity of her mother’s (Mrs H) condition. She also says it did not provide appropriate information about what actions it was taking and it did not update the family.

4. Mrs O and the family say this meant they were not aware of how serious Mrs H’s condition was, so she died alone. They are struggling to come to terms with what happened. It has affected Mrs O mentally and the family blame themselves for not being by Mrs H’s side during her last moments.

5. As an outcome, Mrs O wants someone to take responsibility and admit the neglect towards her mother and family.

6. Mrs H went to the Trust on 10 April 2021. She initially went to A&E and the Trust transferred Mrs H to a ward in the early hours of 11 April. Mrs H was reviewed for surgery, but the consultant felt this could carry a risk for someone in their early nineties, as patients of that age do not always cope well with anaesthetic or recovery.

7. The Trust decided to keep Mrs H comfortable and planned for end-of-life care. On 11 April 2021, the family called the ward and the Trust informed the family Mrs H had a drip to help with fluid build-up and was comfortable. The Trust did not discuss anything else with the family.

8. On 12 April 2021, a medical review was called due to Mrs H vomiting. A doctor saw her and she was noted to be clinically stable. Mrs H died a short time after this and the Trust told the family.

9. Mrs O and the family had a meeting with the Trust on 19 April 2021. The Trust agreed to an action plan to improve communication between departments to make sure this type of situation did not happen again. Mrs O complained further following this meeting. The Trust confirmed it would carry out an investigation and Mrs O received a final response on 8 October 2021.

Communication

13. Mrs O says the Trust did not communicate the severity of her mother’s condition, provide appropriate information about the actions it was taking or update the family. The Trust accepts failings in communication across all areas.

14. We took advice from our adviser, who pointed to the GMC Guidelines as the foundation for communication expectations. The Guidelines say care providers must be considerate to those close to the patient and sensitive and responsive in giving them information and support. The Trust has acknowledged it should have informed the family after it discussed Mrs H not being suitable for surgery and after the CT results, and it should have apologised. The Trust agreed there were communication failures at all levels.

15. Mrs O also complains poor communication meant she and her family could not get appropriate updates. They noted when they called the phone bounced back and forth until they got through to someone. They asked for an update, but the person who answered the phone said Mrs H was not on the system. The Trust informed them there were no ward clerks at the weekend and it was experiencing staffing issues. In the complaint response on 8 October 2021, the Trust apologised for the distress this caused and confirmed it was hiring more staff to make sure appropriate cover was available.

16. We have seen the failings in communication meant the family were not fully aware of the situation, and this has led to distress and guilt for the family, who feel they lost the opportunity to be with Mrs H when she died. We are conscious Mrs O has said she is looking for acknowledgement of failings in this case. We turned to considering what the Trust has done.

17. The Trust informed the family during the meeting on 19 April 2021 it was going to put action plans in place to make sure this does not happen again. The Trust also told the family how it was going to improve on its communication as an organisation. We contacted the Trust to see whether it had provided feedback on the action plan findings to the family, and it confirmed it had not. We asked whether we could share the findings with the family, and the Trust agreed.

18. In the action plan, the Trust explained ‘they have had discussions with the admitting consultant physicians and senior clinicals about improving communication between doctors and family members to ensure the family understands. They have fed it back to their respective medical and surgical teams’.

19. The Trust has also said it has learnt from the mistakes made and will make sure families are always well informed by phone. The bereavement team at the Trust also noted that when family members ring in, they double-check the details for the deceased by checking every section in the patient notes, such as A&E and the emergency assessment unit documents, to make sure it has the correct next of kin information.

20. While we can see the Trust has accepted there were general failings in communication, it has not specifically addressed the effect the lack of communication had on the family. When we spoke to Mrs O on 12 October 2022, she confirmed she feels the Trust has not acknowledged the effect it has had on her family.

21. We asked the Trust to write to Mrs O and the family with an apology reflecting the effect the lack of communication had on them. Specifically, we asked it to recognise the effect of Mrs O’s overall experience on her and her family in terms of distress and loss of faith. The Trust agreed to do this.

22. We spoke to Mrs O on 20 October 2022 to explain this and ask whether she would accept it. After some consideration, she agreed to the letter. We then spoke to the Trust, which agreed to write to the family by 21 November 2022.

23. In summary, although we have found failings in the Trust’s actions, we feel it has acknowledged these failings and taken action to remedy them. We asked the Trust to further acknowledge the effect these failings had on Mrs O and the family, as we felt this was lacking in its complaint response, and it agreed to do so. We think the Trust has taken adequate action to put this right and do not believe any further action is required.

24. This concludes our consideration of Mrs O’s complaint. We hope this statement clearly explains our reasoning. We thank Mrs O for bringing her concerns to our attention.

1. We have carefully considered Mrs O’s complaint about the communication of Gateshead Health NHS Foundation Trust (the Trust). We understand this was a very difficult time for Mrs O and her family, and we are sorry to hear about her experience.

2. Although we have found failings in the Trust’s actions, we can see the Trust has accepted this and taken action to put them right. It has also put an action plan in place to make sure it does not happen again. We do not think any further action is needed to resolve the complaint.