The Trust’s communication on 30 October and how it managed Mr L’s property
17. Mr L sadly died on 30 October at 12.30am. Mrs G complains the Trust did not contact her when her father died, but contacted one of his friends instead. She says her father’s friend collected Mr L’s property, which included his house keys. Mrs G has told us there is CCTV evidence of Mr L’s friend stealing belongings from his home.
18. The Trust clearly recorded what happened when Mr L died. It noted there were no recorded next of kin details in his records so a nurse called his friend whose number was saved in Mr L’s mobile phone. The Trust recorded his friend came to MRI at 1.00am, was notified of Mr L’s death and given his belongings.
19. To help us with this part of the complaint, we have looked at the Trust’s own policy, ‘Care of the deceased person (adult)’. This policy says, ‘if the deceased person’s family/ significant others/identified next of kin are not present at time of death, they should be informed by a professional with appropriate communication skills.’ It says the purpose of this piece of guidance is to make sure the relevant people are aware of a person’s death.
20. Mrs G has told us she did have a voicemail message from the nurse on her father’s ward, asking her to call. Unfortunately, Mr L died during the night and she was asleep when the nurse called her. We cannot see a record of the Trust’s attempted call to Mrs G, but we do not doubt it happened based on her account.
21. We appreciate the Trust did attempt to inform Mrs G of her father’s death, as described in its policy. However, it then called someone else who was not a family member or an identified next of kin. We cannot see this is consistent with its policy. The Trust should have waited for Mrs G to return its call. Whilst we cannot see she was recorded as a next of kin, we can clearly see she was involved in Mr L’s care. The Trust had previously contacted her on 18 and 21 October to discuss her father’s care and she was involved in a face-to-face consultation only two days before Mr L’s death, on 28 October. We cannot see a reason for the Trust to doubt Mrs G was an appropriate person to be informed of Mr L’s death, or for it to attempt to inform someone else.
22. The Trust’s mistake here clearly had an impact on how it managed Mr L’s property. It formally notified his friend of his death and gave him his belongings. This included the keys to his home. There is no indication his friend had been involved in Mr L’s care while he was in hospital.
23. The Trust’s ‘Care of the deceased person (adult)’ policy says ‘all cash, valuables and jewellery removed from the deceased person must be recorded in patient’s valuables book and taken to hospital site cashiers according to the Trust’s Patient Property and Valuable policy’. As the Trust gave all Mr L’s belongings to his friend, including his keys, which would be considered valuables, we cannot see it followed its own policy here. We have also looked at the second piece of policy too.
24. ‘Patient property and valuables’ policy says:
‘4.20.3.3 Valuables can be handed over to next of kin at the time of death whilst the patient remains on the ward.’
And
‘4.20.3.4 Case or valuables belonging to the patient and present on the ward at the time of death (in the absence of family/NOK) will be recorded in the Patient Valuables and Cash Book in the normal manner. During office hours the case and valuables should then be taken to Cashiers and handed over for safe keeping, outside of office hours it should be deposited in the night safe.’
25. We have found the Trust did not follow this policy. As we have already explained, the Trust should not have asked Mr L’s friend to come to the ward. This means we think the Trust made a mistake when it handed Mr L’s belongings to his friend. For the Trust to have followed 4.20.3.3, Mr L’s friend would have needed to be clearly recorded as the next of kin.
26. Mr L died at 12.30am on a Sunday. Based on this, the Trust should have recorded Mr L’s valuables in its patient valuables and cash book, and deposited them in its night safe as described in 4.20.3.4 of its policy.
27. We have found failings here. The Trust did not follow its own policy and we have looked at the impact this had on Mrs G.
28. Mrs G says the Trust’s poor communication and poor handling of her father’s belongings has hurt and upset her. She told us this impacted on how she grieved losing her father as she was dealing with the police and cancelling his debit cards in case they had been stolen.
29. We have considered the likely impact of the Trust’s mistakes. There are two parts for us to look at here, the Trust’s decision to contact Mr L’s friend and its decision to give him the belongings.
30. We have acknowledged above the Trust did attempt to contact Mrs G when her father died. We found its mistake was its decision to contact Mr L’s friend when it could not speak with Mrs G.
31. We appreciate it is unlikely the Trust could have done anything more than it did to notify Mrs G of her father’s death. We think we should consider how the Trust’s decision to contact Mr L’s friend, and give him the belongings impacted on Mrs G’s experience and her memory of her father’s death.
32. We have taken another look at the Trust’s policy, ‘Care of the deceased person (adult)’. This policy gives a brief introduction which says:
‘The death of a person regardless of whether or not it occurs in expected or unexpected circumstances causes distress to the deceased person’s family and loved ones. Dealing sensitively and carefully with people who die and with their relatives and carers is crucially important. Memories of the death and of the person who has died can be affected by the experiences around the time of death and the care after death. The quality of care received at this time can have a significant impact on the grieving process of bereaved people.’
33. When we consider the Trust’s rationale for its policy as described above, we can see why Mrs G has complained about the upset and hurt she has felt. The Trust did not follow its policy by acting sensitively and carefully with Mrs G, and we can see why her experiences after her father’s death have been negatively affected. Time she should have been able to spend grieving was used making a police report and protecting his estate.
34. We think it is important the Trust acknowledges this and we have made recommendations later in this report.
Mrs G could not see her father on the ward
35. Mrs G complains she was not able to see her father on his ward after he died, and the Trust moved him to its mortuary before she arrived at MRI.
36. We are very sorry to read this and we understand why Mrs G has asked us to look at this part of her complaint. We have considered the Trust’s policy, ‘Care of the deceased person (adult)’ which gives clear guidance on what it should do after someone dies on its wards.
37. The policy says, ‘request portering staff to safely transfer the deceased person to the mortuary within 4 hours of death in order to comply with HM Coroner requirement to transfer deceased persons to the mortuary within 4 hours.’
38. The Trust recorded Mr L’s death as at 12.30am and it transferred him to the mortuary at 4.22am.
39. We can see the Trust followed its policy here, and the requirements set out by HM Coroner. To allow Mrs G to have seen her father on the ward, it would have needed to have left him there for much longer than its policy allowed.
40. We understand how upsetting this was for Mrs G. She wanted to see her father in the same environment he was in when she saw him last, only two days earlier. Unfortunately, the circumstances made this very difficult. Mr L died in the middle of the night, and Mrs G did not live locally to MRI.
41. We have found the Trust followed its own policy here. We cannot see it made a mistake when it transferred Mr L at the time it did.
Mr G’s fall on 25 October and the Trust’s care on 27 October
42. Mrs G says her father fell whilst he was moving from his chair to his bed on 25 October and he cut his arm. She complains the Trust did not contact her to tell her this happened. She also complains the Trust left her father lying on a bed pan for two hours on 27 October.
43. We can see in Mr L’s records he did fall on 25 October. The Trust treated the cut on his arm and completed an incident report. We cannot see it informed Mrs G of this. We think it should have, as she was clearly involved in his care. We understand why this caused her upset. The records describe the clear impact the fall had on Mr L, especially his confidence moving around the ward. We can see he preferred to stay in bed from this point on, and we appreciate why Mrs G wanted to be aware of this.
44. We have also looked at the Trust’s records of when it helped Mr L to use a bed pan so he could go to the toilet. The Trust arranged for a physiotherapist to help Mr L improve his mobility at 2.15pm on 27 October. The records of the treatment show the physiotherapist helped Mr L onto a bed pan and recorded he would call the nurse using the call bell once he had finished using it. The Trust staff did not check on Mr L and he was left with the bed pan for at least two hours. The NMC Code says nurses should make sure a patient’s dignity is preserved. We cannot see it did this here.
45. We have looked at what the Trust has done to resolve these parts of Mrs G’s complaint. It acknowledged it should have contacted Mrs G when her father had a fall and explained it has emphasised the importance of doing this to its staff on Mr L’s ward.
46. It also acknowledged it could have done more when Mr L was lying on the bed pan. It explained the physiotherapists did the right thing by getting Mr L’s consent to using the bed pan, and agreeing he would use the call bell when he wanted it to be removed. But they should have informed his nurses of this so they could check on him.
47. The Trust also explained what it would do to prevent this from happening again. It confirmed the physiotherapy service manager has reinforced to their staff how important it is to hand information over to their nursing colleagues when they have finished treating a patient.
48. The Trust has also offered a sincere, written apology to Mrs G for both failings.
49. The NHS Complaint Standards set out what we think organisations should do when they identify where they have made a mistake which has an impact on someone. In this case, the Trust should identify a suitable and appropriate way to put things right for Mrs G. The Trust has done this by giving a meaningful apology and openly explaining what steps it will take to improve its care in the future.
50. The Trust has done enough to put things right for Mrs G here.