Royal Cornwall Hospitals NHS Trust

4. Mrs E was admitted to Royal Cornwall Hospitals NHS Trust (the Trust) on 8 December 2022 after fracturing her hip. Mrs E sadly passed away in hospital on 23 January 2023. Her daughter, Miss E, complains that during her stay in hospital, the Trust: • failed to ensure it gave Mrs E correct nutrition, in the form of food or prescribed drinks • failed to take care of Mrs E’s teeth • failed to treat Mrs E’s delirium

5. Miss E says as a result of this care, Mrs E deteriorated quickly in hospital due to a lack of nutrition and passed away sooner than she should have and suffered pain caused by her teeth. Miss E says she has suffered distress from the loss of her mother and seeing her in pain.

6. Miss E would like an acknowledgement and an apology from the Trust. Miss E would also like service improvements to be put into place to prevent other people from going through the same.

7. Mrs Cynthia E, 86 years old, was admitted to hospital on 8 December 2022, following a fracture to her hip. Prior to her admission, Mrs E was living independently and was able to drive. Mrs E had been diagnosed previously with osteoporosis (a condition in which the bones weaken). Mrs E’s medical records also show a diagnosis of stage three kidney failure, however this is something her family were not aware of.

8. Mrs E underwent surgery for her hip, which included a hip replacement. The Trust then transferred her to Hale hospital for rehabilitation. Staff discharged Mrs E was on 21 December 2022.

9. On 29 December 2022, Mrs E was readmitted to hospital, via A&E. This was following her feeling generally unwell, having a reduced appetite, confusion and low blood pressure.

10. Throughout her stay in hospital, Mrs E’s appetite continued to decline and she refused most forms of nutrition, including meals, snacks and drinks. Miss E stated she began to notice a deterioration when Mrs E was moved to Phoenix ward in the middle of the night.

11. A dietician referral was made for Mrs E on 3 January 2023. She was regularly seen by a dietician following this. She continued to decline nutrition and refused a nasal feeding tube until 13 January 2023, when she agreed to a trial. The NG tube was removed on 15 January and Mrs E refused to have this refitted.

12. Mrs E’s son advised staff in the hospital she was refusing food and drink because she did not want to be a burden on nursing staff when she needed the toilet.

13. Mrs E died on 23 January 2023. Her cause of death is recorded on her death certificate as being acute kidney injury and bronchopneumonia (a type of pneumonia that inflamed the air sacs in the lungs).

Nutrition, teeth care and delirium

15. To decide if we should conduct a detailed investigation into a complaint, we look at what outcome the complainant wants to resolve their complaint. Section 3.59 of our Service Model Guidance says we can resolve a complaint without conducting a detailed investigation if we can deliver the outcomes a complainant asks us to achieve at an earlier point in our case handling process.

16. When we reviewed the information we had, including the Trust responses and Local Resolution Meeting (LRM) recording, we noted the Trust had acknowledged fault on these issues already. It also provided some information about changes it would introduce to prevent these issues happening again.

17. The nutrition aspect of the complaint was fully upheld by the Trust, as it explained in the response of 25 January and during the LRM. The letter from 30 March also explains the incident will be shared with relevant teams to improve communication and speed up the process.

18. The teeth/oral care issue was discussed in the LRM and also in the response afterwards. The Trust accepted the issues and explained it was developing a new policy already.

19. The delirium aspect of the complaint were discussed in the LRM and followed up in the response afterwards. The Trust accepted fault and said it would implement improvements to ensure staff review the delirium policy.

20. We must consider the actions the Trust had already taken to put things right. It apologised for and acknowledged where the care provided fell below the necessary standard. It has also provided some information about the changes it will implement to prevent these issues occurring again.

21. Our Principles of Remedy provides a guide on what organisations should do when maladministration or poor service has been identified. This would include issuing an apology, revising procedures and training staff to prevent the same issues happening again. This is what has happened in this case.

22. We discussed with Miss E what she sought by bringing us her complaint. She explained she would like an apology, an acknowledgment of the failings and service improvements.

23. The Trust has already acknowledged the failings, apologised and provided some information about the improvements it will make. We contacted the Trust to ask whether it would provide more details on the changes it is implementing. This is to ensure Miss E has more confidence that lessons have been learnt from her and her mother’s experience.

24. The Trust confirmed it will provide Miss E with more information and will do this by 9 December 2024. A copy will also be sent to PHSO.

25. In line with our policy, we consider and decide whether the actions taken are appropriate to resolve the complaint. The actions appear to be in line with our NHS Complaint Standards. From our consideration of the complaint and Miss E’s desired outcomes, we believe the actions of the Trust will resolve Miss E’s complaint. Therefore, we will not be taking the complaint any further.

Conclusion

26. We recognise the care Mrs E received was not of the standard it should have been, and this has had a deep emotional impact on her family. We hope the Trust’s commitment to improvements will provide some comfort that lessons have been learnt from this experience.

1. We have carefully considered Miss E’s complaint about Royal Cornwall Hospital NHS Trust (the Trust). We were sorry to hear her concerns about the care her mother, Mrs E, received. We recognise the distress this has caused her and her family.

2. During our assessment of Miss E’s complaint at primary investigation, we saw indications of failings with the care the Trust provided, and we also saw indications of an impact on Miss E and her mother. We discussed this with the Trust who agreed to provide a further response with more information on the service improvements it has made to prevent these same issues happening to others.

3. We feel these actions will resolve this matter. On the understanding the Trust will take these actions, we have decided to take no further action on this complaint.