Terrible Neglect of 90 year old resulting in death

[Lindamannion]

I clearly remember the days when someone in the family was ill and you said they were in hospital, best place for them was the response, well not anymore for the elderly.

 

 

My Mum was admitted to hospital last September 2011, she had suddenly become very confused and hallucinating, she was admitted with a suspected stroke to a stroke rehab ward.

 

After 3 days it was found she had never had a stroke, and we where told she had dementia and was totally incontinent, well this was a shock as a few days before being taken ill she was in town shopping,went to bank and had lunch with a friend. her house was spotless and she managed great for her age.

 

 

I argued with the nurse in charge and said she must have something else as never heard of sudden dementia, response was she had been hiding it from us. They where not interested at all. The only solution was 24 hour care.

 

 

She spent 2 more weeks in the stroke ward, was left in a chair with bare feet, caught pnemonia, left on a comode for over 1 hour, not given her correct tablets, l could write a book, she was suffering from delerium and hallucinating, it was obvious she had a very bad water infection but nothing was done.We arranged for her to go into respite care, as we needed to get her out of there. She was to leave on the Monday 3rd October.

 

 

On the Friday before she was moved to another ward out of hours and with no notes, family where not informed of the move, but found her on Saturday the 1st in another ward, sitting in a chair surrounded by her belongings on the floor in plastic bags. I asked a nurse to check her for water infection, she said they had and she was positive. I sat with her untill early evening and told her l would be back in the morning, this was the last time she spoke to me.

 

 

We recieved a call from the hospital at 05.00 on the Sunday morning to say she was critical after a fall at 21.00 hours on the Saturday night, they put her back to bed but during the night noticed she had a terrible bleed to the brain.

We arrived and she was unable to speak and only move one hand and leg, we where told she would only live hours or days, she lived 6 more days. Four doctors insisted she had a bleed to the brain and fell.

 

 

We asked for an autopsy and she never had a bleed to the brain before the fall but the bleed was a direct result of the fall. Basically she was being injected with a blood thinner which is normal but also being given asprin, hence her blood was like water.

 

 

So l spent 6 days and 5 nights sitting with her, as she was terrified as she could hear us all but not move, she died when all fluid and drips where taken away , l will never forget it as long as live.

 

 

Coroners report said she died of head injury resulting from an avoidable fall.

We could sue but apparently she is a low value case, and maybe the hospital would offer to pay for the funeral costs, as they admitted in a serious incident report mistakes where made. We have done nothing about it as it will not bring her back.

 

 

I will live with this for ever and its been 9 months now and l think about it every day, i will never forive them, it was callous, cold, uncaring and thoroughly cruel.

 

 

My advice is never let your elderly parents go to hospital unless you can sit with them at all times, because they will be neglected and left to die.

Edited August 16, 2012 by citizenB
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[honeybee13]

Hello there and welcome. What a shocking story, I do feel for you. My mother is a similar age and I know how I would feel if it happened to her.

 

This forum is one of the quieter ones, but the good people on here will give you great advice once they're able to get here.

 

My best, HB

[nolegion]

Commiserations on your loss, Lindamannion.

 

There are others here who could comment better than me on the clinical aspects of your mother's 'care', or rather lack of it, and I expect they will in due course, as HB suggests.

 

It seems to me that 'brutal' is the best word for some of the 'treatment' dished out to the elderly by the NHS these days.

 

I wouldn't totally disregard the possibility of making a formal claim against the Trust concerned. If things are as they were when I was last involved in this sort thing, quite few years ago, you will have up tot hree years from the date of death to decide.

 

No-one's life - or suffering - is of low value. It may be tha tthe amount that can be claimed is not that great in the light of your mother'sage etc. but I have known patients' families feel that getting a least something paid represents 'formal' acknowledgement of negligence\mistreatment - and that helps some people with some measure of 'closure'.

 

You would need proper legal advice, but on the basis of what you say about accident reports and coroner's findings, it looks like 'liability' isn't much of an issue. They were at fault. So it's 'quantum' i.e 'how much' (in compensation), which really should not take a specialist solicitor more than a couple of hours to work out.

 

It won't bring anyone back, as you say, but neither is it 'money-grubbing'. It's recognition of what has happened, and - you never know - it might just provide some additional focus on the Trust's shortcomings, potentially to the benefit of the next, hapless, elderly patient in their hands.

 

Best wishes.

[BazzaS]

What was the inquest verdict?

 

Was there a conclusion of neglect even if the death was from "natural causes"? Or a "narrative verdict"?

 

Did the coroner serve a Rule 43 notice on the hospital / the hospital trust?

[Lindamannion]

Hi

 

The coroners verdict was

 

On the 7th October 2011 at 17.15 hours she died in hospital as a result of a subdural haematoma caused by a fall which was avoidable.

 

The hospital rang us after her death to arrange to get the death certificate and arrange with the funeral directors, we asked them what they where putting as cause of death, went very quite on the phone and never really answered and we asked for an autopsy as prior to her death at least four doctors came to us and said she had a bleed to the brain and fell, owing to her treatment before the fall we never believed this, as its happened we where right.

[Nystagmite]

How sad

[Lindamannion]

Another strange thing in my Mothers case is the Stroke ward where most of the neglect occured was closed shortly after the incident and an in house enquiry,

all staff seem to have been transferred to another hospital, the consultant was off with ill health and the locom doctor not available for comment, something went on in that ward and we seem to have met a wall of silence.

[BazzaS]

Hi

 

The coroners verdict was

 

On the 7th October 2011 at 17.15 hours she died in hospital as a result of a subdural haematoma caused by a fall which was avoidable.

 

The hospital rang us after her death to arrange to get the death certificate and arrange with the funeral directors, we asked them what they where putting as cause of death, went very quite on the phone and never really answered and we asked for an autopsy as prior to her death at least four doctors came to us and said she had a bleed to the brain and fell, owing to her treatment before the fall we never believed this, as its happened we where right.

 

 

" she had a bleed to the brain and fell" could be taken to mean:

"had a bleed which caused her to fall" or

"had a bleed" "and had fell".

 

The Coroner's verdict looks like a "narrative verdict" suggesting an avoidable fall caused the subdural haematoma (bleed on the brain), removing the ambiguity.

 

Did the Coroner issue a Rule 43 note to the Trust? (the coroner could do so if they felt there were issues outstanding the Trust needed to look at to prevent similar in future)

Did the Trust make any reference to things they have already done to improve things?.

 

If the Trust has been given a Rule 43 note, then you should get a copy of the Trust's reply as an "interested party".

If the Trust had already taken measures to improve, then the Coroner might feel a Rule 43 note wasn't applicable.

In that case, you might see if approaching the Trust's PALS team might get you access to a copy of their internal inquiry, or, at least either or both of its executive summary or 'action plan'

[Lindamannion]

Hi BazzaS

 

Thank you for your response, yes you are correct she died as a result of the fall, (narrative verdict) the confusion in the ward in the first instance was her transfer from a Stroke ward with no notes, they assumed she had had a TIA or stroke and fell, when in fact she never had a stroke in the first place. This all happened at a weekend. Now l am not sure this makes any difference being a weekend but to put her back to bed and no examination done, just kept an eye on her and call the family 9 hours later to say she was critical and unable to move and semi- concious, also a doctor arriving in evening clothes on the Sunday morning (12 hours after the fall)and giving her anti-coagulant

injections we found hard to take. The sad thing is the fall was just the end of a catalogue of complete lack of interest in her medical problems, she had a chronic water infection and retention, they did cathaterise her once in the stroke ward and removed a massive amount of fluid but never followed it up with no flow report, nothing, after the fall the also cathaterised her and filled 4 bags immeadiatly with toxic urine, awfull.

I could write a book about it all.

 

 

I do not know about rule 43, but l have the Serious incident report , and in that they state new measure will be put in place to ensure this does not happen again.

[Sali]

My condolences Lindamannion.

 

I'm tempted to ask which hospital this was.

 

I totally empathise with your distress. My relative suffered very similar treatment.

 

I understand too how frustrating it can be to try reasoning with medics. I loathed the arrogance I encountered. They may well have studied/trained for years, (although I was left wondering about the standard of this), but that does not give them the right to think that they have all the answers, (we are all fallible whatever our profession and we should never forget this), and to feel free to ignore the people who know the patient best.

 

What I think is so tragic and why cases such as these are repeated, is that our legal system is a complete failure. Why hasn't the outcome of the inquest triggered an automatic prosecution in your mother's case? Justice seems to be only accessible to the rich. Leeching lawyers cherry-pick no-win, no-fee cases that feed their avarice or engage in the lucrative practice of defending career criminals where the taxpayers picks up the tab.

 

I want to see the CPS bring charges of corporate manslaughter for such failures. I'm absolutely disgusted that the bereaved families of the mid-staffs debacle are having to take their own case to court. Can you think of any other profession where those guilty of such a serious crime, which is murder/manslaughter in my view, just walk free? Worse, they are allowed to stay in their jobs and perhaps subject other vulnerable people to the same treatment.

 

I loathe this country, or more precisely I loathe the Establishment that allows such horrors to go unpunished, because I believe that only accountability, and the fear of it, will raise standards and rid our hospitals of the cruel and inept.

 

I was born in this country, I live here and will probably die here...but not in an NHS hospital if I can help it.

[Lindamannion]

Hi Sali

 

Thank you for your response, l have not mentioned the hospital concerned as not sure where to go now, we have contacted a lawyer for advice, and have been told we have a case but owing to my mothers age this would be of LOW VALUE and the best we can expect is they will pay the funeral fees and a small amount for the distress to the family. Well l never really thought of my mother as low value, found this a dreadfull way the phrase it but thats what it says, A LOW VALUE CASE , the hospital concerned has not the best of reputations according to the lawyer and have a team of lawyers fighting theses cases all the time.

Find it appalling that a hospital trust has money for lawyers to fight cases of neglect and in some cases bordering on manslaughter.

I also am confused about the inquest, it went on for four hours, and the verdict was not neglect, but an avoidable fall. Not sure what that means, was the hospital responsible or my mum at fault for getting up from the chair.

It was the lack of treatment for a medical condition and total neglect that made her fall as she was suffering from delerium and hallucinating. Moved out of hours to a new ward with no notes and dumped in a chair with her belongings in bags on the floor.

[BazzaS]

Hi Linda,

 

I don't think anyone's life is "low value" : but the lawyers are possibly looking at this in terms of "I need to advise my potential client that if they sue, they aren't likely to get a large sum in response to a claim", hence that interpretation of "low value" : the claim settlement, not the life, being of low value.

 

Thing is, what do you want to achieve, and how best to do so?

 

So that you know the hospital accepts it made mistakes and has fixed them so that it is less likely to happen again?.

Write to the PALS team, asking how you can best get this assurance.

 

So that you know the hospital accepts it made mistakes and has fixed them so that it is less likely to happen again, if you feel you've already asked for this but been "fobbed off" : write to the Chief Executive of the Trust, explaining why you feel that way. Stress that you know you could sue, especially given the inquest (which doesn't apportion blame, but has reached a legal verdict as to the facts that you can rely on in any civil claim), but that it's not "about the money", but about you knowing they've acted to prevent the avoidable death of your mother happening to someone else.

Can they find a way to give you those assurances that would avoid you having to take Court action?

 

To punish a transgressor?. Whilst it is understandable that someone in your situation would want the "guilty" punished :

Suing would likely only result in a small settlement (again the difference between the value of a life and the financial value a court might ascribe to it), and I'm not sure the "guilty" would appear in court : though it may increase the likelyhood the Press become aware.

Do you believe there was a specific failing by an individual that might be seen as "professional misconduct"?

[Lindamannion]

Hi

 

Yes l understood the low value was pertaining to the amount of any claim, just thought it was an unfortunate way of wording it, and the hosptial has at the inquest said changes will be made to stop this happening again. The press are aware as they where at the inquest, and a report was in the local paper with headlines " Lessons learnt over death fall". What l dont seem to be able to address is the treatment leading up to the fall, it was dreadfull and we wrote a letter to the trust asking for answers and to be honest never really got any. They only seem to want to discuss the fall, and yes there was a specific individual on the stroke ward who's conduct was less than professional.

You are correct its not about the money, but making changes in the NHS is vital and treatment of the elderly needs addressing, nothing seems to do this as reports on lack of care and neglect are increasing at an alarming rate. I would like to thinks lessons have be learnt by Mums fall but l dont think so, on a rather cynical note neglecting the elderly and then paying for the funeral, would be a tremendous saving on the part of the NHS rather than treating them and have them taking up beds. Makes you think.

[Lindamannion]

Hi

 

As l have said the issue of the fall has been dealt with, letters wrote, accident report dealt with and the coroners verdict in.

 

What l need is advice on is how to address the issue of the treatment in the ward leading up to the fall, she was only on the ward she fell in for 24 hours , and they had no notes on her. The inquest was attended by the nurse in charge, and the doctor on call (as it was a weekend) from that ward.

 

Our questions have never been answered on the treatment or lack of treatment she recieved on the Stroke rehab ward, do l write again demanding an explanation, l know all staff where questioned but we have never had any respones on this. Do we have the right to know what happened in the inhouse enquiry?

 

I need an answer as there was a definate case of professional misconduct in that ward, but feel we are being fobbed off. Would really appreciate any advice on this

 

Linda

[BazzaS]

The inquest is the one place that you or your representative can ask questions "that help determine how the deceased came about their death" and that they MUST be answered.

However, the coroner would equally make sure that any questions that apportion blame, rather than issues of fact, aren't allowed.

 

Beyond that, the Trust doesn't have to answer questions, although most will.

Can I ask you for a moment to think about if this were a situation you'd heard about from a friend : bear with me .....

 

Imagine you are helping them write the letter to the PALS dept. of the Trust, and helping them get the questions they want answered straight. One of the things you might want to help them with is a possible pitfall, where the Trust thinks "another letter, we've been over this and explained, and it's the same question .... Or new questions that we've already covered .... We'll reply saying that we've answered before, and there has been an inquest, and we refer to those answers".

 

Now, back to you and the death of your Mum ... I'd want answers too in your situation, but it's how to get those answers without risking that sort of response from the Trust.

You'll have to be "extra reasonable" ... Stressing the aspects that you don't understand and why, and why you (reasonably!) want reassurance that how what went wrong is being prevented from recurring.

 

Have you approached the PALS dept of the Trust?

Would you consider asking them (not to reply to your letter - send that to the Chief Exec) but to help you formulate the letter?

 

Although PALS are employed by the Trust and may be the people collating the responses to any complaint, they are also meant to be independent and confidential advocates - it might be worth asking if someone not already part of the response to your Mum's death can undertake this role for you?

Edited August 20, 2012 by BazzaS

[Lindamannion]

Hi BazzaS

 

Thanks for your response, the inquest was a long drawn out one and questions where asked, most not answered as the Nurse and Doctor representing the hospital could not answer most of them, the Nurse had only been on duty a short time and prior to her fall hand never met Mum, the doctor saw her after the fall briefly ( hes was a diabetes specialist) on call and also could not answer many of the questions. The inquest was really about the fall and her death, and this was dealt with. It was made clear had hospital policy been adhered to she may not have fell, i.e. moving a high risk patient out of hours verbally with no notes.

I am so angry that the NHS can treat people like this with no punishment to those involved,

 

I will get someone to help me write to PALS and explain my concerns, myself and my family are convinced there has been a cover up regarding the Stroke Ward (no longer there and staff moved) . Then to have four doctors say she fell as a result of a bleed or stroke as far too much damage done as a result of a fall. Most people would have accepted that. I agree with Sali and want to see the CPS bring charges of corporate manslaughter for such failures.

[BazzaS]

I've checked with a local PALS team, and there is a "PALS-like" advocacy service that is free, confidential, and independant of the Trust (actually, independent of the NHS!)

 

It is the "independent complaints advocacy service" (ICAS).

 

They don't seem to have a single website : it appears the Dept. of Health funds them through a number of providers, so the provider for your area may have a website for that area.

Apologies that I can't be more precise than saying "try Googling ICAS for your area", or pointing you at :

 

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4090775.pdf

 

for contact phone no's by region for England.

 

Would you consider asking them how best to achieve what you are seeking?

Edited August 20, 2012 by BazzaS

[Lindamannion]

Hi BazzaS

 

Thank you for this information, what do l want to achieve? the truth would be nice, policies put in place to ensure the elderly are treated with the respect they deserve, an end to the daily cruelty of our elderly relatives, the NHS to be made accountable, staff conercerned sacked and prosecuted.

The RSPCA take owners of animals to court for cruelty, maybe someone should start a charity enabling families to take on the NHS, that would bring a quick change in policy.

Once again thank you will look into this.

[Sali]

I have come to the end of the line in believing that formal complaints to PALS, hospital management, the GMC, Ombudsman etc, are going to have a positive outcome for the damaged patient or bereaved relatives, past or future. It's the same old, same old. You'll be told that 'lessons have been learned' and 'issues have been addressed.' You'll be thanked for 'bringing the matter to their attention,' but how they were unable to see the blindingly obvious is never explained. How is it then that standards are deteriorating so rapidly, especially in elderly care?

 

In the absence of a completely independent complaints process, one that can quickly identify and address failures, (not sweep them under the carpet), one that can publish its data to give us real patient choice, the only course (long, painful and perhaps expensive) is litigation. It's almost never about compensation, but about justice and a desperate belief that our actions may improve the service for the next person. It's hopefully a path to coming to terms with the trauma suffered and finding some kind of peace.

 

Without accountability (and I mean prosecuting managers and medics that have deemed to have consistently failed and barring them from the profession) things will never improve.

[Lindamannion]

Thanks Sali

 

Oh you are so right You'll be told that 'lessons have been learned' and 'issues have been addressed.' You'll be thanked for 'bringing the matter to their attention,' exactly what we have been told, and we have been through the whole thing, written to the correct people had a meeting with the hospital, insisted on the autopsy which confirmed they where quite clearly going to give us an incorrect death certificate, not much more l can do, maybe accept the compensation of the funeral costs, but find this an insult to the memory of my Mother, we could pay for a funeral but not protect her from the NHS. All been very sad.