Learning from Experience Database - Serious Case Reviews

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Mr H (Northumberland)

This SCR examines the circumstances leading up to the death of Mr H. He lived in sheltered accommodation and whilst he had some long term physical conditions, Mr H was able live very independently until the last few weeks of his life.  On 23rd July Mr H had a fall at home, and whilst medical assessment was sought from the GP Mr H was deemed as not requiring hospital admission. He was however, eventually placed in a nursing home as he was unable to meet his care needs.  Mr H resided at the nursing home from 28th July to 2nd August when due to a deterioration in his condition he was admitted to hospital. Mr H died in hospital four days after admission. His cause of death was recorded as bronchopneumonia and fractured vertebra with spinal cord compression.  The SCR focused on the failure of professionals to monitor his conditions and to seek appropriate medical help for the significant injuries he had sustained.

Professional learning:

  • Knowledge and insight of family members and carers about their relatives should be carefully listened to by clinicians.
  • Nursing staff observations about how patients present over a 24 hour period can significantly influence medical diagnoses, treatment plans and decisions about investigatory processes, such as x-rays. It is essential that these observations are reliable and properly recorded by the relevant member of nursing staff
  • Delays were caused partly through inefficient communication within the nursing home and between the nursing home and the GP practice. Poor standards of recording of assessment and referral information were also contributory factors.
  • Where there is evidence of confusion, professionals should proactively consider the possibility that the patient may lack capacity to make informed choices about their admission, care and treatment plans.
  • Patients who have mental capacity may still benefit greatly from professionals actively involving family members, to ensure that the patient’s wishes are properly understood, recorded and acted upon. This is particularly true when there is evidence that the patient is experiencing periods of confusion and disorientation.
  • Close working relationships, based on professional trust and respect between GP practices and nursing homes, deliver real benefits to residents and should be actively encouraged and supported.
  • However, such relationships should not become so informal that they come to rely exclusively on informal relationships between individuals, even where trust has been developed over a long period of time.

2012 May Serious Case Review regarding Mr H (Northumberland)