Learning from Experience Database - Serious Case Reviews

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Mrs B (Central Bedfordshire)

Mrs B was admitted to Bedford Hospital on 10 May 2012, with a suspected stroke. Examinations revealed that she was suffering from advanced stage cancer and given a poor prognosis, it was decided that she would be provided with palliative care. It was arranged that this would be provided in a local nursing home, where her husband had been admitted when Mrs B was taken into hospital. She had been his carer, as he suffered from dementia. She was admitted to the same care home on 1 June 2011 and died there on 4 June 2011. The family and some professionals, raised concerns about the care that Mrs B had received and a safeguarding investigation was commenced on 8 June 2011 the outcome of which was ‘not determined/inconclusive’. A recommendation was made to the Safeguarding Adults Board to consider commissioning a Serious Case Review to consider whether she was provided with appropriate care at the end of her life.

Professional learning:

  • Commissioners should ascertain how appropriate support is assured when non-specialist or inexperienced facilities are used to provide the more specialist aspects of end of life palliative care.
  • Multi-disciplinary and proactively framed palliative care plans, including pain management plans, should embedded into local practice of health and social care providers and that families are appropriately engaged in the process.
  • Mechanisms should be developed to facilitate early communication with GPs, for newly admitted care home residents, who need to be newly registered with a GP practice.
  • Patients being discharged from the hospital to care homes, should be given their own copy of the doctor’s transfer letter.
  • NHS to have mechanisms to review the consistency of the content of the nurse led transfer summaries, to ensure that any forward care and medication requirements are clearly stated, where appropriate.
  • Clear standards should be put in place regarding the nature and content of documentation that should accompany medication sent from hospitals to care homes.
  • Thresholds for involving palliative services and the Macmillan service should be agreed and communicated to relevant partners.
  • Mechanisms should be in place to ensure local ‘end of life’ strategy and practice is compliant with the NICE quality standards issued in November 2011.

2012 April Serious Case Review regarding Mrs B (Central Bedfordshire)