"Poor patient journey and terrible standards of care"

Now I want to start off by saying I am an NHS employee myself, working at a higher level, and feel extremely let down by the standard of care given to my grandfather in his final days.

My grandad, an 87 year old man, had 2 falls in the space of a week. He attended the ED at St John’s Hospital where he was x-rayed, had bloods taken etc with some physiotherapy assessment and was sent home the same day.

Now the outcome of the X-ray was that he had an L1 (lumbar) fracture but they couldn’t determine whether it was new or old which was crazy considering the level of pain he was in was surely consistent with a new fracture. He was catheterised (for reasons unbeknownst to me) and sent home without pain relief. Neither my grandad or mother were educated on the use of catheter care/management and struggled with this in his remaining days.

He was in excruciating pain and was also very nauseated and on the days following his same day discharge where he continued to deteriorate over the course of 4 days. He had hospital at home in, with an OOH GP visit where he was eventually given pain relief. He was completely bed bound at this stage with very little oral intake due to his fracture.

His second fall happened early hours of Thursday morning where he attempted to sit up to empty his catheter and fell, this time with a long lie. He was admitted through the ED again, eventually taken into MAU and then into Ward 25. He went from talking in the morning, becoming agitated mid to late afternoon, unresponsive that night and died just before midnight on Thursday. All of this happened within 24 hours.

During his last 24 hours in this world he was admitted to hospital (too late in my opinion - the chance for intervention was gone following the hastened first discharge). He went around 12 hours without pain relief and anti-sickness during this time. At this stage they were still actively treating him but could not confirm what the source of infection was.

When he eventually ended up in Ward 25, one nurse was terrible. Upon arriving we found her chatting to another nurse - we asked if my grandad could finally get some pain relief and her response was “we are discussing your grandfather now”. She eventually came to the room where she gave us a lengthy explanation of the fact that morphine requires 2 nurses for a counter signature and she had a full ward of people requiring medication.

By this point it was evident my grandad had become terminally agitated and was expressing pain although not verbally. At this stage my family and I noticed his IV fluids hadn’t been administered (likely for hours) as his cannula had dislodged. At this stage I got another long winded explanation that the hospital at night team were too busy to come and cannulate. This was where I had to assert the situation which was the fact that my grandads antibiotics were time dependant (already an hour overdue) and he was without IV fluids - probably for hours with minimal urine output. Thankfully following this the other nurse on the ward cannulated him and they eventually administered morphine.

Shortly after we left at around 11pm he died. My mum got the call that his breathing had changed. She had only just walked out the main entrance and returned immediately where he was dead - cannula, nasal oxygen removed and he had been changed into a hospital gown. The nurse said his pulse was “still faint” and he was likely still alive but my mum knew he was dead - he wasn’t breathing.

This whole journey has left me feeling physically sick and I cannot help think that if he had been admitted with care in the first instance, he may have had proper hospital care with rehab and be on the mend. The cause of death on his death certificate was “urinary sepsis” presumably from his catheter. This was inserted without antibiotic prophylaxis and likely incurred either due to insertion technique or poor catheter care as a result of lack of education and knowledge.

I wholeheartedly intend to escalate this further but he still hasn’t been buried. Once we have grieved I will seek to formally complain.