"Shortcomings in monitoring, care planning & communication"

My father was discharged to a residential care home without nursing support, which had agreed to take him as an end-of-life patient with end-stage cardiac failure, oxygenated, on the understanding that St Michael’s Hospice, Hereford, would monitor his care. A Subject Access Request revealed that the Lead Palliative Care Nurse at Hereford County Hospital had intended that my father be assessed for Fast Track Continuing Healthcare (CHC) funding once in the home. No one from the Hospice contacted my father for 19 days, and no Hospice monitoring took place in the care home.

Via a Subject Access Request to view my father’s Health Records, we discovered that St Michael’s Hospice had sent a “welcome to our services” letter to my father’s former address, despite knowing he had moved to the residential care home. When a safeguarding concern was raised by a District Nurse at the care home, we pulled him out and arranged private care ourselves. When approaching St Michael’s Hospice nurses about a Fast Track Pathway for CHC funding (ignorant that a review had been intended) nurses vacillated over my father’s eligibility, admitting in writing that they were unaware the CHC process could be Fast Tracked, yet still making decisions about his eligibility anyway. They cited an ICB policy requiring clear evidence that he would die within 12 weeks, and based on two visits they said they did not feel sure this was likely (despite his ‘stop and start’ deterioration being typical of end stage cardiac failure). The hospice CEO defended this ’12 week policy’ as the correct guidance, and as provided by the ICB, despite the National Framework Guidance explicitly warning against strict life expectancy limits for Fast Track CHC, and despite the ICB Director of Corporate Services denying that any such policy exists.

A senior nurse from St Michael’s Hospice, who had never met my father, described him to CHC assessors as “deteriorating but not rapidly, and still able to eat and drink”. This was a couple of days after his Waterlow risk score had risen from 20 to 32 (over 14 days), stage four pressure sores were recorded as worsening despite the care plan being followed, and a Mid Arm Circumference Measurement (MUAC) had dropped from 23 to 21 cm over eleven days, indicating malnutrition. His frailty was Karnovsky 40 (Disabled; requires special care and assistance) and his swallowing had become increasingly difficult (first noted six weeks earlier) yet an open SALT referral had not been signed, as the GP was on holiday. This was a man who eight weeks earlier could still walk, put his own shopping away, eat normally and and use the toilet without assistance.

Twelve days later, in his final hours, the same nurse stated he was now eligible for Fast Track CHC “as he was confirmed as entering the terminal phase of his life,” contrary to the National Framework (which does not require death to be imminent). An inadequate care package was imposed without consultation, relying heavily on family support, contrary to 

the Fast Track Pathway. The plan allowed for two 30-minute care visits and one 45-minute visit in 24 hours, which - if he had not died shortly afterwards - would have left him alone in wet pads for many hours. When we expressed concern about the risk to his sacral pressure sores, the same senior nurse told us that “continence pads can be worn even when wet,” effectively endorsing leaving him in conditions that would have worsened his sores.

During his final hours, another senior nurse from St Michael’s hospice stood idly by while my sister provided essential care, including digital removal of severe constipation, and observed clear clinical signs (which she recorded) that death was approaching. Despite this, she insisted that he sign a CHC consent form while barely conscious, contrary to NHS consent standards and the Mental Capacity Act 2005, and despite the fact that he had already given verbal consent six weeks earlier. She propped the pen in his hand even though he could not hold it, and did not provide a surface for him to write on. In her notes she recorded that my sister “could not bear to watch.”

Finally, she noted his chief illness as bladder cancer (something he did not have). When we submitted a formal complaint, the CEO dismissed all concerns within days, blaming “the System” while ignoring the written evidence we provided. St Michael’s Hospice’s failures caused avoidable suffering for my father and extreme distress for our family, demonstrating serious shortcomings in monitoring, care planning, communication, and complaint handling.