"The sudden death of my father: good people, poor system"

My father's health suddenly deteriorated. My mother phoned for an ambulance to get him into North Devon District Hospital.

It was only when this happened that I became aware of the severity of his health. 6 days later he passed away.

What was good

All the staff on Fortescue Ward were excellent; the nurses, the catering staff, the administration people, everyone. The quality of care was excellent. My father was made as comfortable as possible, and everyone made time to respond to questions, provided support and help when requested. The ward was extremely busy, yet the nurses were continuously calm, patient, very comforting and made themselves available when needed. The doctors answered all my questions, even the tea lady knew my father's name and treated him with great respect. I cannot stress how impressed I was with every individual that I came into contact with.

What was not so good

There were delays in obtaining a medical disgnosis. The operating model of working in separate teams and transferring a patient from one team to another decreased the communication consistency, altering information (an analogy Chinese whispers).

The lack of one person taking responsibility resulted in the participation of large number of different people that had a massive impact; different faces, different names - making it very difficult/impossible to have consistent communication and made it very confusing for me to cope with, even more so when I was trying to come to terms with the process of losing my father. The team working resulted in a recommendation based on inadequate information as the full picture was not understood. Consequently, inappropriate decisions were made, that is now causing me heartache as I am working my way through the grieving process.

No difference would have been made to the outcome of his death, but the chaotic way of making a diagnosis, telling me and then 2 hours later advising me to find a place to move him to, as that he was no longer in hospital, based on inaccurate information and what I felt was driven by the need to free up the bed, is causing me a lot of pain. I should have been sitting by his bedside, not spending my time investigating nursing homes.

I needed someone to help me understand the dying process and help me understand what was happening to him, so I could be there for him, not frantically trying to organise a place for him to be moved to, full of fear that the hospital would have to move him to another ward and be faced with dealing with another set of faces and be surrounded by other patients. I felt that I was manipulated, pushed it a corner, rather than being with my father.

I fully believe that everyone involved wanted desperately to do the right thing and their hearts were in the right place. I see this was driven by the hospital administrative pressures, a failure within the hospital operating model and processes designed without taking into any consideration that patients and relatives are people, who should not be rushed through a workflow process at great speed.

I want to talk to the hospital about my experience and to work with the hospital to improve other people's experiences. I will approach the hospital directly, but there if there is any support that can be given to make my voice heard, I would appreciate it.