"lack of communication around my mother's death"

My 91 year old mother was admitted to St George's in Wandsworth in July this year. She was weak and suffering from shortness of breath.

Following an unexpected bereavement, my mother had stopped eating. Although she had a lot of support she had reached the stage when she couldn't eat - a sort of anorexia. Arrangements had been made by the community team for her to see a psychiatrist as a matter of urgency. She was already taking anti depressants, but they wanted to see if anything else could be done. She had also been taking co codamol for a long time, to help with severe back pain.

I was away when my mother was admitted. On my return in mid August, I was aware that my brothers and many other visitors were concerned, so I asked to speak to her Doctor.

This is what emerged:

No arrangements had been made for her to see a psychiatrist. Some communications mix up was blamed.

She was dependent on co-codamol for back pain but in spite of repeated requests by my brothers these were not being prescribed. One brother was massaging her back to try to help her, but nobody seemed to care.

This means that her last days were spent in more pain than was necessary,

Although it seemed clear to me that my mother was dying, the doctor seemed content that her breathing difficulties had been cured and arrangements were being made to move her from the hospital. A very nice resettlement person came to see her that afternoon. I doubted my judgement on her condition. At this stage she had a catheter, she could not speak and was taking minimal amounts of food and drink. She was very weak.

At this stage a psychiatrist and co codamol were promised. I have no idea if the medication was ever given.

The following day my mother died. According to a witness this seemed to surprise the medical staff.

My brother received a call from the coroner to say that the cause of death was unclear. It was pointed out to him that at some stage over the past few days my mother had fallen out of bed. This had not been reported to us.

These are my observations:

If my mother had been a young person, I can't help thinking that her malnourished state would have been taken much more seriously. This says something about the way the NHS treats older people

Given the IT at our disposal I cannot accept that my mother's notes, including her need for co-codamol, had not been communicated.

My brothers' (and other family members) requests for co-codamol were ignored, presumably because nurses did not pass them on to a doctor. My brothers did not understand what seems to be the unwritten rule - that unless you spoke to a doctor, action could not be guaranteed.

Ideally, somebody would have identified my mother's true condition and had the humanity to warn us and suggest a Hospice. We could have afforded to pay.