"poor quality of care, poor communication with families and patients"

About: Chesterfield Royal Hospital

(as a relative),

Here is an extract of the failings of my father’s care and this is an extract of the letter sent to the ward Matron and PALS. I can honestly say that I would not send another family member to that hospital ever again and that we would rather travel the extra distance and go to Sheffield. Not only is the care appalling but the lies and an excuse made up after to try to cover them is unbelievable and does nothing to help mourning family members.

Dear? I am writing to you because you were so honest and open with me about my father’s condition. Sadly my father passed away in my arms within approx. 4 and a half hour of being at home. I had returned to West Yorkshire on the Sunday evening, due to a busy work schedule and to attend my mother in laws funeral on the Tuesday and was waiting for my youngest daughter to arrive back from America to break the news that her grandfather only had approx. 4 months left to live.

My daughter that lives in Chesterfield had spoken to the ward sister on my behalf on Monday 25th February at approx. 3. Pm. Here is an extract of the conversation. Basically much the same as you told me, but that:

Pneumonia was getting better, (anti-biotics for 7 days)

Fibrosis getting progressively worse.

Unable to do another chest x ray because the pneumonia would show up scarring.

Tested without oxygen and seemed to be normal, however if making him feel better would be left in place.

Not able to go back on Mirtazapine due to liver function. but would monitor and may go back on reduced dosage.

Still catheterised

Pressure boots in place

Red bottom not stage 1 not breaking, would be monitored

Eating little and often, hence weight gain.

That we had to choose one person for point of contact.

We had already inquired about getting my father back home because it was his wish, he felt that should he have to stay in hospital much longer he would die in there.

My daughter was told that getting him home could be arranged.

Home oxygen could be arranged within 4 hours, can take 24 hours depending on circumstances

Social Services would be involved before discharge

Palliative Care would be involved before discharge

Right For Care Plan would be put in place along with

DNAR form would need to be put in place if required.

Due to my not being able to get back to Chesterfield until the Thursday evening it had been discussed that a family meeting would be held to decide on the point of contact. The majority of the family wanted me to be the designated point of contact, due to my experience within the NHS.

On Wednesday the 27th February I received a call at work from the hospital saying that my father was being discharged that afternoon and that my step mother had decided she would be the point of contact, which meant that she could not (or would not )discuss any further information with me.

This was very upsetting because being so far away from my father meant it was important for me to have up to date information regarding his condition etc., to allow for travel time from West Yorkshire to Chesterfield.

I had to wait until I got home from work that evening to find out that my father had not been discharged due to Home oxygen not being sorted out. My eldest brother went to the hospital at 6. 30 pm to find my father sat on his bed, dressed but only wearing a t shirt, shivering with cold and barely able to string two words together, due to being taken off his oxygen all afternoon, his bags where packed, and he was waiting to go home. My brother had to inform him that he wasn't being discharged that day after all. He then had to get a nurse to get some fresh bedding and put my father back into bed. I cannot begin to imagine just how distressing this was for him.

I was so upset that I rang the hospital the following morning from work to ask (complain about) what had happened, they didn't seem to know which code had been used to order the home Oxygen whether it be 4 hour urgent or 24 hours normal hospital discharge, but did admit that they had known from 5pm that he was not being discharged that day, so why had they not informed my father themselves and got him settled back into bed.

I received a call from my brother at approx. 1. 30 pm to say my father was back at home settled into bed with his oxygen. I waited for my daughter to arrive back from America, whilst packing my bags in order to go stay with my father for the next 6 days and to organise a rota within the family to ensure that dad was never left alone. My husband was finishing work early to drive me to Chesterfield.

At approx. 4 pm I got another call from my youngest brother saying that dad was making strange gurgling noises and that he had called the doctor. I knew immediately what this meant and rang my daughter to get her to my dad ASAP, along with the rest of the family members.

I then had to endure the worst two hour journey of my life fighting through tea time traffic to get to my dad’s side.

I arrived at approx. 6. 10 pm and dad passed away in my arms with me only managing to tell him I had arrived and that I loved him, I tried ring his GP but it was already out of hours and by the time someone from 111 had got back to us it was too late.

Dad's doctor arrived later and immediately apologised because he had not been informed by the hospital that dad was so ill and had assumed that with him being discharged that afternoon that he had probably picked up a chest infection.

We had to then go through the trauma of having to have a post mortem.

My problem is, why was no one around when my father was dying, where was the palliative care team, why did we not have a contact number for them, where was the Right to Care Plan, why had we not been issued with any DNAR form. What if my father had needed morphine and no one was around to administer any syringe drivers. Why was no one from any nursing team available? Dads GP had organised for their district nurse team to visit the next day, even his carers that must have been informed by the hospital that he was being sent home arrived on the Wednesday evening to be told that the discharge had been cancelled, and then they arrived to put dad to bed after he had passed away.

I know that no one can be exact about when a person will die, but surely if my dad had been examined by a doctor before his discharge on the Thursday, why did we not get any indication that dad had deteriorated so badly.

You told me yourself on the 21st that dad was very ill and that we were looking at 4 months and that you did not feel the need to be calling everyone to his bedside at that time, but that you would have a better idea of how long after the anti-biotics had had time to work. (you said you would have more of an idea before my mother in laws funeral on the 26th) Obviously I was unavailable to talk to you again before this date, but that is why my daughter spoke to the ward sister on my behalf

Please can you look into all this and tell me what went wrong, because something clearly did, communication was definitely very poor.

I also have a few other issues that need addressing regarding my dad’s stay in hospital.

I asked again on the Thursday and Friday about why the Mirtazapine had been stopped and still no one could give me an answer, which my dad’s GP has said himself that he saw no reason why it should have been stopped he had checked my dad’s blood results himself on ICE, I know being stopped so suddenly from 30 mg Mirtazipine would not have helped dad's frame of mind.

On the 23rd of February one of the patients in dad’s bay was moved off the ward due to Norovirus, which I saw myself and was told by a member of the nursing team on the Sunday, yet my dad was left in the same bay when he was especially susceptible to infection.

On the 24th we had to point out to the nursing team that my dad’s cannula had been left in place since the Tuesday evening 6 days, which again should not have been allowed, and was only moved when we pointed this out.

We also found out that one of the supplement drinks that he had been given by the hospital was almost 6 months out of date.

Dad was only every given his sleeping meds, Zopiclone whenever myself or my daughter where present to request it for him.

Yet again I have travelled 70miles to be told an absolute utter pile of rubbish by the hospital regarding these issues, even denying that the medication had been prescribed by their pharmacy. To say I am angry and upset is an understatement, and I am not prepared to leave it there and allow such failings to continue. This hospital underwent Care Quality Commissioning inspections in August 2012, they failed on 3 outcomes and these are all the same outcomes are all the same as the issues we had with my father’s stay at the hospital, so clearly lessons have not been learned actions have not been put into place for improvements. I would advise anyone that has to stay at this hospital, please ask to be shown your medical records daily to check what is being actioned regarding your stay in hospital, insist on checking your medication records are accurate, and for any one that has someone admitted to this hospital with dementia or learning difficulties be alert, push the staff to take notice of your concerns and to not, like myself believe that the hospital only has the patients best interest at heart.

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