Settlement achieved following negligent death of elderly patient in hospital

We recently settled a claim for our client, a retired police officer in the Metropolitan Police Force, following the tragic and unexpected loss of his father while in hospital. We managed to negotiate a settlement after securing an admission of liability from the hospital trust, avoiding the need to start court proceedings.

Our client’s story

Our client’s father, who was 82 years of age at the time of the events, had a history of epilepsy which was well-controlled, congestive cardiac failure, stroke, and poor renal function. In early July 2019, our client and his family noticed that he was becoming confused and behaving out of character. Our client’s father attended his GP, who was concerned by his behaviour which had no obvious explanation, and referred him for further observations at St Mary’s Hospital which is part of the Isle of Wight NHS Trust. 

Our client took him to the hospital that day, and he was triaged in A&E before being admitted to the acute assessment unit (AAU). A very cursory examination was undertaken. There was no assessment of volume status (the amount of blood in his circulatory system), no neurological examination and a cursory abdominal examination. His Glasgow Coma Scale reading (an assessment of level of consciousness) was stated as 15/15, although given that he was confused, it was our case that this could only have been a maximum of 14/15. It was also our case that had volume status been assessed as was mandatory, this would have demonstrated that he was fluid overloaded, requiring treatment and careful observation.

A chest X-ray was performed and reported as showing extensive fluid in the lungs as well as an enlarged heart. It was our case that this demonstrated pneumonia and heart failure, and that our client’s father’s confusion indicated delirium due to acute illness on a background of vascular dementia. He was continued on his usual dose of diuretic (furosemide 40mg orally). No antibiotics were given.

Nursing records from 9 July note that he refused all medications and oral care. A bladder scan revealed an enlarged bladder of greater than one litre. The nursing staff managed with difficulty to insert a urinary catheter, and he was said to have immediately settled following this. It was our case that he was in urinary retention on admission, which was a major cause of his delirium and associated distress, though this was not identified due to an inadequate assessment. Despite the note that he had refused all medication, furosemide was signed for on the drug chart on this date.

When our client visited, he was told that his father’s hearing aids could not be located, which prevented him from being assessed by the old age psychiatry team. An appointment was made with the audiology department to replace them, though this never took place. Food and fluid charts for 9 July (day two of his admission) were blank.

Our client received a telephone call on the evening of 10 July to inform him that his father had started wandering around the unit and was behaving increasingly peculiarly.

The following day, our client’s father was reviewed by a medical registrar, who diagnosed worsening vascular dementia. It was noted that he was not allowing the nurses to record his observations. Despite no examination being performed or any attempt recorded to identify causes of delirium and strategies to reduce this, he was said to be medically fit for discharge.

A deprivation of liberty safeguarding (DoLS) form was completed on 11 July stating that he was ‘very confused, wandering, disorientated. Requiring close supervision. Refusing all nursing care. Not orientated to person, time or place.’ It was noted that he was refusing to take his oral furosemide; however, he was not given intravenous furosemide in its place, and so his fluid overload was left untreated.

Our client visited his father on 11 July. He appeared dishevelled and exhausted. Our client noticed that food and fluid charts for the day were blank, and he brought these to the attention of the ward head. He asked for his father to be taken off the ward and was told that this would happen, and that plans were to transfer him to the stroke ward. Our client also noticed that his father’s dentures required cleaning. He had with him a bottle of Steradent denture cleaning tablets and showed this to the nurse. He assumed they would be stored safely, but it transpired that this was not the case.

Later that evening it was recorded in the notes that the nursing staff believed our client’s father had swallowed Steradent tablets. Examination revealed his chest to be clear and his abdomen soft and non-tender. The toxicity database TOXBASE was consulted and advised that though systemic toxicity was expected to be low, issues were most likely to arise from tablets lodged in the oesophagus, causing local erosion to the soft tissues.

Our client was informed by telephone and was told that his father was found with foam on his chin and the tube of tablets in his hand. When our client attended shortly after receiving the phone call, he was advised that the area around his father’s bed had been cleaned following the incident; however, he found a Steradent tablet on the floor near his father’s bed.

That day it was noted that our client’s father’s blood oxygen levels were dropping. On examination he was noted to have multiple crepitations (crackles) in both lungs and his tongue was swollen. A diagnosis was made of allergic reaction, aspiration or congestive cardiac failure with or without infection.

On 12 July our client’s father was prescribed two litres of fluid over 20 hours. A repeat chest X-ray showed fluid-filled lungs, and heart failure was noted to be worsening. He was transferred to the Appley Ward on 13 July 2019. Our client noted that his father’s condition seemed to have deteriorated, and his mouth appeared to be visibly blistered.

On 15 July our client’s father was reported to be feeling slightly better. The plan was to encourage him to take sips of water and to administer the antibiotic co-amoxiclav for five days. On 16 July, he was due to have a speech and language therapy review of his swallowing function, but they were unable to assess formally as he was drowsy. 

He underwent a medical review the same day and it was noted he was increasingly confused and had an enlarged liver on examination. Bloods taken the same day showed worsening renal function. It was our case that the abnormal liver function tests were due to hepatic venous congestion due to under treated heart failure. His respiratory rate was raised and oxygen saturations were beginning to decrease. His condition continued to deteriorate, and he very sadly passed away on 21 July 2019. 

How we helped

We investigated our client’s claim on behalf of his late father and obtained expert evidence from a geriatrician, who supported the following allegations of negligence:

• There was a negligent failure to assess volume status on admission, which is a mandatory assessment to perform in an unwell older patient being admitted to hospital. Following appropriate assessment as to whether the deceased was dehydrated or volume overloaded, a decision ought to have been made as to whether or not fluid should be removed with diuretic medication (ie furosemide).
• There was a negligent failure throughout the admission to assess volume status in order to allow fluids and diuretics to be titrated accordingly. This was particularly important in the case of the deceased due to his renal impairment.
• There was a negligent failure throughout the admission to appropriately treat the deceased’s heart failure and to prescribe furosemide at appropriate doses.
• There was a negligent failure to ensure the deceased’s denture cleaning tablets were safely stored away, and there was a negligent failure to provide close supervision as required following completion of the DoLS form.

But for these breaches of duty, our expert considered that the deceased would have survived.

We sent a letter of claim to the defendant trust setting out these allegations. In its letter of response, liability was denied in full. Our expert geriatrician remained supportive of the claim, and we sent a rebuttal letter highlighting the inadequacies in the letter of response and re-asserting our client’s claim. We finally received a reply along with an admission of liability. 

The defendant admitted that the imaging showed cardiac decompensation and there was a failure to appropriately manage the deceased’s fluid overload. It was also admitted that there was a failure to increase the daily dosage of furosemide. Finally, it was admitted that as a result of the trust’s negligence, the deceased’s condition deteriorated.

Once we had arranged for a grant of probate to be obtained, we were able to begin settlement negotiations. Damages were claimed for the deceased’s pain, suffering and loss of amenity whilst in hospital. They were also claimed for his surviving widow, in the form of a statutory bereavement award, and for funeral expenses, alongside damages to reflect her loss of financial and services dependency. 

Rosie Nelson, senior associate at Penningtons Manches Cooper, comments: “There are important lessons to be learned following the negligent errors made by the defendant trust, leading to the sudden and unexpected death of the deceased whilst admitted to hospital. It is of vital importance when assessing elderly patients, often with multiple co-morbidities, to look at the whole clinical picture in a holistic way to ensure that adequate care is provided. This was a tragic case and I hope that our investigations have provided our client and his family with some solace in answering the questions they had surrounding his father’s death.”

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