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An unsafe ward

BMJ 2013; 346 doi: (Published 25 February 2013) Cite this as: BMJ 2013;346:f1243
  1. Judy Shakespeare, retired general practitioner, Oxford
  1. judy.shakespeare{at}

This is the story of how my father died in a modern British hospital. In late March 2012 he organised his own 90th birthday party, where he stood and delivered an articulate and funny after dinner speech. He was a retired anaesthetist living alone and independently in a small village in the north of England. By the beginning of May he was dead, having sustained a fractured femur in hospital (not Mid Staffordshire NHS Foundation Trust).

He had significant comorbidities, including critical aortic stenosis. In mid-April he was admitted for cardiac assessment and deemed fit for cardiac surgery. Two days after discharge he was re-admitted under a gastroenterologist after a gastrointestinal bleed. His death happened after a fall eight days later.

I believe that a lack of basic care in hospital led to his fall and death. I wrote to the hospital trust, including a personal narrative of events, and I asked questions. The trust has carried out a serious untoward incident review, and I have discussed the outcomes with the trust; it has not disputed any of my comments about his care. I have no interest in litigation, only in improving the quality of care for other patients and families.

These are my personal reflections about why Dad fell, gleaned from my own observations, family members, talking to Dad at the time, and meeting with the hospital staff after his death.

On admission, Dad was assessed to be “self caring.” For the next few days he was kept nil by mouth because repeat endoscopies might be happening; he had three in all. We visited, but no one, including Dad, could get any clinical information. After three days without food or water, he was becoming confused and thirsty and got stuck in the toilet. Two days later, when my sister-in-law tried to express her concerns to a nurse she was asked to leave because the consultant was doing a ward round. She called me because she was so worried about his weakness and confusion and the lack of information. I travelled up the next day. Apparently he fell in the corridor that night, but no one told us this until after his death. He was unharmed but was not reviewed, so he was still considered “self-caring.”

When I arrived, Dad was sitting out of bed. He had bare, swollen feet and severe bilateral gout; he could barely talk because his mouth was so dry; he had shrivelled up in the days since I had last seen him; he was incontinent and clearly confused. The bed was surrounded by clutter; bed tables, stacking chairs, Zimmer frame, slippers, dressing gown, and dirty clothes. I spoke to the foundation year 2 doctor. Neither she nor the nursing staff was aware that Dad was confused. He told me he didn’t know what was going on, everything seemed chaotic, no one seemed to be in charge, no one ever spoke to him and they didn’t answer his buzzer, so he had given up asking to be taken to the toilet. I spent many hours with him and cajoled him into eating and drinking. He was right that no one ever spoke to him.

By the time I left he seemed less confused. The next day he was much better; no longer confused, no longer incontinent, and his humour had returned. He was delighted because he had had a bed bath—his first wash since admission a week earlier. When I was leaving I took him to the toilet and helped him into bed, but he was worried: “I am really afraid of going to the loo at 3 am,” he said. Of course, I didn’t know he had already fallen. Dad was right to be afraid; he fell about that time the next morning. I wish I’d stayed with him overnight to provide the care that the nursing staff did not. His deterioration meant that he was now unfit for surgery, and he died the next night.

We were very upset by his death and so were the nursing staff. In their defence they were understaffed, especially at night, had poor ward leadership, and the physical structure of the ward meant that patients were not visible from the nursing station.

I was interested in what changes had been made as a result of Dad’s death which might make it safer for other patients in the future. The senior nursing team told me that in future patients would be reassessed after a fall and that fluid balance would now be monitored in elderly patients. A major action point was that when observations were being made the nursing staff would actually “talk” to patients. This confirmed my view that Dad was never spoken to, but nevertheless I was shocked. They proudly showed me their “Slips, trips, and falls” policy, by now a hefty tome. I wondered if I had helped at all; common sense being buried under a mound of paper, and good nursing practice only an aspiration for the future.

My Dad was a sick man who may have died anyway. But it felt as though he had been neglected for a week: no food, no water, no washing, no timely help getting to the toilet, no conversation. It seems obvious that a 90 year old would become ill in this situation. No individual was unkind; it was the whole system that ignored him. My Dad was unsafe on that ward. “First do no harm” has been drummed into me through my medical life, but doing “nothing” is not an option either. I think Dad’s story could have happened in many hospital wards in the UK, not just in Mid Staffs. I’m hoping the results and recommendations of that inquiry will improve things for the future.


Cite this as: BMJ 2013;346:f1243

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