Continuity of care: a daughter's story

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As part of our paper on continuity of care for older hospital patients, we asked carers currently involved with a very old person with recent experience in hospital to tell us their stories. Here we hear from a daughter about her mother's care.

My mother was always very active and independent up to her mid-80s, enjoying activities such as book groups, gardening and spending time with her family. Until recently she lived independently next door to my brother. She has now moved to a care home close by.

Six years ago she had community-acquired pneumonia and was admitted to hospital for seven weeks. In hospital she contracted Clostridium difficile [infection] and was transferred between six different wards, including gynaecology, which was obviously not appropriate. It was very difficult to find out who was responsible for her care or who knew the most information about her condition. The nurses could only tell us the name of the consultant on-call that day, and the consultants rotated from day to day.

Throughout her time in hospital, staff continually called my mother by the wrong name. She has been called Harriet all her life, but it is her middle name, so her first name is written on all her records. We drew this to the attention of staff on the ward; it was important, especially as she was suffering from episodes of confusion, but it did not stop. Everyday someone from the family would visit her and wipe the wrong name off the whiteboard. On one occasion, after tracking down a registrar responsible for her care, we explained the situation and he wrote, 'likes to be called Harriet' in big letters on the front of her notes, but it still had little effect.

Recently she was very unwell again and confused and disorientated. She was moved between several wards and unsurprisingly contracted norovirus. It had a profound effect: at her most confused and sick we were unable to visit for a week, leaving her isolated and frightened.

Before she was discharged, there was a multidisciplinary case conference including the family, which went well. Unfortunately, despite the positive case conference, her care plan disintegrated and everything happened in a rush. The ward was keen to discharge her because of the norovirus. She was discharged without the family or the GP being told, and no one made sure that the community nurses were asked to do her injections and she did not get a referral for chiropody. The care home was expecting her, but on the day she was discharged they had very little notice. I had to intervene to make sure the ward staff spoke to them. After she was discharged she was very low, emotionally and physically.

She has also had exceptional care. On a recent admission, when I arrived to visit her, the ward sister introduced herself, explained that she was the main contact and even knew my mother’s correct name. The atmosphere on the ward was completely different; the nurses were busy and engaged, rather than huddled around reception, they checked on her regularly and introduced themselves before starting treating her.

Overall, she has received the best care from staff who have treated and respected her as a person rather than stereotyping her as an elderly person who’s not capable of thinking and doing things for herself.


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