An elderly women was left in agony in the final weeks of her life after "a catalogue of failings" across the NHS.
The Queen Elizabeth Hospital in King's Lynn has commissioned an independent external review into the treatment Eva Patterson received after she was admitted on April 2, 2022, after suffering a suspected gastro-intestinal bleed.
Mrs Patterson suffered a fall during her stay at the QEH, but was discharged without being X-rayed.
Fakenham Medical Practice is also investigating a complaint from her family into the treatment she received after her discharge, while the Norfolk Community Health and Care NHS Trust, whose district nurses provided palliative care, has apologised and offered a £2,950 payment in respect of how it looked after Mrs Patterson.
Frail Mrs Patterson, who suffered from dementia, had a fall in hospital three days after she was admitted on April 5, 2022 - her 88th birthday.
She fell heavily on her right-hand side, where she had earlier suffered a fractured hip in a fall in early 2020.
Her family believe she should have been X-rayed before being discharged on April 7.
She was also given a blood transfusion beforehand despite her family saying she did not have the mental capacity to sign the consent form.
Retired receptionist Mrs Patterson died on June 18, 2022 at the family home in South Creake, near Fakenham. The cause was recorded as vascular dementia and a grastro-intestional bleed.
Her daughter Jane Barker said she was still waiting for answers from the hospital over why it did not X-ray her mother after she fell and the care she received from the GP practice
"Guidelines say every elderly person who falls in the care of the NHS should be X-rayed or given an MRI scan," said Mrs Barker, 55.
"She was in significant pain, every time she moved her right leg it was horrifically painful and she would scream, a real scream.
"Our hope was always that having cared for her for the last six years, she would have a comfortable and dignified death in our home, with her family around her.
"Sadly due to a catalogue of failures, mismanagement and appalling communication across all teams, my mother was left to die in excruciating pain."
Guidelines from the NHS's National Patient Safety Agency state patients who suffer falls should be assessed for symptoms of fracture.
Mrs Barker said she was told her mother was bruised but it would improve.
But the pain continued and she began refusing food over the Jubilee weekend in early June.
Mrs Barker called the Fakenham Medical Practice, who sent a doctor to see Mrs Patterson on June 6.
The doctor told Mrs Barker her mother now required end-of-life care and he would prescribe a pain patch along with medication.
But while the family were given other end-of-life medication for Mrs Patterson, the pain patch was missing when they went to collect it.
Mrs Barker said two patches were delivered in June 16, two days before her mother died.
She said when district nurses arrived to begin palliative care a week earlier, they did not administer pain relief.
Mrs Barker has complained to Fakenham Medical Practice about the delayed arrival of the pain patch.
A practice spokesman said: "We were sad to learn of Mrs Patterson's death, and share our condolences with her friends and family.
"Fakenham Medical Practice takes all complaints very seriously, and we are unable to provide any further comment at this time while the complaints process is undertaken."
Norfolk Community Health and Care NHS Trust (NCHC) has offered a £2,950 out-of-court payment after Mrs Barker complained to the Parliamentary and Health Service Ombudsman about the standard of care their nurses provided.
Carolyn Fowler, its director of nursing and quality, said: "NCHC accepts that there were communication failures in this case which contributed to a level of care that was below the standard we aspire to deliver.
"We are deeply sorry for the harm caused to Eva in her final days of life. We apologise for this and the distress that it caused Eva and her family.
“We have provided assurances to Eva’s family that an investigation into this incident was undertaken in November 2022. Using the findings of this investigation we have ensured improvements are made to our communication processes and skills.”
The Queen Elizabeth Hospital has yet to provide her with a copy of the findings of the independent review.
A QEH spokesman said: "The Queen Elizabeth Hospital King’s Lynn Foundation Trust has taken the complaint of Mrs Barker very seriously, and continues to do so.
"The trust has commissioned an external independent review, for which we await the final report, and the complaint remains open.
"With this in mind it would be inappropriate for us to comment further at this time."
Mrs Barker is still awaiting a copy of the report.
"All I want are some answers and some clarity so I can put this to bed," she said.
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