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Inquest finds communication between clinicians and family 'less than optimal'

Inquest into death of 69 year old placed on a Withdrawal of Treatment Pathway finds clinicians communication 'less than optimal in a number of significant respects'

Bob Goold

28 February 2014

A coroner has found that clinician’s interaction with the family of a 69 year old man who died after being placed on a Withdrawal of Treatment Pathway in February 2013 was "less than optimal in a number of significant respects" and that a formal consultation and decision on the end-of-care pathway should have taken place.

The Coroner for South and West Cambridgeshire, David Morris, delivered his conclusion into the death of Robert Brian Goold, a 69 year old father and grandfather, who died at Addenbrooke’s Hospital on 25 February 2013 following a fall at home.

Mr Goold suffered from Alzheimer’s dementia and was supported to live at home with his wife, Doreen. Mr Goold was admitted to the Neurological Critical Care Unit (NCCU) at Addenbrooke’s Hospital on 4 February 2013 after sustaining serious head and neck injuries.

His condition stabilised with treatment and on the evening of 18 February 2013, a decision was taken to take him off ventilation when it was considered he would have the best chance of breathing independently.

Later that evening, Mr Goold was started on an end of life pathway without the agreement of his family or any consultation with them as regards the decision to commence end of life care in his best interests. Mr Goold survived for 7 more days on the pathway before dying on 25 February 2014.

Mr Goold’s daughter, Susan Phillip said on behalf of the family:

“We welcome the Coroner’s findings in respect of the failings in basic communication which denied us the opportunity to be involved in important decisions that were being made in respect of my father’s care.

“We are pleased that he recognised that the Trust did not adhere to their own internal protocol for end of life care, which provided for the close involvement of family members.

“It remains unclear to us though as to how a responsible clinical decision was taken to commence end of life care, in accordance with the protocol, when no single member of the treating team acknowledged in their evidence responsibility for the decision.

“We remain concerned about the lack of transparency as regards the clinical decision making process. 

“Copies of the Trust’s revised end of life protocol documentation have today been disclosed to us.

“We are pleased that the relevant policies have been reviewed and amended in light of this case, in particular to recognise the need for proper record keeping and documentation of end of life treatment decisions, as well as for regular reviews of the clinical appropriateness of those decisions.

“Crucially, further training in communication is now to be rolled out at the Trust to ensure that other families do not find themselves going through what we had to.”

Charlotte Skouby, solicitor at Leigh Day who represented the Goold family in the Inquest proceedings said: “This is an incredibly sad case of a family being denied the opportunity to be involved in end of life care decisions concerning a much loved husband, father and grandfather.

“The Coroner was clearly critical of the Trust for the shortcomings of their end of life care consultation process, which caused Mr Goold’s family great undue distress.

"Whilst the Liverpool Care Pathway has now been phased out, NHS Trust and unit specific end of life care pathways are still in operation, meaning that this remains very much a real issue for patients and their families.

"It has always been the case that family members should be consulted about serious medical treatment decisions made in the interests of a patient who lacks capacity. It is regrettable that it has taken this case to show the Trust the importance of this consultation process.

“The family are now considering their options in relation to formal legal action against the Trust in light of these findings.”

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