Flora Baber

“Whilst record keeping showed Dr [name redacted] as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed. Also, she did not always receive appropriately pureed food or the assistance that she needed to eat.”

“There was a delay in referring Dr [name redacted] to the speech and language team and in treating her oral thrush. Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this.”

“Family members told me that at one point, they found the member of staff allocated to Dr [name redacted] bay sitting in a chair apparently asleep.”

“Dr [name redacted] was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent. Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy, she was wearing an incontinence pad, and she should use that instead. I was shocked to hear this.”

“Dr [name redacted] had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication. This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home. However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes. At the very end of Dr [name redacted] life, the benefit of pain rel”