Vignette 2.

Poor communication

A 57-year-old man was admitted to the emergency department from a hostel via his general practitioner. Initial and ongoing care was of a high standard, but the patient deteriorated and died rapidly. He had no next of kin with him at death.
Communication with the patient's family was poor during the whole period; there was no evidence from review of the medical records of any contact with them, despite there being a contact number in the medical record of a sister. The hostel manager contacted the family to inform them of the death and they then telephoned the ward with questions. This may have resulted in additional distress to the family. While the care of the patient was of a high standard there was clear room for improvement in communication with his next of kin.