Monica’s Story

The Patient Journey



My mother suffered a severe stroke in December 2006. As a result she was transformed overnight from being fairly independent to being totally dependent and in need of 24 hour care. Before being transferred to a nursing home she spent six months in a Foundation Trust in the north of England. She died in July 2007.
This paper documents her journey and identifies areas of care for both patients, families and carers that could be improved. It demonstrates that inappropriate systems and staff with different values lead to:

  • Poor communication between staff and with patients/relatives
  • Inaccurate, inconsistent and incomplete written information
  • Discrimination on the grounds of age
  • A lack of patient/family involvement
  • Discrepancies in the assessment process
  • The risk of exploitation of vulnerable older people
  • A lack of dignity and respect
  • Inappropriate targets which not help to improve service provision
  • Patient’s symptoms being ignored
  • Patient safety being compromised
  • A lack of clarity and understanding about confidentiality and data sharing
  • Social workers inappropriately managing assessment processes


The single, most important issue, for anyone who has the misfortune to suffer ill-health and require treatment, is good communication. Sadly, this was not an area in which the Foundation Trust excelled. Staff were either unable, or unwilling to communicate effectively and this was an issue that was experienced at all levels.