"Poor care coordination"

About: Royal Perth Hospital / Ear Nose and Throat (ENT) Surgery Royal Perth Hospital Ear Nose and Throat (ENT) Surgery Perth 6000 Royal Perth Hospital / General Medicine Ward 10A Royal Perth Hospital General Medicine Ward 10A Perth 6000

Posted by swingcp56 (as a carer), last month

My relative was admitted in late last year with a jaw bone infection. They received treatment from the ENT and ID teams. After they went home their health continued to deteriorate to the point where they were readmitted via a flight from the Kimberley where they lives, under general medical with malnutrition.
Despite the doctor who saw them mentioning some of their issues are likely to be related to depression, they were fed with via Nasogastric tube and discharged out the hospital 5 days later with the information to their primary practitioner being "care complete". Information on the summary for my relative just listed their up coming appointments. They were given supplements but as they couldn't carry them they left them in the hospital unknown to their relative who collected them.
On discharge they were unable to care for themselves. They had a fall at home in the first week and mentioned they also had a fall in the hospital just before they were discharged.
Luckily they have a caring family. We linked them in with the fabulous team at Derbal Yerrigan. They have supported my relative's rehabilitation for their mental health, physiotherapy, arranged supply of supplements from dietetics at RPH. We have worked hard since an admission earlier this year to enable my relative to be more independent and they were starting to prepare their own breakfast and able to walk small distances without their walker.
Then last month they were suddenly readmitted by the ENT team as the infection has re-emerged and spread. They had had an MRI on recently and the ENT team saw my relative in the morning and said they would discuss their case with the team and they were to attend the ENT clinic at 30 minutes later to discuss the outcome.
At this point my relative called me. I work nearby and was able to come immediately. At my relative's request I attended their appointment with them. I expressed my concerns about their deterioration and mentioned they were having trouble eating again due to the infection. I also mentioned how the family has had to become full time carers since my relative's last admission and we needed to be involved in the discharge planning. They said there was no plan to discharge my relative and they would be happy to work with the family. At my suggestion they also arranged an allied health review.
I have been to the hospital most days as my relative has been confused and upset after each time the ENT team have come through. My relative has significant hearing loss due to the condition they are treating but I feel they still talk to my relative like they completely understand. It is taking my relative a long time to eat, but I believe because it is seemingly convenient for their day they insist on interrupting my relative's breakfast everyday on their rounds and today sent my relative for a hearing test while they were trying to finish their breakfast.
My relative thought they were going to see them again after the hearing test as asked me to come again to talk to the doctors to find out what is happening. I am unable to be informed normally as no one has asked my relative if they would like anyone except their other relative who lives in Albany.
More recently I was told what was happening and that they were ready for discharge as soon as HITH could be arranged.
I am very concerned for my relative's welfare but the doctor I spoke to basically admitted they need to do what works for them and not consider my relative's complex family arrangements. They did at least admit they would not send my relative home if it wasn't safe but given their apparent attitude to collaborative care and what I feel was the very poor discharge planning from last time I don't have faith in their words.
I am now waiting for the Ward MDT meeting to see if allied health are happy to clear my relative for discharge as I understand the team have made this plan without checking in with them and told my relative that this is what is going to happen.
Now I have to phone other relatives who will likely drop everything so they can continue to care for our relative.
The ENT team seem to be stepping back from my relative's care but have suggested they would prefer them to be cared for in Perth so they can keep an eye on them without considering the needs of their current carers.
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Responses

Ben Noteboom

Executive Director,

Royal Perth Bentley Group

Submitted on 15/05/2025 at 6:00 PM

Published on Care Opinion Australia on 16/05/2025 at 9:36 AM

Dear swingcp56
Thank you for taking the time to share your concerns and experiences regarding your relative’s recent hospital admissions and ongoing care at Royal Perth Hospital (RPH). I acknowledge the distress and frustration you and your family have experienced, and sincerely regret that aspects of your relative’s care and discharge planning have not aligned with their needs or the level of care your family expect and deserve.
Though it is difficult to comment on specific aspects of their clinical care on the Care Opinion platform, your feedback has been shared with the relevant clinical teams and hospital leadership to support service improvement, particularly in the areas of communication, discharge planning, and providing seamless care for people from country areas.
Accessing healthcare from a remote region such as the Kimberley presents significant challenges, particularly when care is required in a metropolitan setting far from home, community, and support networks. The burden this places on families - emotionally, logistically, and financially - is considerable, and the Royal Perth Bentley Group is committed to improving how we support country patients and their carers throughout their healthcare journey.
Your feedback highlights several important issues, including:
The complexity of your relative’s medical condition and the impact of their mental health on recovery. Concerns about communication, particularly in the context of hearing impairment and the need for family involvement in discussions and decision-making. The need for coordinated multidisciplinary discharge planning that considers the patient’s functional status, home environment, and carer capacity. The importance of clear, accessible information being provided to both patients and their families, especially when transitioning back to community care.
It is especially disheartening to read that you felt your relative was discharged previously in a vulnerable state and that this may have contributed to further deterioration and readmission. We recognise the importance of culturally safe, community-based care, and appreciate the vital role Derbarl Yerrigan has played in supporting your relative’s journey.
The Nurse Unit Manager of your relative’s current ward is aware of your concerns and has thoroughly reviewed their admission, including the evolving plan for their discharge from hospital. As your relative’s treatment plan becomes clearer, the multidisciplinary team (MDT) may explore the possibility of an inter-hospital transfer to a hospital closer to their family support network. Additionally, I would like to provide assurance that RPH Dietetics and Social Work are working collaboratively with the ward senior nursing and Ear Nose and Throat medical team, ensuring that necessary referrals and supports are considered as part of a coordinated discharge plan, in line with their preferences and consent.
I encourage you to request a family meeting with the MDT prior to discharge if you have any remaining concerns, to ensure the medical, allied health, and social supports are reviewed collaboratively, and you feel the discharge plan is safe, appropriate, and clearly communicated to all involved.
You are welcome to contact our Patient Experience team at RPH on (08) 9224 1637, Monday to Friday 8am to 4pm, or email RPBG.feedback@health.wa.gov.au, should you require assistance in facilitating communication with the ward MDT and ensuring your voice is heard.
Thank you again for your advocacy and the care you continue to provide to your relative. Your feedback is invaluable in helping us improve the way we support patients and families, particularly those from regional and remote communities.
We remain committed to working with you to ensure your relative receives safe, coordinated and compassionate care.
Kind regards
Ben Noteboom
Executive Director
Royal Perth Bentley

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Update posted by swingcp56 (a carer) last month

Thank you for the response.
As we were not getting any progress and our concerns about the serious deterioration of our family member has continued, I managed to obtain the name of the acting NUM. I did receive a response from the Nurse Unit Manager yesterday, although I note they now away until Monday (4 days away).
I am unsure which MDT you are speaking about. There have been several Medical MDT meetings and I understand the ward does hold an Allied Health MDT, however I don't believe the medical team has any engagement with the ward MDT.
It was heartening that the dietician finally caught up with my relative's primary carer yesterday and provided useful information to assist in caring for our family member when they are eventually discharged.
We have suggested on multiple occasions a family meeting or similar to the ENT team. It continues to be a concern that we are unable to work with other medical teams involved in my family member's care. All our advocacy appears to be only able to be conveyed by the home team and we are rapidly losing faith in their ability to see our family member as a person.
I understand that RPH is a teaching hospital, however we have only ever seen registrars. It is concerning the consultant has not seen a patient who is this complex. The only exception was the consultant who was performing the biopsy last night, who also kept saying they were not abreast of the case.
I will reach out to the patient experience team to follow up.

Ben Noteboom

Executive Director,

Royal Perth Bentley Group

Submitted on 23/05/2025 at 9:30 AM

Published on Care Opinion Australia at 1:46 PM

Dear swingcp56,
Thank you for your message and for taking the time to share your ongoing concerns.
I want to acknowledge the frustration you’ve experienced regarding weekend communication with the senior nursing team, and the complexity of your family member’s care. It is clear they are fortunate to have such dedicated support.
The Royal Perth Bentley Group (RPBG) are committed to patient and family-centred care, though I am sorry to hear that you feel your family has not been meaningfully engaged in the multidisciplinary process. Please be assured that their care has been guided by their individual needs, values and preferences. The Head of Department for ENT is now reviewing the situation and will oversee your family member’s care for the remainder of their admission.
We understand your request for a family meeting. However, to ensure the meeting is productive and aligned with the best interests of your family member, it will be scheduled once all the relevant specialties have reviewed the case and are in agreement on the care plan. This approach ensures clarity, consistency and the highest standard of care.
I appreciate your engagement with the Patient Experience team, and I hope this will support improved communication moving forward. In the meantime, we are prioritising senior medical review and will keep you informed of the progress.
Please know that your concerns are being heard, and we remain committed to working with you to ensure your family member receives the care and respect they deserve.
Kind regards
Ben Noteboom
Executive Director
Royal Perth Bentley Group

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Update posted by swingcp56 (a carer) last month

Our family continue to provide significant care to our family member in hospital.
I understand their care has been changed to the Head of Department in ENT and the ID team have provided useful updates in the past few days.
I continue to be concerned that each member of the team are providing care that they feel meets my family member's needs, however each member of the team is working as a silo and they are not seeing our family member as a person just a collection of things that need treating. Each clinician is ticking off the care in their area without any understanding of what others may be trying to do. It's very "not my department" thinking.
My initial contact with the Patient Experience team at RPH on (08) 9224 1637 was very disappointing. They only offered me the option to write a formal complaint and did not provide any additional support. We have had to continue to navigate the system ourselves.
The mention that the care plan would be communicated once decided would suggest that neither my brother in law or his carer are permitted to provide input into this care plan.
I am stunned there does not appear to be a care plan at present and this would seem at odds with the ACSQHC standard where a goal-directed comprehensive care plan is developed in collaboration with patients, carers and family and that safe care is delivered based on this comprehensive care plan.
A lack of collaborative care plan may be perhaps the best explanation for the apparent disjointed care my family member continues to receive where the patient does not feel confident to speak up for what they want and their family who are at their bedside every day are only involved if they happen to be present at the time.
Our focus as a family will be to continue to prevent further weight loss by providing additional food, prevent further falls by taking them for a walk, support their poor mood by getting them out of the room and to prevent pressure injuries from only having a bed to sit on for 3 weeks.
We just want to get my family member out of hospital so we can attempt to rehabilitate them to at least be something more than the shadow of what they were prior to commencing treatment with your service.

Update posted by swingcp56 (a carer) 3 weeks ago

Just to follow up on this story.
My family member was discharged last week. There was a family meeting arranged with both medical, nursing and allied health.
I felt this really highlighted the poor care coordination.
Despite 4 weeks in hospital the physio and OT who spoke said they had only seen my family member once. It is quite impractical to expect allied health to provide support for a patient who is admitted to an acute surgical ward with rapid turnover.
The dietitian had seen my family member multiple times and provided great advice on increasing nutrition to their primary carer. This is in contrast to the ENT registrar who said they would like to see my family member eat more on the morning ward round in the middle of breakfast.
Social work had by this stage backed off and changed person. The new person was less engaging but the previous social worker had assisted with some additional help.
In terms of nursing, my family member would be best described as self caring so other than receiving antibiotics for the infection they had received very limited nursing during their care.
The ENT team took a back seat in the meeting as the primary concern was the infection and once the Surgical team obtained a suitable sample their contribution was done. Interestingly the ENT team who attended were not team members I had seen on any of the ward rounds.
From here it was over to the ID team. They have been more open and willing to address our concerns. They had arranged the transfer to the Hospital in the Home team in Albany. They had referred to dietitians in Albany and added a suggested referral to physio. I asked if referral to the sub acute team would be helpful but they thought this was a geriatric service and not appropriate.
The ID team explained the plan and the follow up. We met the registrar who would be following up and they answered all our questions.
Since this my family member has been referred to the subacute/ rehabilitation outpatient team at a different health service for follow up and my family member and their carers now feel like we are supported and well cared for.
This does show there is a better way but it takes kindness, respect, collaboration, and accountability none of which we felt much of in RPH.

Sarah-Louise Laing

A/Executive Director,

Royal Perth Bentley Group

Submitted on 12/06/2025 at 12:41 PM

Published on Care Opinion Australia at 12:59 PM

Dear swingcp56
Thank you for continuing to share your feedback and for expressing your concerns so thoughtfully. I acknowledge that aspects of your experience, particularly around communication and interactions with the multidisciplinary team (MDT), were challenging, and I understand how distressing this must have been for you and your family.
Families and carers are encouraged to speak directly with the healthcare team during admission, as this allows for more open and constructive dialogue and helps ensure a clearer understanding of the actions taken in response to feedback. I was sorry to read of your disappointment with the family meeting. While clinicians directly involved in a patient’s care make every effort to attend, as a busy inner-city public hospital, there are often competing demands on their time and expertise. In such cases, a colleague from the same specialty is briefed and attends in their place.
Please be assured that the MDT works with care and diligence to support safe and coordinated discharges for all patients, with a strong focus on providing patient and family-centred care throughout the admission.
While platforms like Care Opinion are valuable for sharing experiences anonymously, they do have limitations. In particular, they restrict our ability to fully investigate individual concerns or communicate outcomes directly. This can lead to a gap between the efforts made by the hospital to address serious issues and what is visible to readers and contributors on the platform.
We value all feedback as an opportunity to learn and improve. To help us review your family member’s case in detail, we encourage you to contact our Patient Experience team directly at RPBG.feedback@health.wa.gov.au.
I sincerely wish your family member all the very best in their recovery and ongoing healthcare journey.
Kind regards
Sarah-Louise Laing
A/Executive Director
Royal Perth Bentley Group

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