Avoidable death investigated by Ombudsman

Surgery in the ICUAn investigation by the Parliamentary and Health Service Ombudsman has found the death of a grandmother, following a low risk operation, was avoidable.

The investigation found that failing to properly monitor the patient after the routine hip replacement was one of a catalogue of errors at East Lancashire Hospitals NHS Trust.

Renie Craig’s son, Ian, brought the complaint in March 2016 due to feeling that several mistakes in his mother’s care were not recognised by the Trust’s own investigation.

Tests before the routine hip replacement operation showed Mrs Craig, 77, who had diabetes, had high blood pressure and impaired kidney function. The medical staff failed to investigate these before going ahead with the operation. These factors all meant the patient had an increased risk of developing a kidney injury.

Sufficient fluids were not given to Mrs Craig after the operation, and despite a Doctor requesting her fluid balance be monitored, this was not done. When Mrs Craig’s blood pressure dropped significantly, nursing staff failed to notify a senior member of medical staff. A blood transfusion was given but Mrs Craig became unresponsive and had to be resuscitated before being moved to intensive care.

Furthermore, Mrs Craig developed a wound whilst in in intensive care and required two operations under a general anaesthetic. A few days later, due to a sudden loss of blood from the bowel, Mrs Craig passed away.

The investigation found that given the right care Mrs Craig would have survived. In this case, staff did not plan post-operative care sufficiently, did not monitor the patient’s condition regularly enough, and did not respond quickly enough when her condition deteriorated, meaning Mrs Craig had to have two further operations while already in a weakened state, resulting in this avoidable death.

Rob Behrens from the Parliamentary and Heath Service Ombudsman, said

“Our NHS staff do a professional job caring for hundreds of thousands of people every day under enormous pressure. But as this tragic case shows, it is vital that lessons are learnt when mistakes are made in the NHS.

The Trust has now acknowledged that it was at fault and made changes to ensure that this doesn’t happen again.

Creating an open culture of learning, instead of being defensive and protective, will improve local investigations and how the hospital operates.”

If you or a loved one have received care that you feel is below the standard expected, you may have cause to make a claim for medical negligence. Contact us for an initial chat to see if you have cause to make a claim.

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