Faults in nursing, communication and complaint handling

Mrs E had surgery to investigate her symptoms of jaundice. She understood it would be a routine procedure and that she would be allowed home the same day. Mrs E's liver duct was perforated during the procedure. She developed an infection and became very ill, and was transferred to intensive care. She remained in hospital for a month.

Mrs E complained to the Trust about what happened. She attended a meeting with the chief executive, but no minutes were taken, and she did not receive any written response to the complaint. She later attended a meeting with the Trust's medical director which addressed some of the issues in her complaint.

What we found

We upheld some parts of Mrs E's complaint.

The procedure which Mrs E had carries a significant risk of complications, including perforations. The Trust told Mrs E about this risk before her surgery. Based on her clinical records, we could not say if the perforation had been caused by a mistake by the surgeon. As perforation is a recognised complication, we did not uphold this part of the complaint.

Doctors did not communicate clearly with Mrs E about the complications she experienced. We also found failings in nursing care relating to poor communication, medication and blood tests.

We were concerned about the way the Trust handled Mrs E's complaint. Six months after she complained, the Trust arranged a meeting for Mrs E with the chief executive. However not all of her clinical records were available at the meeting and no minutes were taken. Mrs E and her advocate continued to ask the Trust for a full response but heard nothing. A meeting with the Trust's medical director took place over 18 months after her original complaint. The passage of time meant that the Trust could not answer Mrs E's complaint as fully as it should have done.

Mrs E went through an extremely unpleasant and difficult time during her admission, made worse by the Trust's poor complaint handling.

Putting it right

The Trust apologised to Mrs E, paid her £250 compensation and produced an action plan to address failings in nursing, communication and complaint handling.