Poor care and management of a patient with severe abdominal pain

What happened

Mrs R was admitted to hospital with severe abdominal pain, abdominal swelling and vomiting. The following day, staff began a process to help raise Mrs R's extremely low blood pressure. Mrs R subsequently had emergency surgery to drain a large ovarian cyst. During this procedure, staff identified a perforated bowel, causing faecal peritonitis.

After the surgery, Mrs R's prognosis was very poor and her condition continued to deteriorate. Despite intensive care, Mrs R sadly died soon after.

What we found

The medical team managed Mrs R's deteriorating condition inadequately for the first two days. Mrs R received insufficient fluids during this time. This was compounded by nursing staff's delay in refitting Mrs R's cannula. Nursing staff miscalculated Mrs R's observation assessment scores one evening. If the scores had been properly calculated, this would have led to more frequent observations and an urgent medical review. Mrs R was not seen by a consultant gynaecologist until early the next morning, despite a number of requests to attend.

Although we found significant failings in the care provided, it was not possible to say what the outcome might have been if staff had performed more frequent observations and started fluid resuscitation sooner.

We upheld the complaint.

Putting it right

The Trust acknowledged the failings identified in our report and apologised for the injustice it caused. It paid Mrs D £750 as compensation for the injustice we found and prepared an action plan that described what it did to make sure it had learnt lessons from the identified failings.