Doctors missed opportunity to provide better outcome for patient

What happened

Mrs M had ulcerative colitis (an inflammatory bowel disease). She had been experiencing flare–ups of her condition (pain and diarrhoea).

A sigmoidoscopy (where a doctor looks at the rectum and colon with a flexible tube) found she had severe ulcerative colitis, and she was admitted to hospital for treatment. She was treated with intravenous steroids. The Trust did not think she was improving and after discussions with her consultant and a consultant surgeon, Mrs M had surgery to remove her large intestine resulting in a stoma (opening between the inside of the body and the outside) through which faeces passed into a bag.

Mrs M was initially stable but over the next few days her abdominal drains produced large amounts of fluid and her pain increased. She was given antibiotics five days after the operation and then returned to theatre for a second operation. She continued to be unwell and was moved back to the high dependency unit. Mrs M continued to deteriorate and sadly died.

What we found

There were many things the Trust got right, including the sigmoidoscopy, the treatment Mrs M received before her operation, and the first operation. However, after the first and second operations, the Trust did not get a number of things right. There were no observations for four hours on one occasion, and doctors took little action to investigate the cause of Mrs M's infection. The consultant surgeon failed to hand over Mrs M's care to another consultant when he went on leave and junior staff were left to manage Mrs M's illness. They did not recognise the seriousness of her condition, and communication with the family was poor. There was poor documentation, and the high dependency unit team and the intensive care team did not put appropriate plans in place. Despite blood cultures that showed Mrs M had a widespread fungal infection, this was not diagnosed or treated. Trust staff missed an opportunity that might have allowed Mrs M to recover. However, she was very ill and on the balance of probabilities, it was likely that she would have died at that point.

Putting it right

The Trust apologised to Mrs A and paid her £1,000 for her distress. It drew up an action plan to address the failings that it had not already addressed.