Mr F complained about the death of his mother after a hysterectomy. He said that the hospital had not given appropriate postoperative care and that her death was avoidable.
What happened
Mrs F was admitted to hospital for a hysterectomy, which was performed without incident. A blood test taken after surgery showed that she had an infection, but neither the consultant who operated on her nor the doctor on duty reviewed this. Staff monitored Mrs F regularly and recorded her deteriorating condition but did not tell a senior clinician. It was not until a shift change two days after the operation that a nurse realised the severity of her condition and contacted a senior doctor. Mrs F was transferred to an acute hospital but did not respond to treatment and died the following day.
What we found
The consultant and the doctor on duty should have reviewed Mrs F's blood test results and should have noticed the indication of infection. Nursing staff should have passed on concerns at a much earlier stage. Had these actions happened, it is likely that Mrs F would have been treated much earlier. There was a lost opportunity to give her the treatment she needed. However, given the severity of the condition, we could not say that she was more likely to have survived. During the complaints process, the hospital commissioned an independent report that was highly critical of the care provided. However, the hospital did not take any action as a result of this report and never apologised to Mr F for the failures that occurred.
Putting it right
The hospital apologised to Mr F and produced an action plan to address the failings identified. We did not recommend financial compensation as Mr F said that he did not want such a remedy.
Ramsay Healthcare UK
Hertfordshire
Not applicable
Apology
Recommendation to learn lessons or draw up an action plan