After a hysterectomy, staff took out Mrs A's catheter without considering the significance of 'pink urine', as recorded in the notes. This resulted in a bladder injury that needed additional surgery to repair.
What happened
Mr F went to A&E with intense pain in his arm. Staff diagnosed a blood clot, scanned him and gave him anticoagulation medication to thin his blood. Later that night Mr F collapsed and died. His post mortem found an aortic dissection that had blocked the flow of blood to his arm, not a blood clot. Mr F's wife complained to the Trust about her husband's misdiagnosis. The Trust did not uphold her complaint because
Mr F did not have the usual chest pain it expected in someone with an aortic dissection.
What we found
Mr F's symptoms were not typical for his condition, which made it more difficult to diagnose. However, the Trust missed several chances to correctly diagnose Mr F, including taking account of his previous medical history and unusual symptoms, carrying out a chest X-ray and misreporting a scan. While we cannot say that Mr F's death was avoidable (because his condition was very serious), it is clear that the Trust lost the chance to give him treatment that might have prevented or delayed his death.
'We identified a number of missed opportunities in the care provided to Mr F. While individually these would not all be considered failings, cumulatively they amount to service failure.' Dame Julie Mellor, DBE
Putting it right
We recommended that the Trust apologise for and acknowledge its mistakes and pay Mr F's wife £2,000. We also asked the Trust to identify in an action plan how it would avoid these failings happening again.
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
South Yorkshire
Did not apologise properly or do enough to put things right
Apology
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan