Patient's death was avoidable

What happened

Mrs N went into hospital in spring 2011 with abdominal pain and blood in her urine. Staff discharged her the next day because test results were inconclusive. Mrs N went to hospital several more times because of her pain.

Eventually, staff admitted her for exploratory surgery to try and find the cause of her symptoms. Before the procedure could take place, Mrs N's condition deteriorated and she died in early summer 2011 from sepsis.

What we found

The Trust failed to adequately assess Mrs N's condition, treat her with appropriate antibiotics in a timely manner, or take enough steps to control the clotting of her blood before surgery. The Trust should not have discharged Mrs N after her admissions in spring and early summer, and should have carried out exploratory surgery sooner than planned.

After Mr N complained, the Trust responded promptly and provided evidence-based responses to most of his concerns. However, it did not acknowledge some shortcomings, or apologise for the consequences of the failings it found.

Putting it right

Before our involvement, the Trust reviewed its urology department and took steps to improve its services.

Following our report, the Trust apologised to Mr N for his wife's avoidable death, and drew up an action plan that set out how it would improve its complaint handling.