Mr H's wife, Mrs H, complained that an incident with continuous positive airway pressure equipment meant that Mr H had low levels of oxygen for a significant period of time. She felt that this contributed to his deterioration and the train of events that ended in his death 12 days later. She believed that nurses on the medical assessment unit were not competent in providing continuous positive airway pressure therapy.
What happened
Mr H went to the Trust's emergency department early one morning with acute shortness of breath. Staff treated him with continuous positive airway pressure before transferring him to a medical assessment unit.
Mrs H says that later the same day, a nurse appeared to 'bump into' continuous positive airway pressure equipment, and a piece of the equipment fell off. After this, Mr H complained that he was not getting oxygen. Although Mrs H repeatedly told ward staff about this, staff did not take any action for around an hour.
The Trust admitted Mr H to intensive care, and then transferred him to a trust that could offer treatment using a different process. Despite his treatment, Mr H died 12 days later.
Mrs H's distress at the time of her husband's death was made worse by her knowing that there had been an untoward incident during his care that the Trust had failed to investigate properly. Mrs H's grief was exacerbated by having witnessed her husband's distress and discomfort when he did not receive oxygen.
Mrs H complained to the Trust about the incident, but she was unhappy about the Trust's investigation of her complaint.
What we found
There were serious failings in the way in which the Trust managed Mr H's continuous positive airway pressure therapy. Staff did not diagnose and treat his acute cardiac failure until 24 hours after his admission. Although he subsequently had very aggressive and sophisticated treatment, this was ultimately not successful.
On balance, however, we considered that his cardiac disease was so severe that he would not have survived.
Mrs H had to pursue her complaint for nearly two years in order to obtain an accurate response to her concerns and recognition that something went wrong that had not been put right.
During this time, the Trust failed to reassure her. It did not thoroughly identify and address the problems highlighted by this complaint and it was not open about failings in Mr H's care and treatment.
Putting it right
The Trust apologised to Mrs H for the serious failings we identified in his care and in its complaint handling. It paid her £1,250 compensation.
The Trust agreed to prepare an action plan that described what it had done to make sure that it had learnt the lessons from this complaint and detailed what it had done or planned to do, to avoid these failings happening again.
Croydon Health Services NHS Trust
Greater London
Not applicable
Apology
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan