Failure to provide appropriate bowel care and nutrition reduced a patient's chance of survival

Summary 372 |

Ms R complained about the bowel care given to her mother, Mrs P. She also complained that doctors in A&E did not diagnose that Mrs P had had a stroke. Ms R believed that a stroke led to Mrs P's death.


What happened

Ms T fractured her ankle and went to A&E at the Trust. Staff gave her a moulded cast and made an appointment for an operation.

Ms T later went back to the hospital because she was in severe pain. She had an operation and stayed in hospital for around a fortnight. She raised a number of concerns about the quality of care she received both in this period and her outpatient appointments.

What we found

From the 12 issues brought to us by Ms T, we found four amounted to failings. We found evidence of failings because a doctor who saw Ms T did not record the consultation. Also staff switched off equipment Ms T was using, a nurse used a dressing with iodine, which Ms T is allergic to, on Ms T's wound, and some aspects of the Trust's complaint handling were poor.

Putting it right

The Trust agreed to apologise to Ms T for the failings we identified, and draw up an action plan to show it had learnt from this complaint and had improved services.

The Trust had implemented a new complaints policy after a previous investigation we carried out. This involved a new process of quality assurance through master classes and buddying to review responses, as well as additional training.

Health or Parliamentary
Health
Organisations we investigated

The Newcastle Upon Tyne Hospitals NHS Foundation Trust

Location

Tyne and Wear

Complainants' concerns ?

Did not apologise properly or do enough to put things right

Result

Apology

Compensation for non-financial loss

Recommendation to learn lessons or draw up an action plan