Nursing failure caused serious injustice

What happened

In late summer 2011, Mrs L had bypass surgery that involved creating a new route for the blood using an artificial artery connecting the collarbone artery to the groin arteries.

When she was leaving hospital, Mrs L felt or heard a 'pop' in her shoulder. When she got home, her family noticed a lump over the site of her wound and she went back to the hospital. An emergency nurse in A&E diagnosed a soft tissue injury. The nurse sent Mrs L home with advice that she should go back if she had any more problems. This was a safety net.

Mrs L's condition deteriorated and she went back to A&E by ambulance that evening. Staff admitted her and she went into intensive care. She had an emergency operation in the early hours of the next day. Doctors found that the end of the graft in Mrs L's shoulder had become detached and blood clots had blocked the graft. Blood clots had also formed in the arteries in Mrs L's legs. Doctors reattached the graft and restored the flow of blood to Mrs L's legs. Later that day, she had more surgery.

Mrs L stayed in intensive care until late summer, when she went to a ward. A few days later, doctors diagnosed a spinal stroke caused by a blockage in the blood supply to the spinal cord. In autumn Mrs L was transferred to the Trust's rehabilitation unit, where she stayed until the Trust transferred her to another trust's hospital in spring 2012 for more surgery.

What we found

Although the emergency nurse followed a recognised format for her consultation with Mrs L and appropriately put in place a safety net, she made decisions about Mrs L's further care that were not based on all relevant considerations. The nurse sent Mrs L home even though there were signs of a possible breakdown of the graft and there was bleeding around the graft. These signs should have prompted the nurse to consult and take advice from more experienced colleagues. We concluded that the nurse's actions amounted to service failure.

We also found that in providing Mrs L's care and treatment, staff in the Trust's intensive care unit and in the acute surgical ward did not act with regard for Mrs L's rights as a person with a disability.

Staff at the rehabilitation unit also did not consider her needs as a person with a disability. However, once Mrs L's family had prompted staff on this unit, they considered her individual needs. On the whole, we concluded that the failings we found amounted to service failure.

One serious consequence of the delay in recognising the failure of the graft was a drop in blood pressure, which probably caused Mrs L's spinal cord stroke. This was an injustice to Mrs L. As a result of the service failure and injustice, Mrs L had to use a wheelchair, could not use her mobility scooter and could not leave her home. Mrs Q said that her sister had carers going in to look after her, but she also had to go to her sister's home five days a week to give additional care and emotional and practical support. She said she was her sister's main point of contact, and on occasion even changed her when nursing staff were busy. Mrs Q said that the impact on her has been huge, as before the stroke she would probably visit Mrs L about once a month. This was an injustice to Mrs Q.

Putting it right

The Trust apologised to Mrs Q and paid her £25,000 to recognise the injustice. Unfortunately Mrs L died during our investigation and it was no longer possible to remedy her injustice.

The Trust drew up an action plan to ensure that the organisation and the individuals involved have learnt lessons from the failings identified.