Older woman died on toilet at home after doctor discharged her without performing abdominal examination

What happened

Mrs T, who was in her late 90s, fell ill at home and was seen by her GP. She became unwell overnight and was taken to hospital by ambulance. After arriving at hospital, she was examined by a nurse and later a doctor. The doctor discharged her without examining her abdomen. She later died of perforated diverticulitis on the toilet at home in her granddaughter Miss T's arms. Miss T complained to the hospital and said that the Trust had failed to provide an adequate response and had tried to 'cover up' its failings.

What we found

We found some failings in the way nurses assessed Mrs T. We also found that the doctor should have examined Mrs T's abdomen in line with established good practice. As a result of the doctor's failure to examine her, Mrs T was discharged before further tests could be carried out and before her diverticulitis could be diagnosed. As a result, she died at home, on the toilet, rather than in hospital. This was distressing for Miss T. We found, however, that the Trust had investigated Miss T's complaint, during which it said Mrs T was not assessed as well as she should have been. Accordingly we found no evidence that the Trust tried to 'cover up' what had happened.

Putting it right

Following our report, the Trust agreed to acknowledge and apologise for its failings and put together an action plan that showed learning from its mistakes so that they would not happen again. We recommended the Trust pay £500 in compensation for Miss T's distress.