Cardiac care appropriate but Trust staff did not document an adverse reaction to an enema

What happened

Ms L's mother Mrs D, who was in her eighties, had a history of heart problems. After she was diagnosed with a cyst on her ovary, a cardiologist and an anaesthetist reviewed her suitability for surgery. They put safeguards in place so that surgery could go ahead. But the operation was cancelled on two occasions. When Mrs D was admitted for a third time, her heart medication was stopped and, despite previously reacting badly to a previous an enema, she was given another one in preparation for surgery. This led to Mrs D suffering a heart attack, and she became too unwell for the planned surgery to go ahead. Instead, Mrs D was admitted as an emergency to the intensive treatment unit and the cyst was drained. Mrs D made a gradual recovery and went back to a ward but unfortunately her condition deteriorated a few days later and she died. Ms L believed plans should not have been made to operate on her mother and the cyst should have been drained earlier instead.

What we found

We partly upheld this complaint. In most respects, the Trust managed Mrs D's care appropriately and it had properly explained what had happened and how it had learnt lessons from the complaint. However, we found that Mrs D's adverse reaction to the first enema had not been documented and this meant staff did not consider withholding a second enema. We could not say with any certainty that the second enema led to Mrs D suffering a heart attack. However, we recognised that Ms L was left with the uncertainty because of this, and this was an injustice to her.

Putting it right

The Trust apologised for the upset and uncertainty Ms L had suffered and reviewed its policies on preoperative enemas to make sure that it complied with the appropriate guidelines. We did not recommend a financial payment because Ms L told us she did not want us to.