Mrs T and her husband, were unhappy with the standard of care her mother, Mrs M, received because the Trust did not act on what was found until after the weekend.
What happened
Mrs M was booked to have an endoscopic retrograde cholangiopancreatography (ERCP is a procedure that uses an endoscope and X–rays to look at the bile duct and the pancreatic duct).
Mr and Mrs T said that there was evidence of blood in Mrs M's stools over the weekend after the ERCP procedure and felt that the Trust should have taken action to address this. Mrs M was monitored over the weekend and had four sets of observations completed on both Saturday and Sunday. The trust also made note of consistent black stools in Mrs M's medical records.
However, no action was taken to address the blood in her stools until Monday. A day after blood in Mrs M's stools was noticed, there was a severe drop in her blood pressure.ÿ Sadly she deteriorated over the following week and died.
What we found
We partly upheld this complaint. There is no specific guidance for the level of observations needed after an ERCP procedure; however, regular monitoring is required. The Trust completed regular observations of Mrs M over the weekend so we were satisfied that suitable monitoring took place that was in line with established good practice.
Although the trust appropriately recorded evidence of Mrs M passing several black stools, staff should have made a more thorough assessment of the possibility of internal gastro–intestinal bleeding based on this.
As the black stools were clearly recorded, the lack of further assessment or escalation suggested failings in the actions of the Trust. Mrs M should have been more thoroughly reviewed when the bleeding was recorded. However, taking into account Mrs M's condition, it is unlikely that the drop in her blood pressure was preventable, even if the Trust had acted when the black stools were first recorded.
Putting it right
The Trust wrote to Mr and Mrs T to acknowledge the failings identified by this report and apologised for the impact these had on Mrs M and her family. It also completed an action plan to address the failings identified and prevent a recurrence.
West Hertfordshire Hospitals NHS Trust
Hertfordshire
Not applicable
Apology