Trust failed to provide appropriate care, treatment and nutritional support to woman with learning disabilities

What happened

Miss N had learning disabilities and epilepsy. In autumn 2011 she had surgery at the Trust's hospital for a twisted bowel. Miss N was briefly admitted to the hospital in early 2012 on three occasions with repeated vomiting. Each time she was treated for constipation and sent home. Mrs G said that the Trust delayed diagnosing Miss N's bowel condition. Later in the month, Miss N was still vomiting and was admitted again. During the admission Miss N developed aspiration pneumonia (caused by inhalation of food, vomit or other foreign matter into the lungs) and died.

What we found

We partly upheld Mrs G's complaint. Although Miss N's death was not avoidable, we found there were failings in her care and treatment. These included: delays in assessing and testing Miss N's gastroenterological symptoms; delays in giving nutrition by percutaneous endoscopic gastrostomy (PEG ? feeding via a tube inserted into the stomach) and no consideration of alternative routes of nutrition; there were no tests to exclude bowel obstruction before the PEG was inserted; doctors failed to manage Miss N's epilepsy appropriately; doctors did not communicate adequately with Mrs G about Miss N; mental capacity assessments did not take place and they should have done; and doctors did not act with proper regard for disability discrimination law or Miss N's rights as a person with learning disabilities. These failings led to service failure and injustices to Mrs G and Miss N.

Putting it right

The Trust wrote to Mrs G to acknowledge the service failures and to apologise for the injustices that she and Miss N suffered. It also paid £2,000 compensation to Mrs G. The Trust also prepared an action plan to describe what it had learnt from the failings identified so that they don't happen again.