Wife's death may have been avoided

What happened

In the autumn of 2013 Mrs K fell and broke her hip. She was taken to hospital and had hip surgery the following day. Mrs K then developed renal and cardiac failure and so her condition deteriorated. Several days after her operation, doctors decided to stop active treatment and provide her with palliative care. Mr K complained that staff failed to properly consult him about this and that he never agreed to a palliative approach. Mrs K died just over a week after her operation.

What we found

The Trust's decision to operate was appropriate and the type and amount of anaesthetic it used was in line with good practice. However, Mrs K's fluid management before the operation was poor, and staff were too slow to react to her deteriorating condition after the operation.

As Mrs K had significant pre–existing medical conditions it meant her risk of dying after surgery was high, even if there had been no failings. Therefore, we did not find a link between the failings and the loss of Mrs K's life.

Nevertheless, the failings meant there was an increased risk of Mrs K developing an acute kidney injury after the operation. In addition, the failings after the operation meant there was a lost opportunity to treat her deteriorating condition quickly.

It was clear from the evidence that these events were extremely distressing for Mr K. The loss of his wife was compounded by concerns that this may have been avoidable if her hospital treatment had been different. This additional distress was caused by the Trust's failings.

Putting it right

The Trust wrote to Mr K to acknowledge the failings we found and apologised for the distress caused. It made a payment of £5,000 to Mr K and also completed an action plan to address the failings we had found.