Organisation we investigated: University Hospitals Birmingham NHS Foundation Trust
Date Investigation closed: June 2022
The complaint
Mrs A complained about the care and treatment provided to her late brother, Mr B, by University Hospitals Birmingham NHS Foundation Trust (the Trust). Mrs A complained that the Trust failed to take appropriate action to treat Mr B after an X-ray showed that he had an incarcerated hiatus hernia.
Background
Mr B was 65 years old. He was admitted to the hospital on 18 May 2019, having been unwell for several days suffering from abdominal pain and vomiting. He had a history of health problems and had previously suffered from a sliding hiatus hernia.
His sister, Mrs A, says she was told he was likely suffering from constipation and dehydration. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities, so no action was taken.
Mr B was transferred to an Acute Medical Unit in the early hours of 19 May. He was described as ‘stable’ but was still experiencing abdominal pain. He had a chest X-ray later that morning which showed abnormalities. This X-ray should have been carried out the day before. Shortly afterwards, Mr B’s condition deteriorated and he suffered a heart attack. Attempts to resuscitate him were unsuccessful and Mr B sadly died on the morning of 19 May.
What we found
We found Mr B’s death was avoidable and we have upheld Mrs A’s complaint. Based on his symptoms and abdominal X-ray, the Trust missed opportunities to identify a likely intestinal obstruction and diagnose Mr B’s hiatus hernia sooner. We have determined that this and subsequent failure to treat Mr B with the correct procedure significantly impacted his condition.
Putting it right
The Ombudsman has recommended the Trust should:
-
pay Mrs A £10,000 for the considerable distress and uncertainty she has suffered because of her brother’s death
-
acknowledge the failings and apologise for the considerable distress and uncertainty they caused Mrs A and her family
-
develop an action plan to address the failings in Mr B’s case
-
explain what it will do differently in future.