Organisation we investigated: Barts Health NHS Trust
Date investigation closed: 31 May 2022
The complaint
Mrs Richards complained that the Trust failed to take appropriate action when her fiancé’s condition deteriorated following his transfer from A&E to the Acute Assessment Unit. She also complained that the quality of the Trust’s Serious Incident (SI) report was poor and that she only received it nine months after Mr Shewan’s death despite continually chasing it up.
Background
Mrs Richards and Mr Shewan had been due to get married in January 2019. A few days before the wedding, on 6 January, Mr Shewan complained of feeling unwell and was taken by ambulance to A&E that morning.
He had a two-week history of chest infection and pneumonia, as well as an underlying diagnosis of myelodysplastic syndrome, a type of rare blood cancer.
By mid-afternoon Mr Shewan’s condition had improved and clinicians said he would soon be discharged home. However, after being transferred from A&E to an Acute Assessment Unit, he deteriorated.
Later that evening he was found unresponsive. A cardiac arrest call was made around midnight and CPR commenced. Mr Shewan was resuscitated but remained unconscious, needing ventilation support.
A decision was made the following day to take Mr Shewan off machine ventilation support and he very sadly died soon after.
What we found
We found a catalogue of failures of care that led to the avoidable death of Mr Shewan.
We found that:
- the hospital failed to take the appropriate actions when Mr Shewan’s condition worsened
- Mr Shewan was left alone in a side room for up to one hour and 15 minutes
- the hospital failed to immediately bleep an emergency clinician when the monitor indicated immediate deterioration and a need for urgent A clinician was bleeped after 25 minutes but they were too junior and never responded.
- hospital staff failed to contact Mrs Richards in time to say goodbye
- the hospital failed to question the clinician following Mr Shewan’s death about why they didn’t respond
- there was a delay in completing and sending an investigation report to Mrs Richards. This report acknowledged there had been unacceptable delays and apologised but did not acknowledge the extent of the problems with care or provide assurance that adequate service improvements had been put in place.
Recommendations
PHSO has recommended that Barts Health NHS Trust:
- write to Mrs Richards to acknowledge and apologise for failing to prevent Mr Shewan’s death
- pay Mrs Richards £10,000 in recognition of the distress she has endured
- produce an action plan to ensure the various failing identified will not happen again and supply evidence that it has complied with the PHSO’s recommendations.
Read the press release.