The Parliamentary and Health Service Ombudsman has found serious failings at James Paget University Hospitals NHS Foundation Trust after a six-month-old baby died because his heart defect was not diagnosed and treated, despite multiple opportunities to do so.
On 2 November 2015, Harris James’ GP referred him to the Trust due to concerns about his weight loss following a bout of gastroenteritis. The GP’s referral noted that the area of his stomach just below his ribs was drawn inwards, but this was not recorded in his medical records at the Trust. Staff carried out blood and urine tests and an appointment was made with a dietitian for four weeks later.
Just over a week later, on 12 November, Harris was taken by ambulance to the emergency department at the Trust after he vomited and became limp. A chest X-ray showed that part of his lung had filled with fluid and an electrocardiogram (ECG) showed there were several abnormalities in his heart. The Trust suspected pneumonia so gave him oxygen, antibiotics and fluids, but staff failed to ask a specialist about Harris’ heart abnormalities.
Despite his age and clear signs that Harris’ condition was getting worse, he was not seen by a consultant until the following morning. Soon after that, Harris suffered a heart attack and tragically died.
Harris’ mother, Mary Gunns, a local government officer from Lowestoft, complained to the Ombudsman because she was unhappy with the Trust’s investigation into Harris’ death.
The Ombudsman found that the Trust failed to correctly diagnose and treat Harris’ heart defect, even though his medical history, symptoms, and poor response to treatment for pneumonia were clear signs that something else was wrong.
Ombudsman Rob Behrens said:
'This tragic case shows how important it is that people speak up when mistakes are made.
'It is crucial that the Trust learns from its failures to make sure they are not repeated.'
Mary and Ryan, Harris’ parents, said:
'Our son was an affectionate and sweet little boy whose sudden death devastated our family.
‘We won’t ever be able to forgive James Paget Hospital for its failings, nor will we forget the additional pain caused by its mishandling of our complaint.
‘We hope that following the Ombudsman’s recommendations, the Trust takes action to make sure this never happens again.'
Anna Hills, Chief Executive at James Paget University Hospitals NHS Foundation Trust, said:
'We have apologised to Harris’ family for the failings in his clinical care - and for the manner in which we communicated with them and handled their complaint when they raised concerns after his death.
‘As an organisation, we have reviewed how we handled this case, with the support and guidance of the Parliamentary and Health Service Ombudsman.
‘We have now implemented changes to ensure that, in the future, action is taken to ensure appropriate clinical escalation in similar situations and also that bereaved parents and relatives are treated with the compassion, sensitivity and respect they deserve.
‘I would like to express my sincere condolences to the family once again, on behalf of the Trust.'
The Trust has agreed to the Ombudsman’s recommendations to develop an action plan to address its failings and outline how it will prevent them happening in the future. It has formally apologised to Miss Gunns and agreed to pay her £15,000 in recognition of the injustice its failings have caused.
Today, for the first time, the Ombudsman has published data about its recommendations for upheld and partly upheld heath and parliamentary cases that concluded in April to June 2019. The Ombudsman has also published a data table of complaints received, assessed and investigated about NHS organisations during the same period. This new data will be published every three months alongside our quarterly health complaints statistics report.
This is a key stepping stone in the Ombudsman’s commitment to greater transparency. It will increase understanding about the Ombudsman’s decisions and its impact in helping to improve public services.