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Death of woman after routine operation was avoidable, Ombudsman finds

A grandmother’s death following a low-risk, routine hip replacement operation was avoidable, an investigation by the Parliamentary and Health Service Ombudsman has found. A catalogue of errors at East Lancashire Hospitals NHS Trust, including failing to properly monitor and treat Renie Craig after the operation, meant she died as a result.

The woman’s son, Ian Craig from Blackburn, brought a complaint about the Trust to the Ombudsman in March 2016 after he felt that the Trust’s own investigation failed to recognise several mistakes in his mother’s care.

Renie Craig, who was 77, was scheduled to have a routine hip replacement operation in February 2015. She had high blood pressure and several tests from December 2014 showed that she had an impaired kidney function, yet this was not investigated ahead of the operation. This, along with her age and the fact that she had diabetes, meant that she was at an increased risk of developing a serious kidney injury, which was not taken into account.

After the operation, she was not given enough fluids and her fluid balance was not monitored despite a doctor’s request for this. Nurses also failed to inform a senior nurse or doctor when her blood pressure dropped significantly. Mrs Craig was given a blood transfusion but later became unresponsive and a doctor resuscitated her before she was moved to intensive care.

In March 2015, Mrs Craig had two further operations under general anaesthetic to treat a wound that developed while in intensive care. A few days later, Mrs Craig sadly died from a sudden loss of blood to the bowel.

Even though tests showed that she was vulnerable, hospital staff did not properly plan her care after her hip operation. They didn’t monitor her condition regularly or act quickly when her condition worsened which meant that she had to have further operations when she was already weak.

The Ombudsman found that if the Trust had provided the right care and treatment then Mrs Craig would have survived. Knowing his mother died as a result of the Trust’s failings caused Mr Craig considerable distress.

Rob Behrens, Parliamentary and Heath Service Ombudsman, said:

Our NHS staff do a professional job caring for hundreds of thousands of people every day under enormous pressure. But as this tragic case shows, it is vital that lessons are learnt when mistakes are made in the NHS.

‘The Trust has now acknowledged that it was at fault and made changes to ensure that this doesn’t happen again.

‘Creating an open culture of learning, instead of being defensive and protective, will improve local investigations and how the hospital operates.’

Ian Craig, Renie Craig’s son, said:

My family were devastated after losing my mother following what should have been a routine operation.

‘We lost my father only a few months before so we were already grieving and my mother’s death came as such a shock to me and to my wife and son.

‘I want other trusts to learn from the mistakes made here to make sure that others don’t have to experience a tragedy like this.’

Professor Damian Riley, Medical Director for East Lancashire Hospitals NHS Trust, said:

The Trust extends its sincerest apologies and we acknowledge that there were opportunities to do things differently while we were responsible for Mrs Craig’s care. 

‘Since this incident, we have made significant improvements to try and ensure similar errors do not happen again.’

Following the Ombudsman’s investigation, the Trust wrote to Ian Craig to acknowledge and apologise for the failings in his mother’s care. It outlined improvements that have been made, including changes to fluid monitoring and kidney injury management. At the Ombudsman’s recommendation, the Trust also made a payment to Ian Craig to reflect the emotional impact of knowing that his mother died as a result of the Trust’s failings.

 


Notes to Editors:

  1. The Parliamentary and Health Service Ombudsman provides an independent and impartial complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. We look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. We share findings from our casework to help Parliament scrutinise public service providers and to help drive improvements in public services and complaint handling.
  2. Part of the new corporate strategy for 2018-21 is to increase transparency and the impact of our casework. This case summary forms part of an interim measure to move towards publishing the majority of our casework on our website over the next three years. Sharing insight and learning from our casework will help to improve public services.

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