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Failure to operate on twisted bowel led to man’s death, Ombudsman finds

A man’s death could have been avoided if the Calderdale and Huddersfield NHS Foundation Trust had operated on his twisted bowel, the Parliamentary and Health Service Ombudsman (PHSO) has found. Mr A, an otherwise healthy 71-year-old man, died when his twisted bowel tore following serious failings and multiple delays in his treatment at the Trust.

Mr A went to the emergency department at Calderdale Royal Infirmary (CRI) on Christmas day in 2017 with constipation and abdominal pain. The hospital identified the risk of his bowel tearing and that he needed surgery. Mr A was transferred to Huddersfield Royal Infirmary (HRI) hospital the same day. 

On 27 December, staff at HRI performed an investigation and recorded the same risk of perforation in clinical notes. Similar conclusions were drawn in a further examination on 30 December. However, it was not until the New Year, on 1 January 2018, a week after M A’s initial visit to A&E, that HRI recognised a need for urgent surgery. This was planned for 2 January but was then cancelled and rearranged for 3 January. As a result of the delays, Mr A’s condition worsened, his bowel perforated and he sadly died on 4 January after his organs failed. 
Miss A, Mr A’s sister, complained to the Trust. In its response the Trust said that its care and treatment was appropriate and that Mr A had been managed cautiously. 

Miss A took her complaint to the Ombudsman because she was not satisfied with the response to her complaint and she wanted the Trust to acknowledge its failings. She said her brother would have wanted to improve services so that the same mistakes would not happen again. 

The Ombudsman found that the Trust failed on more than one occasion to follow national guidance and act on the results of its investigations into Mr A’s condition. The Ombudsman also found that the delay in operating led to his avoidable death.

Rob Behrens, the Parliamentary and Health Service Ombudsman, said:

This case shows why the guidelines exist and the tragic consequences when they are not followed. 

'By carrying out our recommendations and putting an action plan in place the Trust can improve its service to ensure this never happens again.’

Miss A said:

Thanks to the Ombudsman, we have some justice for my brother and his tragic avoidable death has been highlighted.

‘He deserved better than the inadequate treatment and original response to my complaint provided by HRI.

‘My brother should still be here today but he would have been happy to know that changes had been made so the same thing won’t happen to anyone else.’

David Birkenhead, Medical Director at the Calderdale and Huddersfield NHS Foundation Trust, said:

We are always very sorry when our care falls below the standards we expect to deliver. We have apologised and have agreed to the Ombudsman’s recommendations to develop an action plan to prevent a recurrence. 

‘Again, we would take the opportunity to send our apologies to the family.’

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. As part of this process the Trust has committed to carry out training on the guidelines for surgeons and improve processes for monitoring high risk patients. It has formally apologised to Miss A in recognition of the injustice its failings have caused.

Read the Case Summary.