The death of a 75-year-old man five days before he was due to marry his partner was avoidable and the result of failures in care, according to the national Ombudsman.
Andy Shewan and June Richards were set to wed in January 2019 after 40 years together. However, on 6 January, Andy, who had underlying health problems, complained of feeling unwell and was taken to the A&E at Whipps Cross Hospital, part of Barts Health NHS Trust.
Despite staff reassuring the couple that Andy would soon be back home, and that the wedding could still go ahead, his condition worsened. He was transferred to the Acute Assessment Unit where that evening he suffered a cardiac arrest. Andy sadly died the next day.
Now, the Parliamentary and Health Services Ombudsman (PHSO) has ruled that that there were multiple failures of care and that Andy’s death was avoidable.
Andy’s fiancée June, 80, said, “I feel very sad and very angry about it. It’s been three years and I still can’t stop crying.
“He died in pain and on his own. It’s so sad, I didn’t get to say goodbye to him because I thought he would be coming home.
“We used to say to each other ‘aren’t we a lovely little family, you, me and Lily’, our lovely dog. Now, I sit here, and I think ‘I’ve lost Andy’.
“His death was avoidable; he could’ve still been here. I could have had him for another week, or it could’ve been a month or years. They’ve taken such a lot from me that no one can give me back.”
Following a thorough investigation, the national Ombudsman found that:
- the hospital failed to take the appropriate actions when Andy’s condition worsened
- Andy 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 did not respond
- hospital staff failed to contact June in time to say goodbye
- the hospital failed to question the clinician following Andy’s death about why they didn’t respond
- there was a delay in completing and sending an investigation report to June. 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.
June added, “Andy was so caring and gentle. He was the loveliest person you could meet and would help everyone. People used to say to me ‘aren’t you lucky to have him’, and I’d say ‘yes’, then he would say that he was lucky to have me.
“I live near the cemetery where Andy is, and I still talk to him. I tell him that I wish he was here and that I miss him so much. This has taken his life and ruined mine.”
Ombudsman Rob Behrens said, “This is a truly heart-breaking case. Multiple failings to provide the right level of care led to the death of a man just days away from the happiest day of his life. The distress this caused June, his fiancée, has been profound.
“Nothing can change what happened or the tragic outcome. I hope that our investigation and recommendations can provide some comfort to June and lead to changes at the Trust that prevent this from ever happening again.”
The Ombudsman recommended that the Trust should:
- write to June to acknowledge and apologise for failing to prevent Andy’s death
- pay June £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.
Chief Executive of Whipps Cross Hospital, Ralph Coulbeck said: “We are deeply sorry for the serious failings in the care provided to Mr Andrew Shewan and extend our heartfelt condolences to his family. We apologised unreservedly to Ms June Richards, paid the full compensation recommended by the Ombudsman, and took steps to ensure this doesn’t happen again.”
Read the case summary.