Ms D complained about the care and treatment that her late father, Mr F, received at Prince Philip Hospital when, on the day that he was due to be discharged following a hip replacement operation, he rapidly deteriorated, suffered a cardiac arrest and, sadly, died. Ms D complained that clinicians were slow to respond to Mr F’s deterioration and, consequently, any opportunity there may have been to stabilise his condition was lost. Ms D also complained that clinicians failed to advise the family of Mr F’s poor prognosis and subsequently failed to provide the family with a clear explanation of the cause of Mr F’s deterioration and death. Finally, Ms D complained that the Health Board’s handling of her complaint about these matters was unnecessarily protracted and added to the family’s distress.
The Ombudsman, assisted by his Clinical Advisers, upheld Ms D’s complaints. He found that an incomplete provisional diagnosis of Mr F’s condition was made by two junior doctors who were inadequately supported by senior physicians. The junior doctors failed to identify that Mr F was in cardiac failure. Whilst it was not possible to say that this directly led to Mr F’s death (given his comorbidities and poor prognosis), the Ombudsman considered that the uncertainty surrounding this matter amounts to a significant injustice to the family. The Ombudsman also found that, as a result of this initial failing, the family was not accurately advised of Mr F’s poor prognosis or, subsequently, of the precise cause of his death. Finally, the Ombudsman found that there were substantial delays in the Health Board responding to the family’s complaint. The Ombudsman recommended that:
a)The Health Board provides Ms D with a fulsome written apology for the identified failings, and, in recognition of the distress and injustice caused to the family, makes a payment to them of £2,500 plus £250 for its poor complaint handling.
b)The Health Board produces a detailed, written escalation policy and makes this available to medical and surgical clinicians of all grades at Prince Philip Hospital.
c)The Health Board demonstrates that it has reminded physicians (particularly consultants) working in the Trauma & Orthopaedic Department, of the requirement to conduct and record a daily, documented review of patients in accordance with guidance issued by the Academy of Medical Royal Colleges and by the Royal College of Physicians.
d)The Health Board demonstrates that it has reminded all middle-grade and senior doctors at Prince Philip Hospital of their obligation to adequately support and supervise junior doctors in accordance with General Medical Council and other guidance.
e)The Health Board urgently reviews its pre-operative assessment protocol to ensure that patients with cardiac risk-factors are identified and receive an appropriate, documented, clinical management plan in advance of any surgery.
f)The Health Board demonstrates that it has taken steps to ensure that clinicians at Prince Philip Hospital are made aware of the role of, and means of liaising with, the Medical Emergency Team in responding to critically ill patients.
g)The Health Board reminds Trauma and Orthopaedic Nurses at Prince Philip Hospital that it is good practice to conduct physiological observations on patients on the day of their discharge.
h) The Health Board reminds the Concerns Team of the need to comply with timescales set out in Putting Things Right regulations and to provide explanations to complainants of unforeseen delays in the production of responses.