MEDICS missed a chance to provide better care for a patient and did not act quick enough after she suffered complications, a health watchdog ruled.
The Parliamentary and Health Service Ombudsman examined the case of a patient known only as Mrs M, who was under the care of the North Tees and Hartlepool NHS Foundation Trust.
The Ombudsman ruled that doctors missed the opportunity to provide a better outcome for the patient, who sadly died.
There were no observations for four hours on one occasion, and doctors took little action to investigate the cause of Mrs M’s infection, the Ombudsman’s report found.
The report said the consultant surgeon failed to hand over Mrs M’s care to another consultant when he went on leave and junior staff were left to treat her.
They did not recognise the seriousness of her condition, and communication with the family was poor, it was found.
There was poor documentation, and the high dependency unit team and intensive care team did not put appropriate plans in place, says the report.
Despite blood cultures that showed Mrs M had a widespread fungal infection, the report stated this was not diagnosed or treated.
Mrs M’s daughter, Mrs A had complained to the Ombudsman that doctors did not act on signs of post-operative complications soon enough and that the family were provided with false assurances of Mrs M’s condition.
Mrs M had inflammatory bowel disease, ulcerative colitis and had been experiencing flare-ups. She was admitted to hospital and treated with intravenous steroids.
The report said the trust did not think Mrs M was improving and after discussions with consultants, Mrs M had surgery to remove her large intestine resulting in a stoma, which is a hole in the abdomen. Mrs M was initially stable but her condition deteriorated within days.
She was given antibiotics five days after the operation and then returned to theatre for a second operation.
She continued to be unwell and was moved back to the high dependency unit. Mrs M continued to deteriorate and sadly died.
The Trust apologised to Mrs A and paid her £1,000 for her distress. It drew up an action plan to address the failings.
The Ombudsman’s report said there were “many things the trust got right”, but added: “However, after the first and second operations, the trust did not get a number of things right.”
It added: “Trust staff missed an opportunity that might have allowed Mrs M to recover. However, she was very ill and on the balance of probabilities, it was likely that she would have died at that point.” The trust did not wish to comment further.