Martin Ryan
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Summary report of an investigation by the Health Service Ombudsman of a complaint made by Mencap on behalf of Mrs Vera Ryan in relation to her late son, Mr Martin Ryan.
Complainant:
Mrs Vera Ryan
Aggrieved:
Mr Martin Ryan (Mrs Ryan’s late son)
Representative:
Mencap
Complaint against:
Kingston Hospital NHS Trust (the Trust)
How the Ombudsmen investigated
What the Ombudsmen found and concluded
Background
Mr Ryan was a 43 year old man with severe learning disabilities, Down’s syndrome and epilepsy who lived in a residential care home. Mr Ryan’s family described him as a charming, strong and energetic man who, before his stroke, was living happily with his carers. They said it took Mr Ryan a while to get to know people and it took people a while to get to know him. They thought this was probably because he could not communicate verbally and because his behaviour was different.
In November 2005 Mr Ryan suffered a stroke and was admitted to a general ward at the Trust. Over the following weeks his care and treatment was the responsibility of a multidisciplinary team including doctors, nurses, physiotherapists and speech and language therapists. For most of the time he was in hospital, carers from his residential home were with him and he was visited occasionally by specialist community nurses. However, throughout his stay he was given no nutrition. The primary causes of his death were recorded on his death certificate as pneumonia and a stroke.
The complaint
Mr Ryan’s mother accepted that the Trust had acknowledged many failings in its care of her son and that it had taken action to try and remedy those failings. However, she remained dissatisfied and complained to the Health Service Ombudsman that her son should not have died. She said that if staff at the Trust had acted differently, he would have survived. In particular, she said she had thought her son would be ‘in good hands’ at the Trust. Instead he had ‘starved to death’. She believed her son had been treated less favourably for reasons related to his learning disabilities.
Mrs Ryan was also dissatisfied with the way her complaint had been handled by the Trust. She felt the NHS complaints process had failed her and she asked the Health Service Ombudsman to find out the answers to her questions about the service provided for her son.
What should have happened
The NHS staff who looked after Mr Ryan should have been mindful of the overall standard governing their work. This standard is made up of two components: the general standard which is derived from general principles of good administration and, where applicable, public law; and the specific standard which is derived from the legal, policy and administrative framework and the professional standards relevant to the events
in question.
In Mr Ryan’s case, legislation and policy about disability and human rights, in particular the Disability Discrimination Act 1995, the Human Rights Act 1998 and Valuing People: A New Strategy for Learning Disability for the 21st Century (2001) were especially relevant to the overall standard. In terms of professional standards, the doctors and nurses should have followed the standards set out by their regulatory bodies.
Mr Ryan’s care and treatment should have met the prevailing specific national and professional standards for management of stroke patients, especially the National Clinical Guidelines for Stroke (1st edition 2000 and 2nd edition 2004) issued by the Royal College of Physicians and the National Service Framework for Older People (2001). These documents set out expectations including: standards for developing specialist stoke units; guidelines for testing and investigating stroke patients; and requirements for multidisciplinary working. By April 2004 the government required all hospitals caring for stroke patients to have developed a specialised stroke service. Furthermore, Mr Ryan’s care should have met the Trust’s own standards, in particular its Eating and Drinking Policy.
The responses to Mrs Ryan’s complaint should have followed the National Health Service (Complaints) Regulations 2004.
How the Health Service Ombudsman investigated
The investigator met Mr Ryan’s family to gain a full understanding of Mrs Ryan’s complaint. It was important to carefully consider their recollections and views. Evidence about what happened to Mr Ryan and how his mother’s complaint had been handled was considered. The Trust also provided additional information in response to specific enquiries.
Several professional advisers provided expert clinical advice to the Health Service Ombudsman. They were: a consultant physician specialising in stroke care; a speech and language therapist; a hospital nurse; and two learning disability nurses.
Mr Ryan’s family, their representative and others involved in the events complained about had the opportunity to comment on the draft report, and their comments were carefully considered before the final report was issued.
What the Health Service Ombudsman found and concluded
The basic facts about Mr Ryan’s stay at the Trust were revealed by the Trust’s internal inquiry. However, Mrs Ryan asked the Health Service Ombudsman to look further into two specific aspects of her son’s clinical care – the failure to feed him and the failures in communication between different members of Trust staff. In particular, she wanted to know whether malnutrition had led to her son’s death. The Trust had told Mrs Ryan that the failures in her son’s care were not for disability related reasons and that he had not died from malnutrition and starvation.
The Health Service Ombudsman found that the key failings in Mr Ryan’s care and treatment could be grouped into three main areas: failings in stroke care; failings in clinical leadership; and failings in communication and multidisciplinary team working.
Stroke care
The Trust had not responded to national and professional recommendations about stroke care. Although prevailing policy and guidelines did not require trusts to have a specialist stroke unit (and this Trust did not have such a unit) the guidelines did require trusts to organise stroke services so that patients were admitted under the care of a specialist team for acute care and rehabilitation. The Health Service Ombudsman found that at the time Mr Ryan was admitted, services at the Trust for stroke patients were fragmented and fell short of professional and national expectations for stroke care set out in policy and guidelines. There was no special team of experts skilled in management of the needs of stroke patients, for example doctors, nurses, dieticians and speech and language therapists, who could identify and meet Mr Ryan’s basic needs, including his nutritional needs.
Clinical leadership
The Health Service Ombudsman found that neither the Consultant nor the Ward Sister provided effective clinical leadership, either for their professional group or the ward team as a whole. Neither of the lead professionals had set up effective systems of organising care and treatment. Nursing shift patterns did not encourage continuity of care and medical cover was fragmented with no effective arrangements at weekends. Neither lead professional recognised that the basic standard of care which doctors and nurses in their charge were providing for a very ill man was inadequate.
Mr Ryan could not swallow due to his stroke and the Health Service Ombudsman found that the medical team, under the leadership of the Consultant, was primarily responsible for deciding on a plan for feeding Mr Ryan. Despite speech and language therapy assessments that Mr Ryan would need alternative feeding (such as feeding him by a tube through his nose or abdominal wall into his stomach), the medical team did not make a decision about alternative feeding until Mr Ryan had been in hospital for 18 days. Soon after that, Mr Ryan became too ill to undergo the procedure to insert a feeding tube.
The Health Service Ombudsman found that the Ward Sister did not take the lead, as she should have done, in monitoring and managing Mr Ryan’s condition. She did not put in place arrangements to guide or support members of her nursing team in caring for Mr Ryan’s needs. It was clear she was not aware of failings in her team: for example, assessments were poor, care plans were inadequate and the delivery and evaluation of nursing care was below a reasonable standard in the circumstances. There was no evidence of nursing actions aimed at meeting Mr Ryan’s nutritional needs.
Communication and multidisciplinary team working
National, professional and local policy and guidelines stressed the importance of multidisciplinary team working in stroke care. However, poor communication and team working between professionals meant the approach to Mr Ryan’s care, including his nutrition, was fragmented, unplanned and ineffective. For instance, there were no multidisciplinary team meetings. This meant there was no forum for professionals involved in Mr Ryan’s care and treatment, such as the community nurses, the speech and language therapists and the physiotherapists, to discuss integrated plans for his care.
There was evidence that various professionals, including the community team and the speech and language therapists, were very concerned about Mr Ryan and tried to raise their concerns, particularly about nutrition, with the medical and nursing teams. But they could not make themselves heard and nothing happened to help Mr Ryan. Nobody took any action to feed him.
Malnutrition and starvation
Mrs Ryan believed her son ‘starved to death’. He was not fed for 26 days and it is an indisputable fact that people need food to live and that without sufficient food people weaken and die.
The Health Service Ombudsman was advised that Mr Ryan had suffered a significant stroke. However, she was also advised that had he been cared for in a Trust where stroke services were organised according to policy and guidelines, he would have had a better chance of survival, albeit with long-term mental and physical problems. However, the Health Service Ombudsman’s medical adviser said that prolonged starvation would have made it less likely that Mr Ryan would have survived because he would have been more susceptible to infection and less able to combat infection when it occurred.
The Health Service Ombudsman concluded that she could not say for certain whether Mr Ryan would have survived if he had been fed. However, what she did say was that the failure to feed him for 26 days undoubtedly placed him at considerable risk of harm. She said that although it was impossible to prove that malnutrition and starvation contributed to or caused Mr Ryan’s death, it was likely that the failure to feed him for a prolonged period was one of a number of failings which led to his death.
The Health Service Ombudsman concluded that the Trust’s failures in its arrangements for stroke patients, clinical leadership, communication, multidisciplinary working and nutritional care were service failure which was at least in part for disability related reasons.
Complaint handling
Mrs Ryan was dissatisfied with the way her complaint was handled by the Trust and she believed her complaint had not been properly dealt with for reasons related to her son’s learning disabilities.
The Health Service Ombudsman found shortcomings in the way the Trust handled Mrs Ryan’s complaint. For instance, the Trust failed to recognise the seriousness of the matters complained about, failed to investigate properly and failed to provide appropriate responses which were accurate and consistent. She concluded that the Trust’s complaint handling was maladministrative but that the failings in complaint handling were not for disability related reasons.
Was Mr Ryan treated less favourably for reasons related to his learning disabilities?
The Health Service Ombudsman concluded that the failings in care and treatment could not be separated from the fact that Trust staff did not attempt to make any reasonable adjustments, as they should have done, to the way in which they organised and delivered care and treatment to meet Mr Ryan’s complex needs. She concluded, therefore, that in some significant respects the Trust’s service failures were for disability related reasons.
The Health Service Ombudsman also concluded that the Trust’s actions and omissions constituted a failure to live up to human rights principles, especially those of dignity, equality and autonomy. By failing to care properly for Mr Ryan, in particular by not feeding him, the Trust failed to have due regard to his status as a person, to the need to avoid the infringement of his dignity and wellbeing that would arise from a lack of attention to his needs, in particular his need for food, and to observance of the principle of equality in the way these rights were to be protected. There was no evidence of any positive intention to humiliate or debase Mr Ryan. Nevertheless, the standard of service did at the very least constitute a failure to respect Mr Ryan’s human dignity.
Was Mr Ryan’s death avoidable?
In considering whether to make a finding about avoidable death the Health Service Ombudsman assessed whether the injustice complained about (in this case Mr Ryan’s death) arose in consequence of the service failure or maladministration she had identified. She concluded that it was impossible to say for certain whether Mr Ryan would have survived if he had been fed. However, while she could not categorically say that Mr Ryan died because he was not fed, she was not persuaded that the Trust could categorically say that this was not the reason for his death.
The Health Service Ombudsman concluded that, had the care and treatment Mr Ryan received not fallen so far below the relevant standard, it is likely that his death could have been avoided.
Injustice
The Trust put forward evidence about changes which had occurred since Mr Ryan was a patient there, and the Health Service Ombudsman found the Trust had taken reasonable action to address the shortcomings identified by its own inquiry and service failure and maladministration identified in her investigation. That said, Mr Ryan’s parents still had reason to be aggrieved by the failings in the Trust’s care and treatment of their son and, in particular, those failings which the Health Service Ombudsman concluded occurred for disability related reasons. Furthermore, they should not have had to wait for an investigation by the Health Service Ombudsman to fully establish the facts about the service provided for their son. Partly due to failings at the Trust, Mr Ryan’s parents had to wait over two years for answers to their questions. These findings represent unremedied injustice.
Moreover, in discovering that their son’s death could probably have been avoided, had the care and treatment not fallen so far below the relevant standard, Mr Ryan’s parents suffered an injustice which can never be remedied.
Therefore, the Health Service Ombudsman upheld Mrs Ryan’s complaint against the Trust.
Recommendation
The Health Service Ombudsman recommended Mr Ryan’s parents should receive apologies and compensation of £40,000 from the Trust. This compensation was in recognition of the injustice suffered in consequence of the service failure and maladministration identified.
In response to the recommendations the Trust’s Chief Executive acknowledged the failings, apologised to Mr Ryan’s parents and agreed to pay the compensation.
The complainant’s response
Mr Ryan’s family and Mencap have said the outcome of the investigation is that ‘justice has been done’ because the Health Service Ombudsman’s report exposes the very serious failures that led to Mr Ryan’s death. They also welcomed the conclusions that some of the failures in care and treatment were for disability related reasons. They said they believe the report will have a positive impact on future care of people with learning disabilities. They welcomed action by the Trust aimed at preventing a similar occurrence. In particular, they have said that the report shows how ‘proper care, using multidisciplinary working, personalised care planning and good communication within teams and with families and carers would greatly improve the outcome for people with a learning disability in our hospitals’.
