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Selected Investigations Completed December 2000March 2001 > Part I, Case no. E.2069/99-00
Complaint against: Oxford Radcliffe Hospitals NHS Trust
Summary of case
On 10 December 1998 Mrs A was admitted to Horton General Hospital suffering from uncontrolled diabetes and pneumonia. Over the next couple of days her condition worsened and she was transferred to the critical care unit on 12 December. On 15 December her condition was sufficiently improved for her to be returned to the ward. Mrs A continued to improve despite developing diarrhoea on 16 December: on 20 December she was moved to a side ward to reduce the risk of infection. When her daughters visited Mrs A on Christmas Day her condition had deteriorated. She was suffering from cold sweats, rapid breathing and a pain in the right side of her back. She had not eaten or drunk that day. One of her daughters alerted a nurse, and Mrs A was given oxygen. Mrs A was seen by a doctor who arranged for an X-ray which showed that Mrs A had fluid on her lung. The doctor said that he would arrange for a lung tap to be undertaken. When Mrs A’s family visited on Boxing Day afternoon, they found that the lung tap had not been undertaken and they alerted staff. A lung tap was undertaken but very little fluid was drained off. Mrs A had not eaten or drunk that day and her daughter thought she might be dehydrated. She alerted a nurse who said she would ask the doctor to check on Mrs A. Her family left the hospital at about 9.30pm and Mrs A suffered a cardiac arrest and died two hours later.
Findings
The Ombudsman took advice from an independent nursing assessor and from one of his own medical advisers. He found that although there were a number of factors which should have alerted nursing staff to Mrs A’s deteriorating condition, they failed to act. He also found that the arrangements to provide medical cover for that Christmas period were woefully inadequate. Nevertheless, the Ombudsman’s medical adviser indicated that Mrs A’s totally unexpected and unavoidable death was caused by an acute gastric haemorrhage of which there was no discernible warning.
Remedy
The Trust have taken steps to re-organise the nursing cover for that ward and have received funding for a new consultant position with a junior grade doctor to support that position.
Full text of this investigation
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