Home > Publications > Selected Cases - Health >
Selected Investigations Completed December 2000March 2001 > Part I, Case no. E.2260/99-00
Complaint against: Rotherham General Hospitals NHS Trust
Summary of case
On 19 February 1998, Mrs C’s father, Mr D, was admitted to Rotherham General Hospital after passing and vomiting blood. It was suspected that he had a bleeding gastric ulcer. Hospital staff told Mrs C that her father was losing lots of blood and nothing could be done until he had had a gastroscopy. The gastroscopy was not performed until 23 February. Each time Mrs C visited her father in hospital, she found him in agony as the steroid treatment he had been taking for rheumatoid arthritis was stopped shortly after his admission. She said that he was not given anything for the pain until shortly before he died, on 1 March.
Findings
The Ombudsman found that following Mr D’s admission, a gastroscopy referral form was completed and marked urgent. Unfortunately, this form never reached the endoscopy unit. A gastroscopy was then arranged for Mr D for 21 February. However, the surgical registrar who was to perform this decided that it could wait until 23 February. However, she did not discuss this with her consultant surgeon. The Ombudsman’s independent clinical assessors noted that at the time there was evidence suggestive of continuing gastrointestinal haemorrhage and that Mr D was at risk of serious haemorrhage. The assessors described this as a severe error of clinical judgment and all other medical staff involved in Mr D’s care saw the need for an urgent gastroscopy. The Ombudsman upheld the complaint. He criticised the actions of the surgical registrar. As Mr D was on a medical ward, he criticised medical staff to the extent that they had overall responsibility for Mr D’s care. He also criticised hospital management for failing to provide nursing staff on the ward with updating training.
The Ombudsman also found that the abrupt withdrawal of steroids without making a firm diagnosis was inappropriate and a firm diagnosis was only possible after gastroscopy. He therefore criticised the locum consultant for stopping the treatment without ensuring a proper diagnosis had been made. He then found that nursing staff had failed to recognise the link between steroid treatment and rheumatoid arthritis and incorrectly assessed Mr D’s pain. He criticised nurse managers for failing to identify training needs. The Ombudsman upheld both complaints. Finally, the Ombudsman found that Mr D’s serum sodium concentration rose steadily following his admission to levels incompatible with satisfactory metabolism and that this was not diagnosed promptly. This failure represented unsatisfactory management of Mr D’s fluid balance. The Ombudsman criticised medical staff involved in Mr D’s care for this. He upheld the complaint.
Back to top
Remedy
The Ombudsman recommended that the surgical registrar’s current employers be made aware of his assessors' concerns. He also recommended that the Trust identify and address the specific training needs of their nursing staff; ensures staff are fully aware of guidelines on emergency gastroscopies and that they consider introducing clearer guidelines on how emergency gastroscopies should be handled out of hours. The Trust should also issue guidance on dealing with patients on steroid treatment; that they consider developing a pain assessment tool for use on the war; and that their arrangements for monitoring patients' fluid balances be reviewed. The Trust agreed to implement the Ombudsman’s recommendations and apologised to Mrs C.
Full text of this investigation
Previous < Contents > Next
Back to top
|
