Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.1001/99-00
Complaint against Barts and The London NHS Trust
Summary of Case
Mr A was attending the Royal London Hospital for renal dialysis. In October 1997, he was given an endoscopy examination because of difficulty swallowing. Mr A subsequently died from mediastinitus (a chest condition) due to a perforated oesophagus. Mr A’s wife, Mrs A, complained to the Trust about his treatment and care. The Ombudsman found that the decision to proceed with the endoscopy and the way it was carried out were appropriate, as was the initial treatment after the perforation occurred. However, the Ombudsman upheld Mrs A’s complaint in relation to the subsequent management: no surgeon was involved in initial decision-making, and although an ENT surgeon’s opinion was later sought, by that stage Mr A’s condition had deteriorated and surgery was no longer a realistic option. The Ombudsman found that Mr A had not received adequate pain relief, and there was a lack of co-ordination at consultant level in respect of Mr A’s subsequent renal failure. The Ombudsman also upheld Mrs A’s complaint about the Trust’s complaint handling: administrative delays were compounded by a lack of ‘ownership’ of the case. The Trust apologised to Mrs A and agreed to introduce a protocol for patients undergoing endoscopy.
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