Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E712/01-02
Complaint against Dartford and Gravesham NHS Trust
Summary of Case
Mrs M was admitted to hospital following a fall. She was diagnosed as having pneumococcal septicaemia and treated with antibiotics. Her condition worsened. Her family had indicated to staff that Mrs M was suffering from severe pain in her right leg. Following her death a post mortem recorded the cause of death as septicaemia, the cause of which was considered to be abcess formation around the site of a previous hip replacement operation.
Findings
The Ombudsman found that the Trust had acknowledged its shortcomings in the nursing care provided and she accepted that appropriate measures had been put in place to improve nursing practice. The Ombudsman took advice from two professional assessors. In relation to the diagnosis and treatment received by Mrs M the Ombudsman found that the Trust failed to identify the source of the septicaemia and provide appropriate treatment. This aspect of the complaint was upheld. The Ombudsman expressed concern that during the course of less than four weeks in hospital Mrs M had been under the care of three locum consultant geriatricians and one substantive consultant geriatrician as well as a changing group of more junior medical staff. She found that there had been no adequate arrangement for handover of care from one consultant to another and no adequate review of the management plan for Mrs M as her condition altered. The Ombudsman recommended that the Trust take action to implement seven recommendations suggested by her professional assessors, and in particular recommended that the Trust should review its arrangements for consultant cover.
Remedy
The Trust apologised and agreed that the recommendations contained in the Ombudsman’s report would be implemented. Subsequently the chief executive produced an action plan which addressed each of the recommendations which had been made. In relation to consultant cover the Trust subsequently employed three elderly medicine consultants (an increase of one since the time of Mrs M’s hospitalisation), each linked to an acute medical consultant, to ensure that there was cross-cover in the absence of any consultant, and sufficient elderly care consultants to provide in-house cover in the event of leave. It was anticipated that this would obviate the need for locum cover in future.
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