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Selected Investigations Completed April - September 1998 > Part I, Case no. E.189/96-97
Matters considered: Failures in medical and nursing care; delay in transfer to intensive care unit (ICU) at another hospital; unsatisfactory complaint handling
Complaint against: Warrington Hospital NHS Trust
Summary of case
Mr B was admitted to Warrington General Hospital on 28 November 1996. When his family visited him the next day they noticed blood on the front of his pyjamas; they later learned that he had pulled out his drip and there was a two hour delay in resiting it. Mr B was in a distressed state and his sons had to restrain him but the family received no help from nursing staff. At 5.45pm on 30 November 1996 a doctor told Mrs B that her husband was in a critical condition and that arrangements were being made to take him to the ICU at another hospital. At 7.00pm Mr B's son asked why his father had not been transferred, and was told that the anaesthetist, who needed to treat Mr B before he could be transferred, was delayed in the operating theatre. Over the next four hours Mr B's son made several further enquiries, but the anaesthetist did not attend Mr B until 11.45pm. Mr B died of Legionnaires' disease two weeks later. Mrs B complained to the Trust about the delay and about her husband's care. In January 1997 a meeting was held between Trust staff and family members. The family were dissatisfied with the meeting and complained that the notes sent by the Trust did not reflect what had been said.
Findings
The Ombudsman upheld all aspects of Mrs B's complaint. He found that Mr B's medical and nursing care were not as good as they should have been. Abnormal blood test results, which indicated the need for earlier intervention, had not been seen or acted upon. The Ombudsman's clinical assessors advised that the delay in an anaesthetist attending Mr B had been unavoidable, as other patients had required urgent attention that night. Nevertheless, the Ombudsman found it unacceptable that Mr B had to wait so long. The Ombudsman found that Trust staff did not have a clear idea of what was expected of them at the meeting with the family; there was confusion over the content of the notes of the meeting, and staff blamed each other. The family's distress was compounded by staff addressing them by the wrong name throughout the meeting, and by another incorrect name in the notes of the meeting.
Remedy
The Trust had changed their system for notifying and acting upon test results; introduced a formal procedure reflecting the importance of consultant-to-consultant communication; and were taking steps to avoid unsatisfactory complaint handling in the future. The Trust apologised to Mrs B and her family for the shortcomings which the Ombudsman identified.
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