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Selected Investigations Completed April - September 1999 > Part I, Case no. E.1019/97-98
Complaint against: St Helens and Knowsley Hospitals NHS Trust
Summary of case
Mrs W, who had a serious chronic liver condition, was admitted to hospital on 15 November 1996 with abdominal pain and having vomited blood. She was discharged on 22 November although no firm diagnosis had been reached and she still had some pain. She was readmitted three days later with severe abdominal pain and on 26 November surgeons operated to remove a section of her bowel. Although her condition improved at first, it later deteriorated and on 19 December a leak from her bowel, at the site of the operation, was diagnosed. The next day a doctor told Mr W that his wife urgently required surgery but that there was a high risk that she would not survive. Mrs W survived the surgery but died soon after. Her husband complained about her discharge on 22 November, that doctors had not taken adequate action when there were signs of complications after the first operation and that the family had not been adequately informed about the seriousness of her condition.
Findings
The Ombudsman was advised by a consultant surgeon, a consultant physician and a senior nurse. The nursing records showed that Mrs W was in pain on the day before her discharge but had been reluctant to mention it in case it might affect her discharge. The nurses recorded that and more pain later, but it appeared that that information had not been passed to the doctors. The assessors advised that it might have been reasonable to discharge Mrs W even if the doctors had known she was still having some pain. Mr W said he was unable to collect all the medication prescribed to take home and that they had not been given any written information on discharge. The records suggested that all the relevant items been prepared, but it appeared that the discharge arrangements had broken down. The Ombudsman upheld the complaint about the discharge to that extent. The Trust's consultant surgeon considered it would have been difficult to have diagnosed the cause of Mrs W's deterioration earlier, but that her recovery in the few days after her first operation had lulled the doctors into a false sense of security. Although it was unusual for a leak to occur so long after surgery, staff should have been more suspicious about the cause of her deterioration, and the delay in diagnosis was unreasonable. The Ombudsman upheld the complaint that the doctors failed to take appropriate action when there were signs of complications. It came as a shock to Mr W to be told, immediately before his wife's second operation, of her poor prognosis. The records of communication with Mrs W and her family were poor and gave very little indication of what they understood of her liver condition or her problems at the time. Lacking any evidence of clear communication with Mrs W and her family until shortly before her death, the Ombudsman upheld the complaint that the family were not adequately informed about the seriousness of her condition.
Remedy
The Trust apologised and agreed to monitor the effective use of new documentation to record communications.
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