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Selected Investigations Completed April - September 1999 > Part I, Case no. E.926/97-98
Complaint against: The Medway NHS Trust, Kent
Summary of case
In February 1997 Mrs B was admitted to the Medway Hospital for treatment related to chronic pancreatitis. Her condition deteriorated and she suffered a stroke. She died shortly afterwards. The complaints were considered initially at local level. A convener subsequently decided not to arrange an independent review panel to look into the relatives' outstanding concerns. Mrs B's daughter complained to the Ombudsman that the consultant physician responsible for Mrs B's care failed to recognise and act on her deteriorating condition; that no active treatment was provided, and no anticoagulant therapy or physiotherapy was given in order to reduce the risk of blood clotting; that a decision not to resuscitate Mrs B in the event of cardiac arrest was not discussed with, or disclosed to relatives; that Mrs B's relatives did not receive a satisfactory explanation as to the precise cause of death; and the handling of the complaint by the Trust and their convener was dilatory and unsatisfactory.
Findings
The Ombudsman, advised by independent professional assessors, did not uphold the clinical complaints. However, he upheld the complaint that the 'not for resuscitation' decision was not discussed with, or disclosed to, Mrs B's relatives. In that regard, the Trust had failed to follow certain principles set out in the central and local guidelines. The Ombudsman also found that the Trust failed to provide a clear explanation about the cause of Mrs B's death. The Ombudsman upheld the handling complaint. Among other matters, he concluded that during the convening stage the Trust secretary was, at times, involved to a degree which could have compromised its independence.
Remedy
The Trust apologised. They agreed to remind staff of their policy on 'do not resuscitate' decisions; to monitor closely their complaint handling to ensure it is consistent with national guidance; and, in particular, to take positive steps to ensure that a more distinct line was drawn between the end of local resolution and the convening stage.
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