Miss G, a woman in her early 50s with learning disabilities and a history of bipolar disorder, was diagnosed with gallstones and needed surgery. She was admitted to a hospital run by the Pennine Acute Hospitals NHS Trust (the hospital trust). They could not operate immediately due to inflammation and she was sent home until the operation could be done. In the meantime, Miss G was unable to cope with the pain, and she was sectioned to the psychiatrist ward run by Pennine Care NHS Foundation Trust (the care trust) because of her behaviour. Her medical notes were not acquired by them and they would not listen to her family. She did not have her operation for four months. Following the surgery, she developed a bowel blockage, for which she had another operation. Sadly, she died two weeks later. While these events took place Miss G was transferred back and forth between these two trusts, despite the fact that they were in the same building.
Miss G’s brother and sister-in-law, Mr and Mrs A, complained to us, supported by Mencap. We investigated both trusts and found that Miss G’s care had not been properly co-ordinated or managed. There was no evidence that the trusts had taken Miss G’s disabilities into account when planning her care, although this was a legal obligation under disability discrimination law. In particular:
- Nursing records did not clearly say what care was planned, what decisions had been made, or what care had been delivered.
- Communication between nurses, doctors and other clinical staff and with Miss G and her family was ineffective, and they did not help her to understand what was happening. This meant distressing events were made even more distressing for Miss G.
- Neither trust made adequate use of community learning disability services to make sure Miss G had support for her specific needs.
- When Miss G missed appointments at the hospital trust, they did not consider how to ensure she attended her appointments. This meant that her gallstones were untreated for over five months, which would have made her feel unwell and in pain.
- After surgery, nobody took account of her specific needs, and she ended up very agitated and ‘running around’.
- Doctors at both trusts failed to adequately assess and manage Miss G’s condition after the second operation, and she was transferred back to the care trust prematurely.
- The psychiatrist at the care trust did not ensure her care was properly co-ordinated and managed. Staff at the care trust did not listen to the people who knew her best — the team that cared for her and members of her family — or allow them to be involved.
The trusts’ failings meant Miss G experienced unnecessary physical and mental suffering. If this period of poor care had not occurred it is likely that Miss G’s death could have been avoided. Mr and Mrs A suffered the loss of a much loved member of their family: an injustice that can never be remedied. We upheld their complaints about both trusts.
Both trusts agreed to acknowledge and apologise for their failings and offer Mr and Mrs A compensation of £15,000. Both trusts also agreed to put together action plans that described how they had learnt from their failings and what they would do to stop them happening again.
Six months after the investigation finished, Mencap told us that Mr and Mrs A were very pleased with the action taken by the hospital trust.