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Avoidable death of woman after multiple failings following routine hip operation


Organisation we investigated: East Lancashire Hospitals NHS Trust (the Trust)

Date investigation closed: April 2018


The complaint

Mr L complained that the Trust’s poor care and treatment of his mother before and after a routine hip operation caused her death.

Background

In December 2014, Mrs L went to a pre-operative assessment at the Trust ahead of her hip replacement surgery. Tests showed that she had high blood pressure and high levels of creatinine which indicated that her kidney function was impaired. A few days later, an anaesthetist checked these results and said that her hip operation could go ahead.

A week later Mrs L had another blood test which showed that her creatinine level had risen, meaning that her kidney condition had worsened. These results were uploaded to an electronic system that staff at the Trust had access to.

Mrs L had her hip replacement operation in February 2015. The surgeon’s instructions for her post-operative care stated that she needed to have routine observations. Nurses monitoring Mrs L recorded that during the night her blood pressure dropped significantly and remained low but no senior doctor or nurse was told. Her oxygen saturation also dropped.

A doctor assessed Mrs L the next morning and noted that her haemoglobin, which transports oxygen around the blood, had dropped by 40%. He gave her a blood transfusion to increase this and intravenous fluids to restore her blood pressure. The doctor said that given her kidney condition, her fluid balance should be monitored.

The next morning Mrs L became unresponsive and a doctor resuscitated her. Her haemoglobin level dropped later that day so she was admitted to intensive care.

A CT scan showed the blood supply to her spleen, kidneys and bowel had been significantly reduced. This deprived them of the oxygen they needed and led to parts of the organs dying.

Another CT scan showed that there was a collection of fluid or congealed blood near the surgical wound on Mrs L’s hip.

In March 2015, Mrs L had two operations under general anaesthetic to treat an infected wound on her right inner elbow that she developed while in intensive care. During the night she fell and dislocated her hip and doctors relocated her hip under general anaesthetic.

Mrs L’s condition deteriorated three days later and sadly, she died. A post mortem examination showed that the immediate cause of her death was ischaemic colitis (a sudden loss of blood flow to the bowel, leading to an ulcer, inflammation, and bleeding). 

What we found

We upheld this complaint. We found that the Trust failed to check Mrs L’s risk of developing an acute kidney injury and subsequent monitoring of her condition was inadequate.

The pre-operative blood test results showed that Mrs L had a high level of creatinine in her blood which should have been investigated. This along with her age and the fact that she had diabetes meant that she was at an increased risk of developing an acute kidney injury.

Clear instructions for fluid balance monitoring were not provided. They were not properly monitored or documented which meant that she became dehydrated.

When Mrs L’s blood pressure dropped significantly, a more senior clinician should have been informed. Monitoring of her blood pressure, creatinine level and fluids should have been carried out more regularly. Instead, these checks became less frequent which meant that her deterioration was not detected and treated quickly enough.

We found that these failings led to a weakening of Mrs L’s system that meant that she was unable to survive the ischaemic colitis which caused her death.

Putting it right

Following our recommendation, the Trust wrote to Mr L to acknowledge and formally apologise for the failings in his mother’s care and treatment. The Trust also made a payment to Mr L in recognition of the injustice as well as writing to him outlining what changes they have made to prevent this service failure from happening again.