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Man’s death from perforated bowel was avoidable


Organisation we investigated: Calderdale and Huddersfield NHS Foundation Trust (the Trust)

Date investigation closed: 1 November 2019


The complaint

Miss A complained about the care and treatment that her brother, Mr A, received at the Trust in December 2017 and January 2018. She said that the Trust failed to act on risks it identified with her brother’s twisted bowel, and perform surgery urgently in line with the clinical guidance. The Trust did not act quickly enough which meant his condition worsened and, as a result, he died.

What we found

We found that the Trust failed to:

  • perform urgent surgery despite recognising the risks of the twisted bowel
  • consider surgery on two occasions when Mr A’s condition did not improve
  • follow national guidelines to change its approach to treatment when Mr A’s condition did not improve
  • meet obligations to Mr A’s family under its duty of candour.

If these failings had not occurred, it is likely that the Trust would have changed its approach to Mr A’s treatment much earlier and performed urgent surgery. It is highly likely that he would have survived following the surgery and his death would have been prevented.

We also found that the Trust failed to meet its duty of candour. It did not disclose contradictory opinions on whether the death was avoidable in its complaint response to Mr A’s family. This meant that there was a missed opportunity for the Trust to acknowledge the failings in its care and treatment of Mr A during the complaint investigation.

Background

Mr A went to the emergency department at Calderdale Royal Infirmary (CRI) on Christmas Day 2017 with constipation and abdominal pain. The CRI identified the risk of bowel perforation and said that he needed surgery. Mr A was transferred to Huddersfield Royal Infirmary (HRI) the same day.

On 27 December, staff at HRI performed an investigation and recorded the same risk of perforation in clinical notes. Similar conclusions were drawn in a further examination on 30 December. It was not until 1 January, a week after Mr A’s initial visit to A&E, that HRI recognised a need for surgery. This was planned for 2 January but was cancelled and rearranged for 3 January. Mr A’s condition worsened. The Trust did attempt surgery the same day but this was too late as his bowel had already perforated. He then suffered a cardiac arrest and was taken to ICU. He died on 4 January after his organs failed.

Miss A, Mr A’s sister, complained to the Trust. In its response it said that the care and treatment given was appropriate and that Mr A had been managed conservatively. The Ombudsman asked for clinical advice from a qualified and experienced colorectal surgeon. He provided clinical guidance which said that patients with risks like Mr A’s should have urgent surgery. He also presented evidence that said that the risk of death had increased very significantly by 3 January.

Miss A complained to the Ombudsman because she wanted the Trust to acknowledge its failings and was not satisfied with its response to her complaint. She said her brother would have wanted to improve services so that the same thing could not happen again.

The Ombudsman found that the Trust failed on more than one occasion to act in line with guidance on results of its investigations into Mr A’s condition. The Ombudsman also found that the delay in operating led to Mr A’s avoidable death.

Putting it right

We recommended that the Trust writes to Miss A to acknowledge the failings we identified and to apologise for the impact they have had. The Trust should produce an action plan to explain how it will ensure that similar failings do not occur in the future.