A 76-year-old woman died after doctors missed repeated warning signs of a bowel obstruction and she was unable to communicate her intensifying stomach pain to medical staff because the Trust failed to provide an interpreter.
The Parliamentary and Health Ombudsman (PHSO) found Turkish-speaking Sevinc Ulkueri’s death at University Hospitals Birmingham Trust was avoidable. During the delay to treatment, her bowel perforated and she developed sepsis. The investigation found that earlier diagnoses and intervention would have saved her life.
This case highlights the importance of effective, open and empathetic communication for public services. This principle forms a central part of PHSO’s new five-year strategy.
Rebecca Hilsenrath KC (Hon), Chief Executive Officer at PHSO said failing to support Sevinc to communicate how she was feeling was contrary to the NHS’ values of fairness and dignity:
“This distressing case highlights the importance of listening to patients. Supporting Sevinc to communicate how she was feeling would have respected her right to be heard. Her input could have led to a faster diagnosis.”
Sevinc’s daughter, Seniz, complained to the Ombudsman that the Trust ignored the warning signs of a bowel obstruction and failed to treat her mother before it was too late.
Sevinc, originally from Istanbul, lived with her family in Solihull. She was admitted to Birmingham Heartlands Hospital in March 2021 after four days of vomiting, abdominal pain, shortness of breath and constipation – all symptoms consistent with a bowel obstruction.
On admission, Sevnic had a chest X-ray and was treated for pneumonia. The X-ray showed multiple bowel loops – bulges in the bowel wall that can indicate a blockage - but this was not acted on until a week later.
Sevinc also had a physical abdominal examination. The checks appeared normal. However, national guidelines state that such observations alone are not sufficient to rule out a blockage. Despite this, and the presence of multiple bowel loops, doctors concluded that an obstruction was unlikely.
Sevinc was encouraged to eat, but should not have been, as increasing pressure around the blockage can increase the risk of bowel perforation.
When the Trust finally diagnosed a bowel obstruction almost a week after Sevinc had been admitted, her bowel had perforated, which meant air and waste leaked into her abdominal cavity. She had surgery to treat an abscess which was causing the blockage but shortly afterwards she developed sepsis and died.
Seniz said:
“How could we have known that when the ambulance took our beloved mother to hospital she would never come home?
“The intense pain, coupled with her very limited English, meant she relied on me and my sister to communicate with the medical team. They repeatedly ignored or dismissed our pleas to take her abdominal pain seriously. Instead, they repeatedly said her bowel was not blocked.
“Our loving mother’s death was both premature and completely avoidable. We will never forgive the hospital for the pain, fear, and suffering our mother endured, and for the lifelong grief they have inflicted on our family.”
PHSO found the Trust missed several opportunities to diagnose a bowel obstruction because it didn’t properly investigate Sevinc’s symptoms. Had it done so, it would have likely identified and treated the blockage. It would have prevented the infection and avoided her bowel perforating and sepsis developing. The Ombudsman also found the Trust failed to meet Sevinc’s communication needs because it didn’t provide an interpreter.
Rebecca Hilsenrath added:
“The failings in this case are some that we see far too often. Delayed reporting on scans, investigations that are not sufficiently thorough, and poor communication with patients and their families.
“Sevinc was unable to clearly express the severity and location of her pain because she was not given the support she needed and to which she was entitled. Patients have a right to an interpreter and NHS services must be accessible to everyone in need of care.
“Listening to patients is crucial. Whether in relation to their treatment, or in the form of a complaint, the patient voice is central to safe and effective care.”
At the Ombudsman’s recommendation, the Trust apologised to Sevinc’s family, paid them £15,000 in recognition of the distress caused, and agreed to improve its approach to investigating bowel problems.