Hospital's care for woman during final days criticised

The care provided by a Belfast hospital for a 61-year-old woman with throat problems in the last four days of her life fell short of what was expected, an investigation by the North’s Ombudsman has revealed.

The probe by Tom Frawley’s office identified 29 failures by staff on a general ward at the Royal Victoria Hospital in the management and provision of the patient’s care and treatment, it emerged today.

The woman, who had a history of angina and thoracic spinal deformity since childhood, had been admitted to hospital after having problems swallowing solid foods and suffering weight loss and loss of appetite.

An endoscopy revealed a slight narrowing of the oesophagus but the procedure had to be aborted and a blood transfusion was given.

After the patient developed a chest infection and was given antibiotics, there was a deterioration in her condition and she was admitted to the intensive care unit where she improved after a week’s treatment.

However when she was transferred to the general ward a bowel dysfunction developed and after unsuccessful attempts to pass a nasogastric tube into her, she died of acute cardio-respiratory failure.

Following complaints from relatives about the handling of their mother’s care and the turning down by the Eastern Health and Social Services Board of their request for an independent review, an Ombudsman probe identified 29 failures including:

Unrecorded and unsatisfactory presentation and communication of information to the patient’s family from the period of her hospitalisation and after her death.

The absence of senior medical advice after the transfer of the patient from an intensive care unit to a general ward up until her death.

A lack of senior cover for and input to her care and treatment in the six days following her transfer and a lack of consultant cover in the absence of a consultant gastroenterologist.

Poor supervision of the patient’s care by medical and nursing staff following the transfer from intensive care.

Inadequate record keeping during some periods of the patient’s hospitalisation, with an absence of the recording of blood pressure, pulse, oxygen levels and temperature from early morning on the day preceding her death.

Excessive dosage of one drug and the administering of other medication without proper documentation, appropriate recording and proper supervision.

Communication failures between nursing and medical staff.

Lack of vital signs recording, especially over the last 36 hours of the patient’s life.

Lack of records in respect of discussions with the deceased’s family during her period of hospitalisation.

Mr Frawley confirmed today he had requested a response from the trust to how it would tackle the problems identified by his investigators over the provision of care and treatment, documentation and management on the general ward.

He expected the Trust to respond by mid-July.

“My investigation revealed that the care afforded to the complainant’s mother during the initial period of her hospitalisation had been in the main appropriate and satisfactory,” he said.

“However the care provided during the last four days, and particularly the last 24 hours of her life, fell far short of what she should have received.

"A series of medical and nursing failures combined to result in a situation where the standard of care which the patient needed and should have received was not provided.

“I would like to believe that many changes and improvements to clinical practice have been implemented since these unfortunate events and I look forward to receiving the trust’s detailed evidence that this is now in fact the case.”

Mr Frawley confirmed that the complainant had received a full and detailed apology from the trust for the distress caused to the family who had also been offered a meeting to discuss improvements offered to the trust.