NHS trust hit with complaints

COMPLAINTS about a surgery performed without a patient's consent and a delay in treatment at the Pennine Acute Hospitals NHS Trust were included in an NHS investigations report.

The "Report on selected summaries of investigations by the Parliamentary and Health Service Ombudsman" includes summaries of investigations carried out into complaints about government departments and other public organisations and the NHS in England.

The latest report, which features cases from October to December, 2015, includes two relating to Pennine Acute, which runs North Manchester General Hospital, The Royal Oldham Hospital, Fairfield General Hospital in Bury, and Rochdale Infirmary.

An investigation into a complaint found that doctors failed to notice soon enough that a patient with a swollen eye had become ill with sepsis.

The patient, in his mid-eighties, was taken to an urgent care centre where doctors provisionally diagnosed orbital cellulitis (an infection of the tissues around the eye) and gave him oral antibiotics.

Transferred
When his condition deteriorated, the patient, referred to as Mr L, was transferred urgently to another hospital within the Trust for review and to start a course of intravenous antibiotics.

He arrived at 9.30pm but, because of delays in A&E and the Medical Assessment Unit, he was not prescribed the antibiotics until 1.20am.

The patient was eventually given the antibiotics at 4am and 5am but he continued to deteriorate and died twelve hours later.

The patient's daughter believed her father's death could have been avoided if he had received earlier treatment for his orbital cellulitis and also complained about the way the trust handled her complaint.

The ombudsman upheld the complaint and said: "There were missed opportunities to diagnose and treat the patient for his developing sepsis by both the A&E and Medical Assessment Unit staff.

"His daughter will never know whether her father might have survived had he received earlier care."

The Trust acknowledged its failings, apologised to the patient's daughter and prepared an action plan to ensure the failings would not happen again.

In the second case a woman, Mrs E, complained that the Trust did not obtain her permission before carrying out an operation on her piles where the growths around her anus were banded (elastic bands placed tightly around the base of piles to cut of their blood supply).

The report stated: "The trust discharged the patient despite the fact that she was losing a lot of blood and she had not eaten anything or gone to the toilet; and she said the Trust failed to give her any paperwork explaining what had been done or give her the four items she had been prescribed.

"She said this caused her and her family distress and that she was 'made to feel dirty, embarrassed and humiliated'."

The patient, who was other suffering with other medical issues involving her feet, left kidney and asthma, also complained that she was treated "discourteously and insensitively" and that she did not receive adequate care and treatment.

Injustice

The complaint was partially upheld, with the Ombudsman finding a service failure which caused injustice to the patient as the banding procedure was found to have taken place without her permission as there was not enough evidence to say the surgeon had her consent.

Pennine Acute wrote to the patient and apologised for the service failure in the care it gave her and for the distress caused.

The surgeon also discussed what he had learned from this complaint with his responsible officer and an action plan to prevent it occurring again was also drawn up by the trust.

A spokesperson for The Pennine Acute Hospitals NHS Trust said: "We would like to reiterate our apology to Mr L's family for the delay in treatment at Fairfield General Hospital, for not giving him IV antibiotics sooner and for not responding to the complaint we received in a reasonable manner.

"The trust has since introduced The Deteriorating Patient Collaborative which, among other things, aims to improve the identification and management of sepsis, particularly in elderly, frail patients.

"This collaborative is part of an overarching Quality Improvement Strategy which will roll out large-scale staff quality learning collaboratives and engage with staff to work on how we can make real improvements and how we can measure their impact on patient care.

"Measurement of these actions for improvements will be fundamental to ensuring sustainability and the reliability of our care.

"Carrying out surgery on Mrs E without her permission is unacceptable and we would like to apologise again for any distress caused and also for discharging her without the medication she had been prescribed.

"We have discussed with the surgeon the implications of him operating outside of the consent Mrs E had provided and the surgeon has been asked to reflect on and learn from the care that he provided to her."