A grandmother died needlessly after what should have been a routine hip replacement because of multiple errors from hospital staff including nurses, an investigation has found.
In a damning report, the Parliamentary and Health Service Ombudsman determined that staff at East Lancashire Hospitals NHS Trust had failed to properly treat and monitor 77-year-old Renie Craig.
“It is vital that lessons are learnt when mistakes are made in the NHS”
The trust has subsequently made changes to its procedures in light of findings from Ms Craig’s case.
Her son, Ian Craig from Blackburn, complained to the ombudsman in March 2016, because he felt the trust’s own investigation had failed to recognise several mistakes in his mother’s care.
Ms Craig was scheduled to have a routine hip replacement operation in February 2015.
She had high blood pressure and pre-operative tests showed she had an impaired kidney function, yet this was not investigated by staff.
The test results, along with her age and the fact she had diabetes, meant she was at increased risk of developing a serious kidney injury, but this was not taken into account by the trust, the ombudsman found.
After the operation, Ms Craig was not given enough fluids and her fluid balance was not monitored despite a doctor’s request for this.
The report highlighted that nurses failed to inform a senior member of staff when her blood pressure dropped significantly.
”We acknowledge that there were opportunities to do things differently”
Professor Damian Riley
Ms Craig was given a blood transfusion but later became unresponsive and a doctor resuscitated her before she was moved to intensive care.
In March 2015, Ms Craig had two further operations under general anaesthetic to treat a wound that developed while she was in intensive care.
She died a few days after the procedures from a sudden loss of blood to the bowel, or ischaemic colitis.
The ombudsman’s report concluded: “Even though tests showed that she was vulnerable, hospital staff did not properly plan her care after her hip operation.
“They didn’t monitor her condition regularly or act quickly when her condition worsened which meant that she had to have further operations when she was already weak,” it added.
“The ombudsman found that if the trust had provided the right care and treatment then Mrs Craig would have survived,” it added.
Following the ombudsman’s investigation, the trust has made changes to the way it monitors fluids and manages kidney injuries in a bid to prevent another situation like this happening again.
It has also written to Mr Craig to apologise for what happened to his mother and has offered him compensation.
Rob Behrens, the parliamentary and heath service ombudsman, said: “Our NHS staff do a professional job caring for hundreds of thousands of people every day under enormous pressure. But as this tragic case shows, it is vital that lessons are learnt when mistakes are made in the NHS.”
Professor Damian Riley, medical director for East Lancashire Hospitals, said: “The trust extends its sincerest apologies and we acknowledge that there were opportunities to do things differently while we were responsible for Mrs Craig’s care.
“Since this incident, we have made significant improvements to try and ensure similar errors do not happen again,” he added.
Mr Craig said he wanted other trusts to learn from the mistakes made in the care of his mother to “make sure that others don’t have to experience a tragedy like this”.