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Thursday, November 26, 1998 Published at 00:23 GMT


Health

NHS disasters under the spotlight

One patient was disconnected from his drip for two hours

The Health Service Ombudsman has detailed investigations into 11 cases in his report.

They include:

The case of the dislodged drip

Mr B was admitted to Warrington General Hospital in Cheshire in November 1996.

When his family visited him the next day they found his pyjamas were spattered with blood.

They later discovered he had pulled out his drip and it has not been replaced for two hours.

The next day, the family were told Mr B was in a critical condition and had to be transferred to another hospital.

However, over five hours later he had not been transferred because the anaesthetist was delayed in the operating theatre.

Mr B died of Legionnaire's Disease two weeks later.

The ombudsman upheld all aspects of the family's complaint. He also found that abnormal blood tests which showed the need for urgent treatment had either been disregarded or not acted upon.

Warrington Hospital NHS Trust said it had changed its system for acting on test results since the case and had made other improvements to its service in the light of the case.

The case of the decomposed corpse

A complaint against Central Nottinghamshire Healthcare NHS Trust for leaving the body of a dead woman unrefridgerated in the hospital mortuary for over 30 hours in July 1997.

This meant that the body was so decomposed that the family were unable to see it.

The hospital accepted it had made errors in releasing the body to the undertakers.

It said the storage problem was due to the woman being too large for the hospital's refridgeration unit.

The ombudsman said that the body should have been moved to a storage unit which was big enough.

Hospital staff should have arranged the transfer, but there was a breakdown in communication over which staff were responsible for contacting the undertakers.

The trust has apologised and reviewed the management of the hospital mortuary.

The case of the undiagnosed cancer

A woman admitted to Surrey and Sussex Healthcare NHS Trust in June 1996 with suspected internal bleeding was not given an ultrasound scan which could have picked up that she had liver cancer.

A scan had been suggested by one doctor who suspected cancer, but a senior doctor overruled the decision.

The elderly woman was discharged after being diagnosed with constipation.

Around a week later, she was readmitted and diagnosed with liver cancer. She died eight days later in hospital.

The senior doctor said he did not believe it was worth putting elderly patients through tests when there was nothing that could be done to save them.

However, the ombudsman ruled that the woman should have been allowed to know the cause of her illness and given the option of spending her last days in hospice care.



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Health Contents

Background Briefings
Medical notes

Relevant Stories

26 Nov 98 | Health
Woman's corpse left to decompose in hospital

28 Oct 98 | Health
Tumour patient 'denied scan'

27 Oct 98 | Health
Suspension system to be reviewed

23 Oct 98 | Health
Abused by the complaints system





Internet Links


Ombudsman report

Institute of Health Services Management

Department of Health


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