26.02.19
Ombudsman finds ‘catalogue of errors’ led to grandmother’s death in routine hip operation
A “catalogue of errors” in a routine hip operation by staff East Lancashire Hospitals Trust led to the death of a 77-year-old grandmother, an investigation has revealed.
The Parliamentary and Health Service Ombudsman (PHSO) found that the ‘low risk’ hip replacement operation in 2015 led to the “avoidable” death of Renie Craig.
East Lancashire Hospitals NHS Trust has apologised and said it has made significant improvements to its services to ensure “similar errors do not happen again.”
Renie Craig had the hip operation in February 2015 despite having high blood pressure and an impaired kidney, and following the surgery she was not given enough fluids – with her fluid balance failing to be monitored despite a doctor requesting so.
The ombudsman said her age and the fact that she had diabetes meant that she was at an increased risk of developing a serious kidney injury.
When Renie’s blood pressure “dropped significantly”, nurses failed to inform a senior doctor and following a blood transfusion and two further operations, she died in March.
The ombudsman said in a statement: “A catalogue of errors at East Lancashire Hospitals NHS Trust, including failing to properly monitor and treat Renie Craig after the operation, meant she died as a result.”
It upheld the complaint, finding that the trust failed to check Craig’s risk of developing acute kidney injuries, and the subsequent monitoring of her condition was “inadequate.”
Following the ombudsman’s recommendations, the trust has written to Renie’s son to acknowledge its failings and formally apologise and make an undisclosed payment “in recognition of the injustice,” as well as outlining what changes had since been made.
Medical director Damian Riley 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.”
Craig's son, Ian, commented: “We lost my father only a few months before so we were already grieving and my mother's death came as such a shock to me and to my wife and son.”