Ombudsman finds death fine hospital guilty over care


A “damning” ombudsman’s report has found a hospital guilty of widespread failings in the care provided to a woman with learning difficulties and high support needs who died after a routine operation.

The findings of the parliamentary and health ombudsman came just weeks after the same hospital – Basildon University Hospital – was fined £50, 000 over the 2006 death of a man with learning difficulties whose head became trapped in his bed rails.

The ombudsman found that the care and treatment provided by the hospital to Lisa Sharpe before her death in 2004 fell “significantly below a reasonable standard”.

Her family claimed their concerns were ignored for nine days after she underwent a routine operation to insert a feeding tube – even though she had begun to vomit bile.

When an x-ray was finally taken, it revealed she had pneumonia. Despite her condition, the hospital failed to provide any pain relief.

Mencap, which has supported Lisa Sharpe’s family, said the ombudsman’s report highlighted a string of failings, including a lack of basic nursing care, the failure to manage her pain, and a breach of the hospital’s public sector duties under the Disability Discrimination Act.

Mencap said it knew of two other people with learning difficulties and similarly high support needs who had died at the hospital.

Beverley Dawkins, Mencap’s national officer for profound and multiple learning disability, said: “The ombudsman’s report is damning – that doctors and nurses failed to provide Lisa with even basic medical and nursing care is unacceptable, and a sign of a wider indifference towards people with a learning disability within the NHS.”

She said Mencap was pleased that the hospital had signed up to its new Getting it Right charter, which explains the adjustments healthcare professionals should make when treating someone with a learning difficulty.

But Dawkins said the hospital’s progress could “only be measured by what happens when the next person with a severe learning disability is cared for on one of its wards”.

Maggie Rogers, director of nursing for the trust that runs the hospital, said: “We would like to emphasis our apologies and condolences to Lisa’s family and we are very sorry that we were not able to resolve the family’s concerns after Lisa’s sad death in 2004.

“The ombudsman’s medical expert acknowledged that much of the care was good. We accept the ombudsman’s recommendations; much of the learning and many improvements have been implemented and will continue to be strengthened.”

Last month, a Mencap survey found almost half of doctors had seen a patient with learning difficulties being treated with neglect or lack of dignity or receive poor care.

Meanwhile, Mencap has been granted a judicial review of the way the parliamentary and health ombudsman investigated the deaths of six people with learning difficulties in NHS care, whose cases were detailed in Mencap’s Death by Indifference report three years ago.

15 July 2010