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This article was published on September 3rd, 2014
The Royal Blackburn hospital is yet again under the spotlight after it appears hospital bosses have been made to apologise after a catalogue of errors have been highlighted by the Health Services Ombudsman for England.
The problems began after an elderly lady was admitted to hospital after having suffering a fall. The patient had numerous pre existing conditions including heart disease, osteoporosis and hypothyroidism. This was her third admission, after a number of nasty falls previously, and so the hospital staff should have had a comprehensive record of her problems and therefore her needs.
The daughter became very concerned with the quality of care her mother was receiving and lodged a formal complaint raising her concerns. Hospital bosses accepted some of her concerns but dismissed the majority and so the daughter felt that she was not being taken seriously. She then contacted the Health Services Ombudsman who then investigated her complaint.
The Health watchdog found four service failings:
The patient suffered four falls whilst in hospital which was unacceptable considering they knew she had a history of falls. – ‘despite numerous indicators that, from the outset, she was at significant risk of falls there is no evidence that staff produced a (falls) prevention plan’.
Doctors and medical staff had failed in their duty of basic care to ensure she was sufficiently hydrated after an intravenous drip was removed, despite family and the patient repeatedly asking for water.
Medical staff had placed a ‘Do Not Resuscitate’ order by the bed of the patient without discussing it with the whole family which was distressing for them.
The hospital staff had failed to diagnose the patient with delirium despite showing numerous symptoms of this in hospital and only diagnosed it 10 days before her death.
The 81-year-old grandmother of 12 spent a total of two months on the wards when she developed a severe infection, including signs of sepsis, and died of aspiration pneumonia.
The Ombudsman report advised the trust to apologise to the family for their failings and produce an action plan to avoid the same problems occurring.
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