Death of woman after minor surgery due to 'significant failings'

Claire Fitzgerald, 28, was admitted to hospital after complaining of a painful lump on her neck. She died the day after the surgery.

Her family said that she was not properly assessed before the operation and not adequately monitored afterwards.

The Scottish Public Services Ombudsman, Jim Martin, yesterday agreed there were significant failings by staff in their care of Miss Fitzgerald, especially given her learning difficulties.

He told NHS Tayside to "provide an explicit, unambiguous and meaningful apology".

Miss Fitzgerald was born with the muscle-wasting condition myotonic dystrophy and also had learning difficulties.

She was admitted to Ninewells Hospital in Dundee in March 2008 for surgery on her parotid gland. Before the surgery she did not receive a formal assessment by a consultant anaesthetist.

After surgery she was returned to the ward, where she was found to have low blood pressure. She was left to sleep and her vital signs were not recorded during the night. At around 10:30am she was found to be unresponsive and a cardiac arrest call was made at 10:58. It was not possible to resuscitate her and she was pronounced dead. The cause of death was recorded as "primarily to dystrophia myotonica".

Miss Fitzgerald's father raised concerns about aspects of his daughter's care and a general concern about the treatment of people with learning difficulties.

He told the ombudsman: "All I know is that if she had not been in for what was a minor operation she would still be with us today."

The ombudsman investigated the checks made before having the surgery. His adviser said it was "unacceptable that a patient with myotonia was not properly assessed by a senior anaesthetist at a formal pre-operative clinic prior to elective surgery".

"He considered this to be a serious failing on behalf of the medical team," the report said.

The report said that, given Miss Fitzgerald's health problems, her blood pressure should have been checked regularly in the night.

The ombudsman wrote: "I have found systemic failings in the post-operative … specifically in relation to the lack of recording of blood pressure and other vital signs, communications, record-keeping and decision making.

"I conclude that failings on the part of the consultant anaesthetist, the consultant surgeon and the nursing staff all contributed to this."

An NHS Tayside spokeswoman said: "We accept all of the Ombudsman's recommendations and will be writing to the family offering a full apology."

The ombudsman said the case highlighted that health professionals needed to take into account patients' special needs.

'Apology comes too late'

A MAN died of a heart problem days after being released from hospital, a report said.

NHS Greater Glasgow and Clyde were criticised over the treatment of the 27-year-old who died alone four days after being sent home.

Michael Inglis, who weighed 27.5 stones and had a history of drink and drug abuse, was admitted to the Victoria Infirmary in Glasgow in May 2007 after being referred by his GP with a number of symptoms.

The ombudsman said the hospital should have made more checks to rule out heart problems.

Mr Inglis mother, Elizabeth Miller, yesterday said she had mixed feelings about the report, as the apology had come too late.

'Decision was not questioned'

AN ELDERLY woman with dementia was taken off antibiotics after hospital staff said she had refused treatment, an ombudsman report found.

May Arbuckle, from Edinburgh, was taken to hospital after suffering a fall. She was later transferred to Liberton Hospital and was given a course of antibiotics, some of which she refused.

The ombudsman said no assessment was made of her ability to make that decision.

Mrs Arbuckle's condition deteriorated and she died just over a week later.

Her husband, Tom, complained and the ombudsman concluded that NHS Lothian had not provided appropriate treatment or antibiotics.