National Ombudsmen
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Death of woman after routine operation was avoidable, Ombudsman finds

A grandmother’s death following a low-risk, routine hip replacement operation was avoidable, an investigation by the Parliamentary and Health Service Ombudsman has found. 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.

The woman’s son, Ian Craig from Blackburn, brought a complaint about the Trust to the Ombudsman in March 2016 after he felt that the Trust’s own investigation failed to recognise several mistakes in his mother’s care.

Renie Craig, who was 77, was scheduled to have a routine hip replacement operation in February 2015. She had high blood pressure and several tests from December 2014 showed that she had an impaired kidney function, yet this was not investigated ahead of the operation. This, along with her age and the fact that she had diabetes, meant that she was at an increased risk of developing a serious kidney injury, which was not taken into account.

After the operation, she was not given enough fluids and her fluid balance was not monitored despite a doctor’s request for this. Nurses also failed to inform a senior nurse or doctor when her blood pressure dropped significantly. Mrs Craig was given a blood transfusion but later became unresponsive and a doctor resuscitated her before she was moved to intensive care.

In March 2015, Mrs Craig had two further operations under general anaesthetic to treat a wound that developed while in intensive care. A few days later, Mrs Craig sadly died from a sudden loss of blood to the bowel.

Even though tests showed that she was vulnerable, hospital staff did not properly plan her care after her hip operation. They didn’t monitor her condition regularly or act quickly when her condition worsened which meant that she had to have further operations when she was already weak.

The Ombudsman found that if the Trust had provided the right care and treatment then Mrs Craig would have survived. Knowing his mother died as a result of the Trust’s failings caused Mr Craig considerable distress.

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