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Hospital trust found to be ‘not honest’ about stroke death



An ombudsman has found that a hospital trust has failed to be be honest with a woman whose mother died after suffering a stroke.

As first reported by the BBC, the hospital trust based in Wolverhampton have apologised for its failure to be honest and paid £750 compensation.

Jane O’Connor promised her mother Ann Cotterill who died three months after she suffered a stroke that she would “fight every step of the way” to prevent what happened to her from ever happening again.

It is this “persistence” from Jane that the ombudsman believes led to her discovering the real nature of her mother’s care.

Two months after her mother had suffered a “catastrophic” stroke in November 2017, Jane found that Ann was also being treated for atrial fibrillation.

Jane, being a nurse herself, questioned why blood-thinning medication was not already being prescribed due to the greater risk of stroke that is associated with atrial fibrillation.

Jane says: “I’d asked questions about why my mum had a stroke and people told me they didn’t know, but they did know.”

The ombudsman report shows that an independent review which was commissioned by the trust, would find that the atrial fibrillation could have caused the stroke.

Thus meaning that blood thinning medication could have prevented it.

This conclusion was not easy to come to, it took months of complaints and  according to the watchdog these complaints were responded to with complete lack of honesty and openness.

Jane is now pursuing legal action against the trust over her mother’s care. 

The ombudsman’s report only directly deals with the failures the trust made in handling her complaint.

Having witnessed her mother being treat for atrial fibrillation and questioning the lack of blood thinning medication, Jane lodged an official complaint with the trust in January 2018.

An initial investigation was completed by the trust in March 2018, a month after Ann died aged 76.

However, the trust concluded that there was no link between Ann’s episodes of atrial fibrillation and her stroke.

According to the ombudsman, the trust missed two opportunities to treat the atrial fibrillation itself.

After Ann was fitted with a heart monitor, two episodes in January and September 2017 were only pick up in October, shockingly, an email containing the dat was missed by the cardiologist and no further action was taken.

Another shocking discovery made by the ombudsman was an email from a cardiologist apologising for not prescribing blood thinning drugs for Ann’s atrial fibrillation, yet this was excluded from the trust’s investigation and also not provided to Jane.

Jane would only discover this email months later, after a Freedom of Information request.

The trust’s invitation team made no attempts to contact Jane, which was criticised by the ombudsman, Jane herself secured a lengthy meeting with those involved in the investigation in August 2018.

Due to a recording device failure, only four minutes of that meeting is on record.

Jane was not willing to accept what was said in the meeting, so she continued with letters of complaint, with some of those directed to trust chief executive David Loughton.

Her MP even contacted the trust, but was told it had carried out an investigation.

She attend a meeting of the Wolverhampton Clinical Commissioning Group board in November 2018, in which she demanded answers publicly.

It was only after these interventions, that the trust sought an independent review of what had occurred.

In December 2018, an independent cardiologist appointed by the trust, concluded it was possible the atrial fibrillation caused the stroke.

The ombudsman determined that the trust were aware of this in January 2018 when Jane made the initial complaint, but had not acted upon it.

The trust was found to “not appear to have been clear, accurate, open or honest as it could and should have been”.

The ombudsman also states that the trust should have opened a serious incident investigation in January 2018 and that it’s failure to do so was “maladministration”.

It took until March 2019 for Ann’s death to be considered a serious incident by the trust.

Jane says she was “fortunate and strong enough” to fight “at a time when my thought process should have been all about mum and grieving for our loss of her.

“It comes with a cost to me, to my wider family, because they have had to sit and watch me do all of this and I have trawled through mountains of paperwork and emails and medical notes to get where I am today for mom.

“There is no need for them to be so resistive, why couldn’t they just be honest?

“The duty of candour is on the trust to be open and honest with me and at no point were they, unless I dragged it out of them, so it has been a very difficult journey.”

Jane also says that she was “very concerned” her mother’s case was not a “one off” and furthermore questioned the time it took for her case to be resolved.

In a statement made by the trust, it says it has made several changes to improve “service users’ experience”, which includes “additional training, weekly high-level reviews of grievances and incidents and complaint handling training commissioned through the ombudsman’s office”.

The trust has refused to make any further comments due to the ongoing clinical negligence claim.