The man, who had difficulty breathing and was in distress, needed a ventilation tube inserted before being transferred but had to wait six hours to be seen by an anaesthetist at Warrington General Hospital. His drip became dislodged and was not replaced for two hours, leaving him with bloodstained pyjamas and bedding. Abnormal test results, showing the oxygen level in his blood was low, were not acted on. He died two weeks later.
The case is among the first involving clinical judgement to be investigated by the ombudsman, Michael Buckley, whose powers were extended to include clinical matters in 1996. It highlights the extreme pressures on the NHS and the lottery faced by patients when there are not enough staff to care for all those who require immediate attention.
The man, Mr B, was admitted to hospital on 28 November 1996 and was visited by his family the following day. At 5.45pm a doctor told his wife, Mrs B, that he was in a critical condition and would have to be transferred to the intensive care unit of a neighbouring hospital. The doctor added that the following six hours would be crucial.
By this time Mr B had pneumonia, his breathing was laboured and he was becoming increasingly distressed. His two sons had to restrain him from removing his oxygen mask. Before he could be transferred he needed a tube inserted into his lungs so that he could be ventilated on the journey but no anaesthetist was available to carry this out until 11.45pm.
Mr Buckley did not criticise the anaesthetists involved in the case because the three who were on duty at Warrington hospital at the time were fully stretched attending to other very ill patients.
The hospital admitted the care provided was "sub- optimal" but said there was nothing it could have done differently in the circumstances and that Mr B's death could not have been avoided.
However, Mr Buckley criticised the hospital for failing to ensure there was direct communication between the medical and anaesthetic staff in such an emergency. Even if an earlier transfer would not have saved Mr B's life, it "would at least have meant that he was more comfortable and received sooner the level of care that he needed".
In separate cases, the ombudsman also criticised two GPs for striking patients off their lists unreasonably or precipitately. In a case in Scotland a GP struck off a patient who had complained when he was given a prescription for a painkiller instead of the antibiotics that he had requested for a bout of flu. Mr Buckley did not criticise the GP's decision to withhold antibiotics but said he had acted in the heat of the moment in striking off the patient.
In the second case, a GP in Yorkshire struck off the parents of a woman who had removed herself from the list of a partner after a disagreement. The parents had been on their GP's list for many years without difficulty.
GPs have the legal right to strike patients off their list without giving a reason but Mr Buckley said in the particular circumstances of the two cases the GPs' actions were unreasonable and contravened the principles of good practice.Reuse content