The East Berkshire health authority demonstrated at best a 'culpable lack of attention at all levels of management' over its failure to prevent a catalogue of blunders at the King Edward VII Hospital in Windsor, the MPs say.
An elderly woman, dying of cancer, was parcelled around from one ward to another each weekend for more than two months because of bed shortages; she developed pressure sores and was shut away in small side rooms, even though staff knew she suffered from claustrophobia. She died three days after being admitted to a hospice.
To add insult to injury, the Ombudsman's inquiry into her case was dogged by 'unacceptable interference' by senior authority officials, including intimidation of nurses called to give evidence.
The Royal College of Nursing yesterday expressed concern that the incident was not isolated. It demonstrated the need for a tough new independent inspectorate for the NHS to protect patients from managers with a cavalier disregard for their welfare, the college said.
Other culprits uncovered by the Ombudsman included:
A consultant at the Royal Free Hospital, north London, who told the mother of an eight-year-old girl he believed she had abused her daughter. Their daughter was suffering from a rare skin condition and had suffered no abuse;
The London Ambulance Service, which arranged for a seven-months pregnant woman with symptoms of impending miscarriage to be taken in an Army Land Rover to a hospital that lacked obstetrics specialists. She was wrongly transported in a carrying chair rather than a stretcher. She lost the baby.