• Ombudsman says hospital staff failed to properly monitor elderly patient
  • PHSO finds trust staff did not recognise or plan for the higher risk from routine operation
  • East Lancashire Trust has changed practices and made a payment to family

A catalogue of errors by staff at East Lancashire Hospitals Trust led to the avoidable death of a pensioner following a routine operation, the Parliamentary and Health Service Ombudsman has found.

Renie Craig died aged 77 in March 2015 after a routine hip replacement. Following surgery, she was not given enough fluids, and her fluid balance was not monitored, despite a doctor requesting this. 

Nurses also failed to raise the alarm when her blood pressure dropped significantly. She was given a blood transfusion but had to be resuscitated and treated in intensive care, where she remained until her death from a sudden loss of blood to the bowel.

An investigation by the PHSO also found Mrs Craig’s impaired kidney function, identified in 2014, was not investigated before her surgery. Along with her age and diabetes, she was at an increased risk of kidney injury but this was not taken into account before her operation.

The ombudsman found hospital staff did not properly plan her care and didn’t monitor her regularly or act quickly enough when she deteriorated. It ruled that, if the trust had provided the right care, Mrs Craig would have survived.

Her son Ian Craig made a complaint against the hospital in 2016 because he was concerned the trust’s investigation had not recognised mistakes in his mother’s care.

He said: “I want other trusts to learn from the mistakes made here to make sure that others don’t have to experience a tragedy like this.”

Damian Riley, medical director for East Lancashire Hospitals Trust, said: “The trust extends its sincerest apologies and we acknowledge that there were opportunities to do things differently while we were responsible for Mrs Craig’s care.

“Since this incident, we have made significant improvements to try and ensure similar errors do not happen again.”

Improvements made since Mrs Craig’s death include changes to fluid monitoring and kidney injury management by staff. The trust has also made a payment to Mrs Craig’s family.

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