Patient died after 'gross failure to provide basic medical attention'

Olufemi Okuyedi, aged 25, was admitted to the hospital’s acute admissions unit in April 2014 and died the following morning from an intestinal obstruction following a poor handover between a day shift doctor and a night shift locum registrar.

HSJ understands Okuyedi was not seen by the locum doctor and waited seven hours without fluids or blood tests in the acute admissions unit. X-rays taken earlier in the day were also not reviewed or acted on.

A jury inquest at Hertfordshire Coroner’s Court last week recorded a verdict of death by natural causes, contributed to by neglect.

West Hertfordshire Hospitals Trust, which runs the hospital, told HSJ it accepted failings had occurred, adding: “The jury found that there was a brief and unsatisfactory handover from day to night staff and the care plan recommended and agreed with an emergency department consultant was not fully carried out.

“The jury concluded this constituted a gross failure to provide basic medical attention and for this, we are deeply sorry.”

The trust added: “The registrar involved was employed via an agency. We have shared information with the agency regarding the locum doctor’s lack of engagement during the shift and the implications of this. We have also agreed with the agency that the locum doctor will not be employed by West Hertfordshire Hospitals Trust in future.

“It is not clear from the serious incident root cause analysis whether the locum doctor was reported to the [General Medical Council]. Therefore, and now in light of the inquest findings, we will forward the information to his responsible officer to make a decision.”

Following Okuyedi’s death, the trust told HSJ it had carried out a full investigation and identified improvements including the introduction of a “hospital at night” service with a senior nurse team to support clinical care of patients seven nights a week from 8pm to 9am. This team will respond to calls to take blood, insert new drips or review patients.

It has also increased the number of surgical consultants on call from one to two, and a consultant now attends both morning and evening handovers. A new emergency surgical unit has been set up, as well as a new programme to “vigorously” pursue an ambition that staff make accurate notes about patient care.

The trust said it had already admitted liability for the failings in Okuyedi’s care and offered an unreserved apology to his family.