- The ombudsman has found ‘serious failings’ in case at James Paget University Hospitals FT
- Investigation finds six-month-old boy died after heart defect was undiagnosed despite ‘clear signs’ something else was wrong
- Trust also criticised for failing to apologise when parents complained
“Serious failings” have been found at a foundation trust where a six-month-old baby died because his heart defect was not diagnosed, despite multiple opportunities to do so.
The Parliamentary and Health Service Ombudsman said James Paget University Hospitals FT failed to correctly diagnose and treat Harris James’ heart defect, even though his medical history, symptoms, and poor response to treatment for pneumonia were clear signs that something else was wrong.
The ombudsman also found the trust “was not open and accountable” in the handling of a complaint made by the baby’s parents, and “failed to acknowledge and apologise for its mistakes in a timely manner”.
Anna Hills, chief executive of the trust, has apologised for failings in his clinical care after Harris’ GP referred him to the trust in November 2015.
The boy’s parents said they “won’t ever be able to forgive” James Paget Hospital for its failings and “additional pain caused by the mishandling of our complaint”.
Ombudsman Rob Behrens said: “This tragic case shows how important it is that people speak up when mistakes are made.
“It is crucial that the trust learns from its failures to make sure they are not repeated.”
On 2 November of that year, Harris’ GP referred him to the trust due to concerns about his weight loss following a bout of gastroenteritis.
The GP’s referral noted that the area of his stomach just below his ribs was drawn inwards, but this was not recorded in his medical records at the trust.
Staff carried out blood and urine tests and an appointment was made with a dietitian for four weeks later.
Just over a week later, on 12 November, Harris was taken by ambulance to the emergency department at the trust after he vomited and became limp.
A chest X-ray showed that part of his lung had filled with fluid and an electrocardiogram showed there were several abnormalities in his heart.
The trust suspected pneumonia so gave him oxygen, antibiotics and fluids, but staff failed to ask a specialist about Harris’ heart abnormalities.
Despite his age and clear signs that Harris’ condition was getting worse, he was not seen by a consultant until the following morning. Soon after that, Harris suffered a heart attack and tragically died.
Harris’ mother, Mary Gunns, a local government officer from Lowestoft, complained to the Ombudsman because she was unhappy with the Trust’s investigation into Harris’ death.
A statement from Mary and Ryan, Harris’ parents, said: “Our son was an affectionate and sweet little boy whose sudden death devastated our family.
“We won’t ever be able to forgive James Paget Hospital for its failings, nor will we forget the additional pain caused by its mishandling of our complaint.
“We hope that following the ombudsman’s recommendations, the Trust takes action to make sure this never happens again.”
The trust has agreed to the ombudsman’s recommendations to develop an action plan to address its failings and outline how it will prevent them happening in the future.
It has formally apologised to Miss Gunns and agreed to pay her £15,000 in recognition of the injustice its failings have caused.
Ms Hills, James Paget chief, said: “We have apologised to Harris’ family for the failings in his clinical care — and for the manner in which we communicated with them and handled their complaint when they raised concerns after his death.
“As an organisation, we have reviewed how we handled this case, with the support and guidance of the Parliamentary and Health Service Ombudsman.
“We have now implemented changes to ensure that, in the future, action is taken to ensure appropriate clinical escalation in similar situations and also that bereaved parents and relatives are treated with the compassion, sensitivity and respect they deserve.
“I would like to express my sincere condolences to the family once again, on behalf of the trust.”
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