Basildon University Hospital's care of a woman with a
severe learning disability "fell significantly below a reasonable
standard", according to the Parliamentary and Health Service
Ombudsman.
Lisa Sharpe's mother, Mary, was dissatisfied with
the level of care her daughter received at the hospital before her
death in 2004, and was supported by learning disability charity
Mencap in making her complaint.
A feeding tube was inserted into Lisa's small bowel
during a routine operation which staff said was a success. However,
she began to vomit bile and her family say they expressed concerns
that were ignored for nine days. When Mrs Sharpe requested an x-ray
they found Lisa had pneumonia and the family was told she only had
two hours to live.
Yet Lisa went on to suffer for days and died from
suffocation when her lungs filled with fluid, two weeks after
having the feeding tube fitted. She was not given pain relief at
any point.
Mrs Sharpe said Lisa's death was avoidable, but she
was given poor treatment because of her disability. It took until
November 2008 to get an inquest and it has taken the ombudsman
three years to complete the investigation.
The ombudsman found that the care and treatment
provided to Lisa "fell significantly below a reasonable standard"
and that the service failure in the nursing care she received
"added to Lisa's suffering and to the distress of Mrs Sharpe and
her family."
The report said there was a lack of appropriate
assessment and plans, a lack of basic nursing care and a failure to
manage Lisa's pain. It also said there was a failure by the trust
to have due regard to their obligations to Lisa under disability
discrimination law, a failure to take appropriate professional
responsibility for Lisa and a failure to support Mrs Sharpe and her
family.