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.