Doctors at Wigan Infirmary incorrectly put an elderly woman on a care pathway and gave her end-of-life treatment, a new report has said.
The Health Service Ombudsman said several mistakes were made by Wrightington, Wigan and Leigh (WWL) NHS Foundation Trust in its care for Winifred Brogan, who was admitted shortly before her death in November 2013.
The report concluded treatment should not have been withdrawn from Mrs Brogan, 93, and she should not have been put on an integrated care pathway (ICP).
A mistake by the hospital also meant Mrs Brogan was not given the antibiotics prescribed when she left hospital, but it was not possible to say what effect this had.
The ombudsman was satisfied WWL had put policies in place to ensure this could not happen again and also rejected claims by Mrs Brogan’s family that she should not have been given Tazocin medication.
The ombudsman looked into the case of Mrs Brogan, who went into hospital after feeling sick and having a temperature and was diagnosed with sepsis and pneumonia, after a complaint by her daughter Pat.
After being put on the ICP Mrs Brogan went home as her family did not agree with the course being taken. She came back to Wigan Infirmary a few days later where she died on November 14, 2013.
An investigation concluded Mrs Brogan was put on the ICP just a few hours after a doctor suggested she should be monitored for up to 48 hours. This meant all active treatment was stopped.
The omdbudsman also found discussions involving Mrs Brogan’s family and a multi-disciplinary team should have taken place and there was no evidence Mrs Brogan had been assessed by a senior consultant.
The report concluded: “Mrs Brogan should not have been placed on the ICP and treatment should not have been withdrawn.
“Mrs Brogan was a frail 93-year-old lady and it is possible she may not have survived her final illness regardless of the treatment she received from the Trust. However, she was not given the best opportunity to live for longer.
“It is clear that this period of care has been distressing for Mrs Brogan’s family and we have decided to partly uphold this complaint.”
The report recommended the Trust pay Ms Brogan £1,000 and said the case should be discussed with the doctors involved. WWL stopped using the ICP in July 2014 in favour of individualised care plans.
The investigation also found a new health information system was being put in place by WWL, which would ensure discharged patients got their antibiotics.
A WWL spokesman said: “We would like to, once again, extend our sincere condolences to the family and friends of Mrs Brogan. We recognise that during her bereavement, Ms Brogan was put under additional distress and pressure due to the standard of treatment received by her mother and in the pursuing of her complaint; for this we offer our sincere apologies.
“We would like to assure Ms Brogan that the Trust has taken forward all the recommendations from the PHSO’s report and changes are either embedded or being implemented within the organisation.
“Andrew Foster, Chief Executive has formally written to Ms Brogan, expressing his deepest sympathies and outlining in detail the changes implemented as a result of the PHSO report.”