Decision report 201001091

Summary
Miss C raised a number of concerns about the treatment her late father (Mr A) received in hospital.

Mr A had become unwell after surgery, complaining of abdominal pain. He was found to have several bleeding ulcers. Mr A received treatment for these, but his condition deteriorated and he died a few days after the surgery took place. Miss C felt that there had been a delay in transferring Mr A to theatre and then for surgery, and that his pain relief was inadequate. She felt that a proton pump inhibitor (PPI) (a drug that reduces acid in the stomach) should have been prescribed earlier.

Having looked at the case, our medical adviser found that Mr A had received reasonable treatment and that there were no unreasonable delays. We found that Mr A was taken to theatre for surgery when it was clinically appropriate to do so.

We did, however, find that Mr A's pain management was inadequate for a period during the admission. While recognising that Mr A's pain was difficult to manage, our adviser was concerned that someone with a history of chronic duodenal (lower intestine) ulcers did not have PPI protection throughout his recovery. We took the view that Mr A's abdominal pain should have been identified and addressed earlier and made a recommendation to the board about this.

Recommendation
We recommended that the board:
• apologise to Miss C for the failure to fully address Mr A's pain issues.