by Jan Ooms
On 7th June 2006, my wife, Lilibeth Ooms died at Raigmore hospital, about 5 weeks after abdominal surgery. She was 45 years old and, although she had been many years on kidney dialysis, she was in good health. In the last 2½ years I have asked questions through the only avenues available to me – the Procurator Fiscal (PF) Case Ref – IN06003244, the NHS Complaint Procedures, and the Scottish Public Services Ombudsman (SPSO) Case Ref – 200700519.
My conclusions are based on long (2½ years) careful consideration of the information that I have and, should they be wrong, then it is only because there has been a reluctance to answer questions, provide information, or conduct a thorough investigation of all the evidence.
Jan Ooms 㺔/10/2008
- The PF took legal advice when deciding not to investigate my wife’s death and gave the usual reason of “it would not be in the public interest ..”. The only medical advice the PF obtained was from the Hospital’s Consultant Nephrologist who would have been a subject of any investigation. That medical advice cannot, therefore, be regarded as impartial and I have no idea what the legal advice was.
- In 2004 there was a (differential?) diagnosis for sclerosing peritonitis (SP) entered into her medical records but, given the number of times her medical records were not consulted I am inclined to believe that the new renal doctors at the hospital also did not read this. As a consequence, my wife never knew of her condition nor was she monitored or offered treatment for SP.
- Given her long medical history of peritoneal dialysis (PD) and peritonitis as well as the symptoms that she presented between 2004 and 2006, it seems incredulous that SP was not suspected.“SEP should be suspected in case of bowel dysfunction and abdominal pain in patients on or having been on PD, since in many cases it has been diagnosed some or many months after the patient has been transferred to Hemodialysis”. JNEPHROL 2001; 14. It is difficult not to believe that there was professional incompetence in not diagnosing SP.
- In the last week of April 2006 there were 3 different diagnoses for each of her emergency hospital admissions. Had she been treated for constipation on her first admission it is possible that an emergency laparotomy 5 days later might have been avoidable? Her 2004 medical records should have guided the doctors towards a diagnosis.
- There is a significant amount of medical literature (pre 2004) about Tamoxifen and immunosuppressive therapy for treating SP.
- Hospital physicians during the NHS Complaint Procedures (2007) told me that she did not present with SP symptoms between 2004 and 2006. There are however several entries in her medical records which indicate that she did. Those physicians should be required to explain this ‘deception’. The explanations and information they gave me show that the NHS Complainant Procedures is not working (or perhaps it is for them?).
- My wife was not properly informed of the risks from surgery on May 1st 2006. The SPSO upheld this part of the complaint.
- The haemodialysis treatment my wife received post surgery was undoubtedly complicated but was made more so because management of her fluid removal was based on guesswork rather than on any accurate monitoring of her haemodynamic status and, on several occasions, also against her feelings. It led to pulmonary oedoma in the first instance and later to hypovolaemic shock and death. The SPSO recommended that, in future cases, fluid should not be removed so rapidly. However, in my wife’s case, it was reasonable to have done so and to have done so against her wishes?
- The medical advisers to the SPSO after ‘investigating’ her medical files concluded that her treatment was reasonable. However, one of these advisers did not have sight of the medical notes for the period from 2004 up to 2006. Another one supposedly investigating her dialysis treatment said that it should be left to “the person on the ground”. In other words there was no investigation of the management of her dialysis which was one of the issues of the complaint and there was also no investigation about her SP symptoms prior to 2006 surgery which was another part of the complaint. The investigation can hardly be said to be thorough when evidence is not even looked at. What the medical advisers seem to regard as reasonable care and treatment is of such a low standard that the competence and performance of any doctor could never be judged as unreasonable.
- I believe that her nursing care was good.
- One medical adviser to the SPSO volunteered an opinion that the surgery was carried out with reasonable skill. It may have been but there is no evidence to say that it was and to support another physician without evidence calls into question the impartiality of the SPSO’s medical advisers. Whether surgery (laparotomy) was done expertly or not, she was left with multiple intestinal perforations at the end of it and this iatrogenic injury was the cause of septicaemia, pericarditis, and death 5 weeks later.
- The Nephrologist who was responsible for her treatment believed that she had left ventricular failure but did not use ECG or request a cardiology consultation. By so doing he contravened the following BMA/GMC guidelines for doctors: “referring the patient to another practitioner when indicated” & “arranging investigations where necessary” & “recognise the limits of your professional competence”. She died of pericarditis which was not diagnosed until post-mortem but there might have been a diagnosis and treatment had there been appropriate investigation and consultation.
- The Nephrologist admitted that he was not aware that pericarditis could be a complication. She had renal failure and infection and both are known to cause pericarditis. Is there not something in BMA /GMC guidelines about doctors “keeping your knowledge and skills up to date” ?
- I suspect that the reason why she did not receive cardiology investigation or consultation was because some medical staff felt that further care was futile. I perceived this attitude among some medical staff and, unknown to my wife and I, they had already decided that she should not be resuscitated. Since they had consistently misdiagnosed I believe that they could not predict her future with any degree of certainty. When she did die it was not from any cause that they had diagnosed. By depriving her of diagnostic investigation or consultation, they ensured that pericarditis or any other cardiological complication would not be diagnosed and, consequently, she would not be treated for it. It was also the opinion of the hospital’s independent reviewer that she did not receive the appropriate investigation and treatment because staff believed she was dying and knew that she had a DNAR (Do Not Attempt Resuscitation) order. There may be another name for this but, for the present, I shall call it involuntary euthanasia.
- The DNAR order was made without the consent of either my wife or myself. In fact she made her wishes known (by letter) to the Hospital’s Consultant Nephrologist that she wanted every opportunity to be explored to ensure her survival including a possible transfer to another hospital. The DNAR order was signed by the Consultant Nephrologist after receiving that letter.
- Those who make mistakes should be required to explain their performance and the onus should not be on the relatives to provide evidence or to campaign for a fair and thorough investigation of those mistakes. The whole process is done confidentially so that the wider public does not find out; the complaint is ‘contained’. “Secrecy is the badge of fraud.” ~ Chadwick, Sir John There were many mistakes which are now being covered up by those who have the responsibility for investigating them. “It is error alone which needs the support of government. Truth can stand by itself.” ~ Thomas Jefferson.“The complaints system is a farce and it is purposely biased against complainants”. ~ Ooms, J.
Editor’s note: Although this case refers to the Scottish Ombudsman service, the denial and manipulation of the facts is exactly the same as that dished out by PHSO. Jan has campaigned for many years to improve this situation.