HEALTH bosses have been forced to apologise after a three-year dispute with a campaigner whose elderly mum died at the Royal Blackburn Hospital.
Sharon Kinlin-Martin, 55, said there was a ‘comprehensive failure’ by the hospital to fully investigate her mum’s death, and claimed that staff suggested she had ‘mental health problems’ to deter council officers from probing her concerns.
81-year-old Burnley pensioner Joan Kinlin, who had pre-existing heart disease, hypothyroidism and osteoporosis, was twice admitted to the Royal Blackburn in 2011, after suffering two nasty falls, and spent a total of two months on the wards between February and June.
She developed a severe infection, including signs of sepsis, and died of aspiration pneumonia on June 1.
During the last month of her life, Mrs Kinlin-Martin had become increasingly concerned about her mum’s care and she later lodged a formal complaint.
The trust admitted some shortcomings, but dismissed several concerns and offered no apology, so Mrs Kinlin-Martin took the case to the Health Service Ombudsman for England, who has found there were four ‘service failures’, although these were not found to have caused her death.
These were: * During her first admission Mrs Kinlin suffered four falls, and the ombudsman found ‘despite numerous indicators that, from the outset, she was at significant risk of falls there is no evidence that staff produced a (falls) prevention plan’.
* Despite family members’ concerns about the pensioner’s hydration levels, and Mrs Kinlin herself asking for water, the report found doctors failed to properly assess her condition and fluid balance over a four-day period in mid-May, after intravenous fluids had been withdrawn.
* Staff placed a ‘Do Not Resuscitate’ order on the grandma-of-twelve, without proper discussions taking place with the family.
* Mrs Kinlin, of Wycoller Avenue, was only diagnosed with delirium about ten days before her death, despite showing signs of this previously, and the report said ‘the necessary investigations of her mental state could have been carried out sooner’.
Before her mum died, Mrs Kinlin-Martin had also raised a ‘safeguarding alert’ with Blackburn with Darwen Council about her care. A separate report by the Local Government Ombudsman (LGO) has found that officers passed the concerns on to East Lancashire Hospitals NHS Trust (ELHT), but then failed to scrutinize the trust’s investigation into the alert. It found that ‘for five months the council had little idea of what the trust did to respond to the alert’.
The LGO report also contained details of a conversation between a council manager and an officer at the hospitals, in which the officer said she had been told that Mrs Kinlin-Martin ‘had some mental health problems and the family had asked for all contact to go through other family members’.
Mrs Kinlin-Martin, who does not have mental health problems, believes this was a ‘tactic’ used to discredit her version of events, and said: “Not only was this statement untrue but it also asks serious questions about allowing staff who work for an organisation at the centre of a safeguarding alert to be trusted to carry out a robust investigation which implicates their own colleagues.
“There’s a culture that exists in some hospitals where staff are not able to raise concerns without putting their job on the line, and I believe this statement was made to undermine what I was saying.”
However, the trust said they could not find a record of the comment, and questioned whether it had been made.
Meanwhile, although the reports found there was no evidence that Mrs Kinlin’s death could have been avoided, Mrs Kinlin-Martin still disputes this and has submitted further evidence obtained from sepsis experts.
She is also pursuing a medical negligence claim, through Emma Jones, of Leigh Day solicitors, who settled more than 100 claims for victims of the Stafford Hospital scandal.
Ms Jones said: “I believe the way Sharon has been treated by the trust has been appalling. Trusts should be open and transparent when it comes to complaints and it’s taken her three years to get this far. By highlighting these failures we hope trusts will be forced into some change.”
Mrs Kinlin-Martin, who lives in Dorset, first made an official complaint to the trust in October and received a response in February 2012. The trust accepted there had been some shortcomings, but the Ombudsman report said: “Despite producing an investigation report the trust did not offer Mrs Kinlin-Martin any apology for the acknowledged shortcomings. Similarly they gave no indication that they have learnt any lessons from these failures to prevent a recurrence. I therefore find the injustice to Mrs Kinlin-Martin remains unremedied.”
It told the trust to apologise and produce an action plan to ensure similar failings are avoided in future.
ELHT has now apologised to Mrs Kinlin-Martin and chief nurse Christine Pearson said in a statement: “We would firstly like to repeat our apology to Mrs Kinlin-Martin, and extend it to other members of her family, for those aspects of our service which fell short of our own standards. We are also sorry for any distress resulting from the way the trust responded to the concerns she raised. Our complaints process has improved significantly since that time.
“Although some aspects of the trust’s care were criticised, the Ombudsman did not find that this contributed to Mrs Kinlin’s death. He also acknowledged some positive practise and the difficulties faced by the trust in communicating with multiple family members, who sometimes did not speak to each other.
“We are grateful to Mrs Kinlin-Martin for taking the time and trouble to set out her concerns. We can assure her that changes will be made as a result of her complaint."
The complaints process at ELHT was heavily criticised by NHS chief Sir Bruce Keogh last year, for ‘lacking compassion’ and failing to properly investigate concerns from patients and family members. Deputy chief executive Lynn Wissett, who was responsible for the complaints process, announced her retirement on the day the Keogh Report was published, although bosses said she had been planning to step down.
The trust, which spent a year in special measures due to the failings identified in the Keogh Report, has since taken steps to improve the process, and now offers all complainants a face-to-face meeting with the relevant doctors. Bosses said 70 per cent of complainants now feel they are ‘listened to’ and their concerns are properly dealt with.
Steve Tingle, director of commissioning and adults at Blackburn with Darwen Council, said: “We have previously fully accepted the findings insofar as these relate to the council and implemented the actions well in advance of the publication of the report. We once again fully and unreservedly apologise for the distressed caused and have made sure the necessary lessons have been learned from this case.”