Belfast Telegraph

Belfast health trust apologises over man (75) who died after visit to A&E

Report: Marie Anderson
Report: Marie Anderson
Adrian Rutherford

By Adrian Rutherford

A health trust has apologised for a series of failings in the care and treatment of a patient who died after he was admitted to hospital.

The 75-year-old was taken to the Royal Victoria Hospital in Belfast with breathing difficulties.

While in the emergency department, his condition deteriorated, and he passed away two weeks later as a result of heart failure.

The hospital's own investigation found delays in the treatment he received in the emergency department and failures in aspects of his care, but concluded it was difficult to state definitively whether earlier treatment would have prevented his death.

His son disputed the conclusions and claimed the Belfast Health Trust did not take responsibility for his father's death.

A report by the Northern Ireland Public Services Ombudsman, published this week, has identified a series of failings.

These included delays in the patient's triage and review by a clinician. Marie Anderson's report also found the incorrect triage category was allocated to the patient, a "significant failure" which, she concluded, had caused further delays.

The Belfast Health Trust has "apologised" for the care given to the patient.

The man had been admitted to the Royal Victoria Hospital after arriving by ambulance on January 7, 2016. His condition deteriorated and despite intervention, he passed away on January 23.

A Serious Adverse Incident (SAI) investigation and report identified failures in care, and delays while in the emergency department. The SAI report concluded that it was difficult to state definitely whether earlier treatment would have prevented his death. It found the cardiac event most likely occurred before his attendance.

The man's son made a complaint to the Ombudsman, at the time Ms Anderson, who launched her own investigation.

It examined the man's medical records and documents relating to the Trust's SAI procedure. It also obtained independent professional advice on aspects of the patient's care in the RVH's emergency department.

The Ombudsman found the man waited a total of 41 minutes to be triaged upon arrival.

He then waited three hours and 25 minutes before he was seen by a clinician. This was described by an independent assessor as "inappropriate".

Both these waits comfortably exceeded the hospital's targets.

Enquiries also revealed that the man waited longer than other patients of the same triage category who arrived after him.

Ms Anderson's report stated: "I noted that two patients who arrived shortly after the patient had a much shorter wait, despite being assigned the same triage category of three.

"The first of these patients waited three minutes to be triaged and was seen by a doctor within two hours 59 minutes.

"The second patient waited seven minutes to be triaged and waited three hours nine minutes to be seen by a doctor.

"Therefore both patients were attended by a doctor before the patient, despite arriving later."

The Trust explained how, that evening, the queue for patients who had arrived by ambulance was moving more slowly than the queue for 'walk-ins'.

Based on specialist advice, the Ombudsman found the man was incorrectly triaged by staff.

This was a significant failure as it added to the delay in him receiving the necessary care, her report states.

The Belfast Trust said: "We sincerely apologise to the family of this patient and appreciate this is a very difficult time for them.

"We accept the NIPSO report and acknowledge that failures were made. We have assessed the incident in detail to improve our understanding of what went wrong and we have undertaken work to improve the SAI process going forward."

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