Family Not Informed Of NHS Investigation For 10 Months, Breaching Duty Of Candour Rules

The devastated daughter of 67-year-old man who died following complications following an operation after breaking his leg has said she hopes lessons are learned after the NHS Trust responsible for his care breached Duty of Candour rules.

Stuart Brunst, from Aughton, Lancashire, died on 2 October 2015, just three weeks after undergoing surgery at Southport District General Hospital for a broken femur. Following the operation it was found that screws were inserted incorrectly and became dislodged. Stuart sadly passed away after developing a fat embolism.

His daughter, Anita Brunst, instructed expert medical negligence lawyers at Irwin Mitchell to investigate the treatment her father was provided with by the Trust and to assist the family with the Inquest into his death.

As part of the investigations, it has now been discovered that the NHS Trust did not comply with their obligations under the Duty of Candour rules as it failed to tell the family about an internal investigation into the death for 10 months.

The family have now been made aware that the investigation identified key failings in Stuart’s care many months before they were advised that the investigation had even taken place, depriving the family from being able to take part in the investigation or voice their concerns to the Trust.

After the Trust’s internal investigation a number of recommendations were made to improve care, including the recommendation that staff must be able to recognise when screws are not engaged following this type of operation and that staff must ensure x-ray requests are sent to the x-ray department. The Trust has also introduced a procedure to ensure that any x-ray requests that are refused by the radiology team and logged onto the computer system and the requesting doctor advised of the refusal.

Following a one-day inquest into his death, Senior Coroner Christopher Sumner, concluded that the “actions, and, at times, inactivity, of the Southport District General Hospital”, which was responsible for Stuart’s care, “did amount to neglect as defined, and contributed to the death of Mr Brunst”.

The inquest heard that one of the screws inserted into Stuart’s broken femur was not fitted correctly, that this issue was not identified when x-rays were conducted in the operating theatre, despite the error being apparent on the x-rays, and that there were delays in Stuart receiving further x-rays following the operation when he was complaining of pain.

The failure to fix Stuart’s broken femur properly during the operation meant that he suffered pain when he tried to weight bear as the broken bones were not fixed back together meaning that the metalwork inserted during the operation could move about in his leg.

The investigation by the Trust found that the surgeon who conducted the operation had not inserted the screws correctly and that there was a failure to recognise this at the time of the operation when x-rays were done. It was also found that there were delays in carrying out further x-rays after the operation when they should have been taken.

Anita has expressed grave concerns about the treatment her father received at the hospital, which is operated by the Southport and Ormskirk Hospital NHS Trust.

Anita also expressed concerns that the Trust did not inform her family that her father’s death was being treated as a “serious incident” and that they were not told about the investigation until 10 months after her father’s death and only after the involvement of lawyers at Irwin Mitchell.

Since the inquest the Trust has admitted liability for the poor care that Stuart which led to his death and expert lawyers at Irwin Mitchell are now negotiating a fair settlement for his family.

Sarah Sharples, a specialist medical negligence lawyer at Irwin Mitchell, representing Stuart’s daughter Anita, said:

Expert Opinion

“Stuart’s sudden and tragic death has obviously had a significant impact on his family and they are struggling to come to terms with the series of events that caused his death, which stem from him undergoing routine surgery for a broken leg.

“While the Trust has now advised Stuart’s family of the investigation that was carried out, that failings in care were identified and invited the family to a meeting to discuss the report, Anita is understandably extremely upset that the Trust failed to comply with the Duty of Candour regulations and inform them an investigation was taking place into Stuart’s death.

“The Duty of Candour requires Trusts to be open and honest when something goes wrong with treatment that causes harm or distress to someone in their care. Simply put, it means that families should be told when something goes wrong, there should be an apology and an explanation should be provided. None of those things happened in this case, in fact, quite the opposite. The Trust recognised the severity of what had happened to Stuart very quickly but rather than be open and honest with the family about their concerns, they carried out an investigation without the family’s knowledge, even when that investigation went on to find failings with the care provided. This type of conduct is in direct contrast to what the Duty of Candour seeks to promote.

“By depriving the family of being part of the investigation they were prevented from providing their own comments and engaging with the process to ensure lessons were learned.

“Anita hopes the Inquest into her father’s death, the findings of the Coroner and the Trust’s own investigation will lead to improvements in the treatment of patients to prevent other families going through the tragic loss she and her family have endured. She also hopes that they learn from their mistakes in terms of the way that they conducted their investigations so that families are not left in the dark in future.”

“In a legal sense, neglect means that the care was so poor that Stuart did not receive basic medical attention. The fact that the Coroner felt strongly enough in this case to find that the Trust’s acts and omissions amounted to neglect is a clear indication of the severity of the failings in Stuart’s care.” Sarah Sharples - Senior Associate Solicitor

Anita said: “Dad’s death has had a huge impact on us and we are still struggling to come to terms with the huge hole he has left in our lives. For him to go into hospital with just a simple broken leg and to die like this, is extremely hard to deal with. My Dad’s death, and what happened afterwards, left us with a lot of unanswered questions.

“We were utterly shocked and disappointed that we weren’t informed of the investigation being conducted by the Trust, and their findings, until ten months after Dad’s death. Following his death we had very little contact, support, words of sympathy or apology from the Trust, despite the findings of their investigation being known to them, and we feel that isn’t the way we should have been treated.

“We can only hope that the investigation conducted by the Coroner and his findings that the Trust’s neglect played a part in dad’s death, will continue to shed light on the treatment he received and will lead to the Trust continuing to make improvements in the care that they provide to patients to ensure that this never happens to another family and that, in the future, they comply with their Duty Of Candour.”

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