AN INVESTIGATION has found that a patient at York Hospital was likely to have suffered unnecessary pain and hunger in the days before her death.

The Parliamentary and Health Service Ombudsman has called for an action plan to be drawn up to explain what will be done to ensure failings in Jacqueline Penrose’s care do not happen again.

A report by the Ombudsman says the hospital failed in its assessment and management of Mrs Penrose’s pain before she died last August of multiple duodenal ulcers and chronic kidney disease.

It said there were delays in giving her pain relief, and at times she wasn’t given it despite reporting pain.

When she was given such relief, it was not by the most effective route, as she was being sick, and there was also a medication error.

It said such failings had understandably caused her husband Michael distress, particularly as he was unable to visit her while she was in hospital because of Covid restrictions.

The report said staff also failed to provide nutritional support in line with relevant guidance to Mrs Penrose, aged 64, of Stamford Bridge.

It said food charts, used to record what a patient has eaten, were included in her medical records but on three days the charts were not completed.

“On one day, the chart shows Mrs P had eaten yoghurt for breakfast, but there are no further details for the rest of the day,” it said. “Similarly, what looks like the following day, the chart shows Mrs P had eaten half of her cereals, but nothing for the rest of the day.

“It is not possible to say from the records available whether the Trust accurately recorded Mrs P’s nutritional intake.

“It is possible the Trust had not completed the food charts, in which case, it is possible Mrs P was receiving adequate nutrition. It is also possible the food charts are accurate, in which case, Mrs P was likely receiving insufficient food.”

It said it had also found failings in the completion of a death certificate for Mrs Penrose, and found that the hospital failed to continue prescribing a drug, lansoprazole., saying it was likely she was not given the best chance of a successful outcome because of this.

Mr Penrose said he had taken his wife to hospital after she had been feeling unwell,dizzy and lethargic and he never saw her again.

He said her poor treatment should never have happened and he hoped the trust would take action to ensure no other patient experienced this again in future.

He said: “She was in absolute agony. There was a failure of due care. They have let her down.”

He said he had gone to the Ombudsman after he had exhausted the trust’s own complaints procedure and after he had been told by a consultant that everything possible had been done for his wife.

Unreserved apology by hospital

YORK Hospital bosses have apologised unreservedly for failings in its care for Mrs Penrose.

A spokesperson for York and Scarborough Teaching Hospitals NHS Foundation Trust said: “We are sorry for the unnecessary distress caused to Mr Penrose, his wife and their family. 

“We have written to Mr Penrose in response to the Ombudsman’s findings and have apologised unreservedly for any failings. 

“Whilst the Ombudsman’s decision was that they saw no failings in the care and treatment which would have caused, or contributed to, Mrs Penrose’s sad death, they did partially uphold some elements of Mr Penrose’s complaint. 

“There are a number of actions we are required to take as a result, and our plans to address these will be shared with Mr Penrose and the Ombudsman.”

Trust chief executive Simon Morritt said in a letter to Mr Penrose that the trust fully accepted the Ombudsman’s findings and that service improvements would be made to address the failings. He said he would write again within eight weeks to confirm the action being taken.