Near death and shouting, in pain all night and day, being totally confused and hallucinating a nurse said “he will just have to deal with it.”
This is a tragic story of the treatment of the last days of Robert Sheppard. It is a tale of medical error, bad treatment, appalling hospital facilities, mistakes, bad nursing care and a potential cover up of a hospital acquired infection. It could have been completely different if the hospital hadn’t blocked him from being transferred to a local hospice so he could have spent his last days in peace. His widow found out later that the hospice would have taken him.
His widow, Wendy, came forward when she read the story on this blog of the ” avoidable death” of Mr P, a heart patient , a couple of months before at the same hospital. This came out during an employment tribunal hearing brought by Dr Usha Prasad, a cardiologist, when the former head of cardiology, Sr Richard Bogle admitted the hospital should have reported his death to the coroner and the Care Quality Commission three years ago. The judge handling the case Tony Hyams-Parish, airbrushed all the details of the death from his judgement.
The story also reveals the timidity of the Parliamentary Ombudsman, Robert Behrens, who when he examined Mr Sheppard’s treatment, avoided investigating wider safety issues at the hospital.
The facts in this story are stood up by two confidential letters from the former chief executive of the Epsom and St Helier University Hospital Trust, Daniel Elkeles to his widow.
Mr Elkeles was full of apologies about his treatment but played down the issue of a hospital acquired infection there – which would have had to be reported by law..
Mr Sheppard, who was well treated as a cancer patient at the Royal Marsden Hospital,- was admitted to St Helier’s emergency department with an obstructed bowel on October 10, 2018. A mistake was made when a nasogastric tube was inserted to drain fluid from his stomach but had to be repeated after it became clear it had not reached his stomach. The Ombudsman absolved the hospital from the initial mistake as there are no national guidelines about inserting nasogastric tubes.
Mr Sheppard was put on the Mary Moore Ward in an old building. He was given by mistake a blood stained pillow, he had no bedside lamp and another patient’s damp possessions had been left on his bed.
He picked up a bacterial infection called klebsiella which attacks people with a weak immune system but was discharged on October 22.The hospital insisted that nobody else admitted at the time had the infection.
He was readmitted the next day to ward B1 with a chest infection and tests were carried out and he had got the bacterial infection. From there until his death on November 13 he remained with a fever and back pain and also became hypoglycaemic.
The ward facilities were not much better than Mary Moore ward. Brown water came out of the taps because of a rusting 82 year old water main but the hospital insisted the water was safe. Again he did not have a bedside lamp that worked and bandages were found in his bedding. He requested a wheelchair but the hospital said it didn’t have one for his ward. Also hand sanitiser was not replaced.
As his life ebbed away the chief executive apologised for the ” insensitive ” way the medical staff treated him over his wishes to be resuscitated .
Doctor was ” Grim Reaper”
Wendy said “One morning a Doctor came into Robert’s room and stood at the end of his bed rather akin to The Grim Reaper and read out a list of the areas Robert had his Cancer in his body. Robert already knew about everything. It was just the way it was done he felt they had written him off. It was a point of justification by the Hospital without mentioning the Hospital acquired infection Robert had caught courtesy of St.Helier Hospital telling him the Cancer was going to kill him instead. “
The weekend before he died was the worst. He was visited by his 92 year old mother and brother who found him unconscious. His wife stayed with him but found nurses were not bothered to see him and finally workman came in to repair taps just he was about to die.
The chief executive has apologised for this. ” I am extremely sorry that we did not respond with compassion and understanding to your request for nursing support at the end of Mr Shepherd’s life. I am very disappointed that you endured this situation alone and can only apologise that we failed you”.
Even after his death mistakes were made. His initial death certificate airbrushed out the bacterial infection and his cremation notice described Mr Sheppard as retired when he was still working for the Met Police.
” I will never forgive St Helier hospital “
Wendy said:” Dying with dignity was something not given to Robert. I will never forgive St.Helier Hospital. It’s failures towards Robert were ‘swept under the carpet’ by the Hospital management. My complaints were misconstrued to make St.Helier look in a better light and incidents that happened weren’t recorded in Robert’s medical notes so I am told. “
The Ombudsman’s report concluded: “We have found failings with the support doctors and nurses gave to Mr D[Robert Sheppard] and Ms N[Wendy Sheppard] in the final stages of his life, and that Mr D’s privacy was interrupted in the final moments of life. We also found a failing with how nurses responded to Ms N’s requests for hand sanitiser. What happened led to a loss of dignity for Mr D and made his death even more upsetting than it already was for Ms N.1
The Ombudsman rejected Wendy’s concern about the hospital bacterial infection – weakly citing that for data protection reasons it could not investigate other people. It also said it had no power to investigate mistakes in death certificates. Another example of the weakness of the Ombudsman system.
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I could hardly believe what I was reading.
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This hospital needs to be condemned…my 95 year old mother was admitted a few years ago and I have never witnessed such dreadful nursing and care given to old people most of whom were infirm one way or another
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What an awful way to treat people, my heart bleeds for this man and his family, how those involved in is care could treat him in this manner is beyond me. As for the ombudsman, well words fail me, just shows how they get away with their lies and sweep things they don’t want us to know under the carpet . imo if Joe Bloggs did this he’d be dismissed for gross misconduct, especially not reporting his findings to CQC !!!
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Another glaring example of the ineffectiveness of the Ombudsman. I have just posted a blog on PHSO the true story. Your followers should take note of the recent Health Select Committee report regarding health complaints. To me it does not read well and will do nothing to avoid the terrible situation you have highlighted here
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I am not surprised of this. Sad to say that this police officer got his just desert along with his family.
When Barts NHS Health RLH Whotechapel managers Gastro department told lies on my partner plus me which led to me incarcerated for near 15 hours, the CEO still in job along with the team that made malicious allegations. My partner is black so am I but as she would complain on behalf of others they went after her. Lewisham Police say they were only acting on the report they got and apologized despite 3 other police gave evidence in my defense as I was at home. So no sympathy from me.
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Just to point out that Robert Shepherd is a civilian worker for the police. He is not a police officer and I don’t see why you should wish suffering on another human being and his family just because you had a raw deal from the NHS and the police in an unrelated incident.
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Totally agree David
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This is not personal. I was a special for 4 years and resigned as I saw how the administration desk staff and officers looked at, treated black people etc. So it’s not of wish evil, but saying that it took this sad experience for his family friends see how terrible the system is. These people do not think things can happen to them. So he who feels it knows it. Sad for him and his family but hope they will understand what lots people experience daily in the abuse mismanage of the hospitals. The Once Great NHS.
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Samuel. At least that is a more human response. I am very well aware of how bad the system is. This story of the treatment of Robert was triggered by a case I am following at the same hospital. The person is a well qualified and competent cardiologist but lost her job there. She also happens to be Asian and a woman and in my opinion has suffered a double discrimination there in the all male cardiology department. I am also investigating other cases where patient safety has been put at risk as well as looking how 3.8 million women were cheated out of their pensions. I think people sadly know the system is rotten more than you think.
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Wendy, I’m so sorry but not at all surprised at your husband’s treatment. We plebs need someone to protect us from the cruel people who behave like this; the fact that they are part of the NHS is all the more abhorrent. What is the point of the Ombusmen Service? They need to be given responsibility and accountability for full and thorough investigations and ‘teeth’ to punish the wrongdoers: this especially applies to those in power.
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The Ombudsman is not correct to say that he has no power to investigate mistakes in death certificates. This would be maladministration in the preparation of the Medical Certificate of Cause of Death. The Ombudsman has no power to change the death certificate though. The Ombudsman does not tend to investigate mistakes such as these because they are unlikely to be due to systemic failure and therefore unlikely to lead to service improvement which is the main focus of the Ombudsman, rather than justice for the complainant.
Similarly the Ombudsman could have chosen to uphold the complaint about the incorrect placement of the nasogastric tube since this is an example of system failure. However the Ombudsman usually chooses to only uphold black and white complaints where national standards have not been followed or met. This is because he tends to be wary of judicial review being initiated by powerful health bodies in decisions that are not clear cut. This follows a 2018 Court of Appeal decision which found against the Ombudsman and in which the judges inexplicably decided that relying on the professional opinion of a medical expert when making a decision in cases such as this was a “lottery” and therefore irrational and unlawful. The Ombudsman is not concerned about judicial review by complainants though as it is unaffordable for most people. This means that the scales of justice are tilted heavily in favour of health bodies in decisions reached by the Ombudsman.
Please read the phsothetruestory website or contact phso-thefacts@outlook.com for more info.
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‘Mistakes’ on death certificates are mostly an indication of a systemic problem of poor training and governance in completing them. The standard of completion of certificates in my experience over 25 years is extremely variable, and very often very poor. Even reportable deaths have not been reported to coroner, despite it being in the instructions on the certificate book cover.
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The Ombudsman tends to narrowly define system failure as failure to follow standards. In addition the legislation under which he operates states that an injustice must be identified. In the case of an incorrectly completed MCCD he would not identify any injustice, which he defines as an impact on an individual. The fact that the Ombudsman does not tend to investigate broader issues of poor training and governance and limits his definition of injustice to an impact on a individual demonstrate some of the many reasons why the Ombudsman system is not fit for purpose.
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Nicholas, do you work for the ombusman service? You fully make the case for getting rid of them entirely as they serve no use and setting up a body who will protect the public from malfeasance by all sorts of organisations & businesses – starting with the government. Aye, but there’s the rub – the government had their teeth removed to ensure they are not held to account.
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As I wrote on the 20.3.2022… was a crap hospital and still is.
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My sister also died at St Helier in October 2022 from something that should if been treated in tge beginning of her 8 months of hell in hospital and subsequent unnecessary death ..along with some terrible nurses and unqualified staff
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