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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