Trust apologises for 'missed opportunity' to detect twisted bowel that killed man

Fred Brown, who was 68 and had learning disabilities, died on April 22 last year at Telford's Princess Royal Hospital after initially being diagnosed with lower lobe pneumonia.

And the Shrewsbury and Telford Hospital Trust (SaTH) has apologised to his family for shortcomings including a "missed opportunity" to diagnose his twisted bowel.

The trust also admitted not documenting his phobia of hospitals, and not contacting the adult learning disability service when he was in hospital.

Mr Brown went into the Princess Royal Hospital with chest pains on April 16, and six days later he died of a twisted bowel.

At an inquest into his death, Shropshire's assistant coroner Joanna Lees made a verdict that he died of an "unidentified bowel obstruction, secondary to pneumonia".

In a SaTH document headed "In the matter of the inquest into the death of Frederick Brown" and sub-headed "Shortcomings in care" the trust laid out a number of admissions about his time in hospital.

However the document said: "It is not accepted that the points below were necessarily causative or contributed to Mr Brown's death."

They include: "On April 17 Mr Brown's observations were not repeated at appropriate time scales.

"Mr Brown did not have a learning disability passport.

"On April 20 Mr Brown was not examined by the attending FY1 doctor.

"Mr Brown's learning disabilities should have been considered when assessing his condition."

Devastated

Mr Brown's sister Diane Kesterton, a nurse herself, said the loss of her brother had devastated their close-knit family.

She said: "After protecting him all those years I feel like I failed him right at the end.

"I'm absolutely disgusted at his care in hospital.

"If I had treated my dog half as badly as that I would have been prosecuted by the RSPCA."

Diane said she has since been invited for talks with hospital officials about Fred's death.

"Fred was a lovely person, he couldn't see the bad in anybody," she said.

"He would give you his last halfpenny if he thought you needed it, he was the heart of the family really.

"We are quite a small family, that is probably why we are so close."

Mr Brown, who had hydrocephalus, lived with his mother in Hodnet near Market Drayton, and was close to Diane and her children Neil, Julie and Penny.

He worked at a variety of jobs in the area until he suffered a fall about five years ago and lost mobility.

Adored

Diane, 65, said: "He spoiled the kids so much, they adored him.

"He worked every day of his life before he had his fall.

"Even the week before he went into hospital he had been out bowling with the Headway charity."

Deirdre Fowler, director of nursing, midwifery and quality at SaTH, said: “This was a complex case involving a very rare condition, but we recognise that there were a number of areas where our care fell short of what we expect and we would like to take the opportunity to apologise to Mr Brown’s family for this.

“A full and thorough investigation has been carried out, which included an independent review, to ensure that lessons are learned.

"This includes individual learning for medical staff and discussions with the Adult Learning Disabilities Service to encourage clinical staff to refer patients early for support with interpretation of the patients’ needs.”