An under-fire hospital came under fresh pressure on Friday after it emerged that a second family received a whistleblower tipoff about serious failings in the care of a patient who died, the Guardian can reveal.
West Suffolk hospital (WSH), used by Matt Hancock’s constituents, is already facing criticism over its unprecedented demand for doctors to provide fingerprint samples in an attempt to track down an anonymous letter writer who alerted widower Jon Warby to surgical mistakes made before his wife died in August 2018.
It has emerged that in a new case, relatives of retired lorry driver Horace Nunn were not told of suspected mistakes in his care until two months after an injury in hospital that contributed to his death in July 2016.
They only learned of a problem when a staff member tipped them off that the hospital was planning to investigate delays in the diagnosis of a neurological problem, known as an epidural haematoma, in March.
The new tipoff raises further questions about patient safety standards at the Bury St Edmunds hospital, and a possible breach of the strict NHS-wide “duty of candour” obligation to tell patients and relatives about damaging lapses in care.
Last month the Guardian revealed Hancock repeatedly failed to respond to concerns the hospital was bullying and intimidating senior staff to prevent them raising patient safety issues. Last week, the Guardian further disclosed the trust had spent more than £2,500 on handwriting and fingerprint experts in its hunt for the whistleblower in the Warby case.
Mistakes in 79-year-old Nunn’s care began after he collapsed with sudden and severe back pain on the afternoon of 3 March 2016 at his home in village of Ingham, Suffolk.
It took paramedics more than three hours to get Nunn to WSH, seven miles away. It was not until late morning the next day that the cause of his pain was correctly diagnosed, according to the trust’s investigation, seen by the Guardian.
An external expert brought in by the trust to review Nunn’s care found the injury could have been prevented. The report said: “An external expert concluded early identification would have potentially prevented the neurological injury.”
Nunn died five months later in July 2016. An epidural haematoma was one of the four causes listed for his death.
A coroner criticised his care as “sub-optimal” and found an infection he acquired during his stay in hospital was another cause of his death.
The hospital’s investigation identified a series of mistakes. Staff failed to correctly diagnose his spinal problems when was admitted in March, even though he was displaying symptoms such as pins and needles in his right foot and inability to lift his left leg.
The mistakes listed included the time it took the ambulance to reach him; an initial failure to conduct a neurological examination or urgent MRI scan; a subsequent failure to conduct a medical review of his care, and a delay in his transfer to a larger hospital, Addenbrooke’s in Cambridge.
A source close to the Nunns said: “The family initially were not aware that anything had gone wrong. They were told by someone at the trust that there was an investigation. They then received a root cause analysis report, which set out what happened and where things had gone wrong and could have been better.”
In March 2019 Suffolk’s senior coroner, Nigel Parsley, found Nunn’s death was the result of a “naturally occurring medical condition following his paralysis and paraplegia after suffering an epidural haematoma”.
Parsley noted this spinal injury was a complication of the warfarin medication Nunn was receiving to prevent a blockage of the lungs. The rarity of this complication was one of the reasons for the delay in diagnosis, he said. Parsley criticised Nunn’s care as “sub-optimal” but he concluded that it probably did not directly cause his death.
Gurpreet Lalli, from the law firm Irwin Mitchell, which is representing the Nunn and Warby families, said: “We are continuing to be instructed by a number of families who have concerns about what happened to their loved ones while under the care of the trust. Some of the firsthand accounts we continue to hear are worrying.
“Transparency is key to helping maintain confidence in the NHS and upholding patient safety. Therefore, staff must feel that they can speak out on any issues they come across within the workplace, safe in the knowledge that they will be protected for doing so.”
Dr Rinesh Parmar, chair of the Doctors’ Association UK, said: “We are incredibly concerned that a second whistleblower has had to raise concerns directly with a family regarding possible harm at West Suffolk.
“This pattern speaks of a toxic culture where clinicians feel unable to speak up when things go wrong for fear of retribution. Given recent reports of West Suffolk’s ruthless response to hunt down anonymous whistleblowers, these fears appear to be well founded.”
West Suffolk NHS foundation trust confirmed it informed Nunn and his family of possible problems with his care when it started an investigation in May, two months after his injury.
In a statement it said: “We would like to reiterate our sincere sympathies to Mr Nunn’s family. We opened a serious incident investigation into Mr Nunn’s care after concerns were raised internally about aspects of his treatment. We informed Mr Nunn’s family of this the same day the serious incident was declared.”
