University Hospitals Birmingham Trust has paid £15,000 to a family after a woman died of bowel obstruction. She was unable to communicate her intensifying pain because the Trust failed to provide an interpreter. 

A 76-year-old woman died at University Hospitals Birmingham Trust after doctors missed repeated warning signs of a bowel obstruction and she was unable to communicate her intensifying stomach pain to medical staff because the Trust failed to provide an interpreter.

The Parliamentary and Health Ombudsman (PHSO) found Turkish-speaking Sevinc Ulkueri’s death was avoidable. During the delay to treatment, her bowel perforated and she developed sepsis. The investigation found that earlier diagnoses and intervention would have saved her life.

Rebecca Hilsenrath, chief executive of PHSO said failing to support Ulkueri to communicate how she was feeling was contrary to the NHS’ values of fairness and dignity. 

“This distressing case highlights the importance of listening to patients. Supporting Sevinc to communicate how she was feeling would have respected her right to be heard. Her input could have led to a faster diagnosis,” she said. 

The woman was admitted to Birmingham Heartlands Hospital in March 2021 after four days of vomiting, abdominal pain, shortness of breath and constipation. She had a chest X-ray and was treated for pneumonia. The X-ray showed multiple bowel loops but this was not acted on until a week later.

She also had a physical abdominal examination. The checks appeared normal. However, national guidelines state that such observations alone are not sufficient to rule out a blockage. Despite this, and the presence of multiple bowel loops, doctors concluded that an obstruction was unlikely.

Communication breakdown

When the Trust finally diagnosed a bowel obstruction almost a week after she had been admitted, her bowel had perforated, which meant air and waste leaked into her abdominal cavity. She had surgery to treat an abscess which was causing the blockage but shortly afterwards she developed sepsis and died.

PHSO found the Trust missed several opportunities to diagnose a bowel obstruction because it didn’t properly investigate the woman’s symptoms. Had it done so, it would have likely identified and treated the blockage. It would have prevented the infection and avoided her bowel perforating and sepsis developing. The Ombudsman also found the Trust failed to meet her communication needs because it didn’t provide an interpreter.

“The failings in this case are some that we see far too often. Delayed reporting on scans, investigations that are not sufficiently thorough, and poor communication with patients and their families,” said Hilsenrath. 

The problem of communication issues is one that comes up again and again. 

Writing in Healthcare Today, Kavita Parmar, chief commercial officer and co-founder at Word360, said that in too many organisations “language needs are still treated as an add-on rather than something embedded into clinical workflows”. 

Proper communication skills are not a nice-to-have. As Matt Taylor, chief executive of language services provider Dals, pointed out recently, in the 2021 Census, 1.5% of those in England and Wales said they could not speak English well, and 0.3% not at all. 

“These percentages are only likely to rise, and we cannot simply expect almost 2% of the population to forgo healthcare or accept substandard care,” he said. 

In this case, at the Ombudsman’s recommendation, the Trust apologised to the family, paid them £15,000 in recognition of the distress caused, and agreed to improve its approach to investigating bowel problems.