Woman died after doctors missed bowel obstruction
FamilyA grandmother died after doctors missed repeated warning signs of a bowel obstruction and failed to provide an interpreter, leaving her unable to communicate intensifying pain, the health ombudsman has found.
Sevinc Ulkueri, 76, from Solihull, died after her bowel perforated and she developed sepsis, following delays in treatment at Heartlands Hospital, Birmingham, in March 2021.
An investigation by the Parliamentary and Health Service Ombudsman (PHSO) found her death was avoidable and that earlier diagnoses and intervention would have saved her life.
University Hospitals Birmingham Trust said it was committed to learning from the incident to reduce the risk of it happening again.
"We would like to express our sincere condolences to Mrs Ulkueri's family for their loss and are sorry for the circumstances that led to her death in 2021," a spokesperson said.
"We remain committed to learning from this incident to reduce the risk of such events happening again and to ensure patients receive safe, timely, inclusive and compassionate care at all times."
Ulkueri's daughter, Seniz Greenhalgh, complained to the PHSO that the trust had ignored the warning signs of a bowel obstruction and had failed to treat her mother before it was too late.
"We will never forgive the hospital for the pain, fear and suffering our mother endured, and for the lifelong grief they have inflicted on our family," she said.
The trust has agreed to improve its approach to investigating bowel problems, with the PHSO also recommending it give the family £15,000 in recognition of the distress caused.
Ulkueri, originally from Istanbul, was admitted to the hospital after four days of vomiting, abdominal pain, shortness of breath and constipation, symptoms consistent with a bowel obstruction.
She was treated for pneumonia and given a chest X-ray which showed multiple bowel loops that can indicate a blockage - but the PHSO said this was not acted on until a week later.
The health ombudsman said a physical abdominal examination also appeared normal with doctors concluding an obstruction was unlikely, but national guidelines stated such observations alone were insufficient to rule out a blockage.
Ulkueri was also encouraged to eat, but the PHSO said she should not have been, as increasing pressure around the blockage could increase the risk of bowel perforation.
When a bowel obstruction was diagnosed almost a week after she was admitted, her bowel had perforated, meaning air and waste leaked into her abdominal cavity.
Ulkueri had surgery to treat an abscess causing the blockage but developed sepsis and died.
Greenhalgh said her mother's death was both "premature and completely avoidable."
"The intense pain, coupled with her very limited English, meant she relied on me and my sister to communicate with the medical team," she added.
"They repeatedly ignored or dismissed our pleas to take her abdominal pain seriously. Instead, they repeatedly said her bowel was not blocked."
The PHSO found the trust had missed "several opportunities" to diagnose a bowel obstruction because it didn't properly investigate her symptoms.
The trust also failed to meet Turkish-speaking Ulkueri's communication needs because it didn't provide an interpreter, it said.
Chief executive Rebecca Hilsenrath KC added patients had a right to an interpreter and the NHS "must be accessible to everyone in need of care".
She said: "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.
"Sevinc was unable to clearly express the severity and location of her pain because she was not given the support she needed and to which she was entitled."
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