Medical Negligence

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The death of Dirk Ooms: NHS mistakes and cover-ups
By Jan Ooms (Dirk's son)

Evidence not accepted by the Ombudsman

The assessors in the Ombudsman's report stated that: "… there is no information as to the state of the upper airway at this time or the degree of difficulty involved in intubation". But what about the following statements?

• Dr Mowbray (I.C.U.), at a meeting on 16/7/98, was recorded saying four times that my father's throat had closed up and, when questioned about intubation, explained, "intubation had been difficult" & "… they had trouble getting the tube down."
• Mrs Cowan (Director of Nursing) said, at a meeting on 3/6/98, "his breathing stopped through obstruction" and ".. it (intubation) had been difficult".
• The Patient Discharge notes clearly state "Intubation of the trachea was difficult due to …"
• Dr Little at the hospital's Independent Review (3/2/99) commented about the success of intubation "given the difficulty of getting a tube beyond the obstruction".
• In an internal memo dated 6/2/98 to Mrs Cowan, Dr Mowbray wrote of intubation "I am sure this procedure must have been technically difficult because of the presence of a very swollen epiglottis …"
• An ITU staff nurse said in a statement on 2/2/98 "Apparently intubation was difficult …."

Why did the assessors claim that there was no evidence for airway obstruction and difficulty in intubation? The Ombudsman's Report - "Unfortunately, the SHO anaesthetist was not interviewed as part of the Trust's investigation and could not be contacted"(ii). It was the anaesthetist who performed the intubation!

When I wrote (26/4/01) to the Ombudsman to remind him about the evidence supporting the fact that my father had airway obstruction and a difficult intubation, the Ombudsman replied (25/5/01) that Dr Mowbray and Mrs Cowan were not present during intubation. Their evidence was dismissed and the implication, therefore, was that the information given to us during the course of the complaint procedures was incorrect. So what other information may have also been incorrect? It does question the whole concept of what is evidence when the Ombudsman is able to select only that which agrees with his conclusions! It also raises questions about the NHS Complaint Procedures if complainants are expected to accept inaccurate or incorrect information and misleading explanations.

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