A hospital trust is offering a second apology to a Suffolk man whose mother died while in its care.
The apology comes after an ombudsman's report identified further failings in the care of Maureen Mayes, 83, who died at West Suffolk Hospital, Bury St Edmunds, on March 7, 2021.
The former snooker hall manageress who spent most of her life in Sudbury died from a respiratory tract infection nine days after she was admitted with pneumonia.
In November 2021 Dr Jane Sturgess, learning from deaths clinical lead at the hospital, carried out an internal review and the hospital apologised when it was found they had confused Ms Mayes' antibiotics, overdosed her on diazepam, failed to monitor her weight and failed to complete a mental capacity assessment.
But her son Karl Mayes, who was sceptical about the quality of her care from the beginning, took the case to the Parliamentary and Health Service Ombudsman, which has now highlighted four more areas where the hospital failed.
"My mother got through World War II but couldn't get through nine days in West Suffolk Hospital," said Mr Mayes.
"It breaks my heart. She was a hardworking person all her life. She had four children and you couldn't have wished for a more loving and caring mother. She would literally give you her last penny."
The ombudsman report found that staff did not properly manage Ms Mayes' fluids, which led to her becoming dehydrated, although this was unlikely to have led to her deterioration.
It found that staff did not arrange colleagues with critical care skills to review Ms Mayes, did not carry out a sepsis screen, and delayed monitoring her blood gases after she was given supplementary oxygen therapy.
The ombudsman's medical advisor said had staff measured Ms Mayes' arterial blood gases sooner, this may have lead to an earlier diagnosis of respiratory failure and in turn staff may have considered non-intravenous ventilation sooner.
However, they said it is unlikely this would have made a difference to the outcome.
Staff also failed to carry out a sepsis screen when Ms Mayes met three of the criteria in the NICE sepsis guidance to indicate she was at risk of serious illness or death, but again no evidence of clinical impact was found.
The report said staff took too long to change Ms Mayes' antibiotics and highlighted that the original response from the hospital did not acknowledge all the failings that had occurred.
It also stated that Ms Mayes was given three 5mg doses of diazepam between 8.32am on March 3 and 8.46am on March 4, when she was used to having only 2.5mg per day.
However, the report could not say the failings in prescribing diazepam were what led to Ms Mayes' deterioration and noted the trust's previous apology.
A letter was sent from West Suffolk Hospital to Mr Mayes which apologised for the ombudsman's new findings.
The ombudsman recommended that an action plan, a copy of which must be sent to Mr Mayes by December 15, should also be put in place.
Mr Mayes said: "They have got to prove to us that they will make changes. The ombudsman has stated that they have to show us their action plan.
"I hope for all other patients that visit that hospital that they do improve and review the action plan thoroughly.
"I shall be watching every step. I don't want this happening to another family. I will do my best to make sure that things have improved."
Dr Ewen Cameron, chief executive of West Suffolk NHS Foundation Trust, said: "I offer my sincere condolences to Mrs Mayes’ family at what remains a very difficult time.
"We take all complaints extremely seriously and our teams across the Trust investigate these thoroughly to identify how we can improve.
"Last month, following the result of the Ombudsman’s investigation, I wrote to the family on behalf of the Trust to apologise for the distress caused and for the findings the Ombudsman upheld.
"Whilst the Ombudsman’s report found no evidence that the Trust’s failings had significant clinical impact leading to Mrs Mayes’ death, we are taking forward recommendations made in this report and are developing an action plan. It is vital when things go wrong that we acknowledge our mistakes and ensure we learn and improve.
"This plan will build on the internal review we undertook previously, which identified key learnings - the results of which have been shared with the family."
The Trust said they refreshed their Patient Safety Incident Response Framework (PSIRF) earlier this year.
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