Sent via email

1 March 2015

Mr David McVitte

Chief Executive

Ealing Hospital NHS Trust

Dear Mr McVittie,

Re: Dr Sunil Ranjan Chowdhury DOB 4.9.31

My father, Dr Chowdhury, who was a retired doctor, suffering from multiple system atrophy (MSA), was taken to Ealing hospital by ambulance on Wednesday 21 January, when he suddenly became unconscious. My mother called the emergency service.

Although Central Middlesex hospital is the nearest hospital, A&E there has recently been shut down.

On arrival at A&E, mum and I were present and we advised the A&E of the medication my father was on. This included the type and dosage of insulin – he was diabetic. After several tests, the doctors advised us that his condition was OK and there was nothing that they were worried about. However, they would admit him.

On Thursday 22 January, I received a phone call from the pharmacy querying the type and dosage of insulin my father was on. I advised him.

On Saturday 24 January, when I went in to visit dad, I was advised that dad had not been fed for 2 days. They thought he may be aspirating. I was concerned and asked if that was the case why they had not fed him either intravenously or via a nasogastric tube. They did not reply, except to say that they were unable to do anything until the consultant returned to work on Monday. So, they had planned to starve a vulnerable adult for 4 days, before deciding on a feeding plan. After much fuss (from me), the senior staff decided to try and feed him with semi-solid food. Dad had this without any coughing or any problems – the nurse agreed that dad was not aspirating. So, they then commenced his feeding after 2 days of starving him.

In addition, I discovered on the same day, that he was not been given any fluids either. The drip remained unconnected. I queried this. The staff advised me that the there was a problem with the drip monitor. After complaining 3 times, staff eventually got this to work.

On Saturday 31 January, dad looked really poorly and was on oxygen. He did not have any lunch. However, his blood sugar was high at 15. We queried if he was given his insulin. The nurse couldn’t find anything regarding his insulin in his notes. It transpired that dad hadn’t been given any insulin for the last 10 days he was in the hospital.

I asked to speak to his doctor. I was advised that his consultant would not be in until Monday and that there was a locum covering. I asked to speak to her. She said there wasn’t anything she could do as his insulin was not written up in his notes.

Whilst looking through his notes, I came across another patient’s paperwork. A Chaudry with a different first name. I brought it to the attention of the ward sister, who removed and took the paperwork away.  How could this have happened? In addition, worryingly were my father’s details on insulin entered in another patients notes?

On Monday, the consultant spoke to my mum and said he did not know that dad was on insulin. This was despite the fact the doctor in A&E was advised and I had received a phone call from the hospital pharmacy. He was also worried that I would be putting in a formal complaint. One would have thought as a consultant he would be more worried how such a thing could have happened in the first place and investigate.

After discussing the matter with the consultant, mum asked me not to make a complaint while my father was still in the hospital as it could be detrimental to his ongoing treatment. She was clearly worried

His insulin started on Monday 2 February. Dad perked up on Tuesday and Wednesday. He was eating and chatting. However, sadly he passed away on Thursday 5 February.

As well as coping with his death, I had to repeatedly call the ward and patient services to get his death certificate. So that his death could then be registered and we could organise his cremation. It took 2 days and end of Friday to get this and this was only after I ended up physically in the ward to approach the team after my PET CT scan. Due to running around and dehydration, I ended up with severe haematuria and bladder infection and I ended up at Northwick Park hospital.

It is shameful that my father who had worked as a doctor for nearly 50 years and was really valued both by his patients and staff to the point that they remained in contact with him even after retiring for 15 years should have ended his days at Ealing hospital with such poor treatment.

I would like a clear explanation of how these failures occurred, and I expect that I should be properly involved in any root cause investigation

With regards

Sharmila Chowdhury