Damning report reveals doctors failed Barrow mum

Jodie Simpson’s family was devastated to discover the 38-year-old had been left in a permanent vegetative state following an accidental overdose in August 2012.

Jodie had been looking forward to a family holiday she had booked for later in the year.

But while on a drinking binge during a low period she took some diabetic medication without realising the harm it would cause to someone without the condition.

Her brother Mike Devlin, who works at BAE Systems, raised the alarm after finding her unconscious.

Tragically, Jodie had suffered a permanent brain injury from which there was no hope of recovery, rehabilitation or return.

But it took four years before Jodie was allowed to die with dignity following a ruling by the Court of Protection.

Thanks to the determined efforts of her family the true scale of the failings of Cumbria Partnership NHS Foundation Trust in Jodie’s case can now be revealed. 

Jodie’s mum Jean Simpson made a formal complaint to the Parliamentary and Health Service Ombudsman and their findings can now be revealed in a damning report. 

The ombudsman found that Jodie and her family suffered an injustice because consultant David Footitt failed to refer Jodie to a specialist neuro-rehabilitation centre until February 2014 - 17 months after the overdose. 

The PHSO said the trust ‘failed to get it right’ in a number of aspects of Jodie’s care and the delay in the referral was a ‘service failure’. 

The trust has repeatedly apologised to Jodie’s family and has now vowed to implement a number of recommendations made by the PHSO. 

Mrs Simpson said she and her family went through ‘four years of hell’ as a result of the trust’s failings. 

“Jodie was kept alive unnecessarily,” she said. 

“She was prevented from dying with dignity for four years.

“It was torturous.”

Mrs Simpson, a former community nurse of 30 years, said she and her family were ‘treated as insignificant’ and experienced ‘distress, anguish, desperation and sadness’.

In its damning report the PHSO partially upheld Mis Simpson’s complaint and concluded: “The trust did not refer Miss Simpson to a specialist tertiary centre to access the assessments, diagnosis, care, treatment, support and advice that she needed when it should have done.

“It also did not sustain the physiotherapy that she needed.

“There were missed opportunities to provide Jodie with the care she needed and the failure to ensure prompt treatment when the spasticity in her limbs increased is likely to have contributed to some of the deformity she experienced.

“Miss Simpson’s family was caused distress over and above that which they were already experiencing.”

INJUSTICE: The ombudsman's findings in full

• The trust incorrectly informed Miss Simpson’s family that a diagnosis of a permanent vegetative state could not be made until 12 months had elapsed since the injury occurred. 
• The trust should have immediately referred Miss Simpson to a specialist neuro-rehabilitation centre.
• The trust ‘failed to get it right’ because it did not refer Miss Simpson to a specialist centre for diagnosis (or further assessment) until September 2013 - seven months after it should have done that (at the very latest). This was service failure. 
• Miss Simpson’s consultant acknowledged that he had forgotten to pass the referral form over to the trust’s acquired brain injury team to complete and send. 
• The trust did not take the steps it should have done to ensure access to specialist care and support was provided to Miss Simpson. 
• The trust failed to manage the provision of botulinum toxin injections (to improve passive posture in joints with worsening spasticity) appropriately.
• The delay in arranging timely splinting after February 2013 and providing a botulinum toxin injection once an increase in spasticity was noted is likely to have contributed to some of the deformity that Miss Simpson subsequently developed in her limbs. That was an injustice to Miss Simpson.
• The trust failed to get it right in that it did not provide ongoing physiotherapy support that Miss Simpson needed. The trust’s actions fell so far below the applicable standard in this respect that they amounted to service failure.
• The trust’s failings contributed to a delay of around 18 months had she been referred to a specialist centre sooner. 
• The PHSO investigation team can understand why Mrs Simpson was ‘let down’ by the trust. That was an injustice to Miss Simpson.
• The PHSO appreciates how the failings will have been, and continue to be, a significant source of distress for the family. 

'Sincere apologies'

THE boss of the trust which has been criticised by the ombudsman for its failings in the care of Jodie Simpson has apologised to her family. 

Professor Stephen Eames CBE (pictured right), chief executive of the Cumbria Partnership NHS Foundation Trust, has vowed we will use the report from the Parliamentary and Health Service Ombudsman and their recommendations to ensure that we learn from the identified failings’.

In a letter to Jodie’s mum Jean Simpson Prof Eames said the trust would ensure ‘that no one else has to go through a similar experience in the future’.

“Please accept my sincerest apologies for the failings identified by the PHSO with regard to your late daughter, Miss Jodie Simpson’s care and treatment that was provided by the trust,” he added.

Cumbria Partnership NHS Foundation Trust has identified a number of actions to be taken based on the recommendations of the PHSO’s report. 

In the damning report the PHSO said the trust ‘should have recognised it did not have the necessary clinical expertise to explore or make a diagnosis of a permanent vegetative state much earlier’. 

The report states: “The trust should have arranged for Miss Simpson to be admitted to a specialist tertiary centre for diagnosis (or further assessment)... at the latest, six months after Miss Simpson’s brain injury (February 2013)... it is highly likely a diagnosis (of a permanent vegetative state) would have been reached by February 2013 had she been referred in October 2012.”

The trust did not refer Jodie to a specialist neuro-rehabilitation centre until February 2014. 

As a result of the PHSO’s report the trust will now immediately make a referral to a specialist tertiary centre following a new acquired brain injury and disorders of consciousness. 

The trust has also agreed to update its policy relating to splinting and physiotherapy for patients with brain injuries after Mrs Simpson complained about the ‘worsening spasticity’ of Jodie’s wrists and ankles. 

The PHSO report found that, in Jodie’s case, ‘splinting (was not agreed) until June 2014 - around 18 months after the initial assessment’. 

The trust has acknowledged, the report added, ‘that the frequency of physiotherapy was not sustained because of staff sickness’. 

The report stated: “The trust failed to provide Miss Simpson with the ongoing physiotherapy support she needed.”

A full review of the trust’s neuro-rehabilitation provision in South Cumbria will also take place to identify any other possible improvements. 

The trust will also adopt national clinical guidance relating to botulinum toxin guidelines after the PHSO investigation found that regular reviews were not carried out in Jodie’s case relating to the use of such injections to aid the passive posture of her joints. 

In the trust’s action plan, produced in line with the recommendations made by the PHSO, there are also proposals to consider establishing Acquired Brain Injury Champions within hospitals.