NHS Disabled Patient Deaths: Carole Foster

Carole Foster was diagnosed with mild learning disabilities when she was three. She could read but only write if she was copying what someone else had written. At 18 she was found to have bipolar disorder and sectioned under the Mental Health Act.

Thanks to considerable efforts by the local learning disability support team in charge of her care, Carole was able to live largely independently. She had her own flat in Radcliffe, near Bury, travelled by bus unaided to a day centre four days a week, did her shopping and paid her own bills. Music, magazines and TV soaps were her pastimes and she had some good friends. “She had a better social life than me,” recalls her sister-in-law Wendy Foster.

But losing her father Graham when she was 46 was a big blow to her emotional health, especially as she used to spend weekends at the family home with him and her mother Fay. She became very frightened, and terrified of physical pain. Her brother Geoff and Wendy helped fill the void left by her father’s loss and Carole gradually improved.

In March 2006 Carole was admitted as an emergency patient into the care of Fairfield hospital in Bury, run by the Pennine Acute Hospital Trust, with serious abdominal pain and vomiting. She was diagnosed with gallstones and discharged, without pain medication, to have surgery later.

But Carole proved unable to cope at home and in May was admitted to a psychiatric ward. That was when the problems began that later culminated in her death. Despite being in great pain and distress, staff did nothing about it, her family say. “She went 15 to 16 weeks without pain relief. Nobody understood or appreciated the pain she was in,” said Wendy. “The staff hadn’t got a clue about how to deal with learning disabilities.”

The psychiatric staff – who worked for the separate Pennine Care Trust, which provided mental health services – did not obtain Carole’s medical records, despite being based at the Fairfield, yards from the clinical team that had treated her, so did not know she had gallstones, a debilitating and very painful condition.

That September Carole had surgery for a small bowel obstruction and hernia but, after she was returned to the psychiatric ward, her condition worsened. She ended up on a life support machine but on 2 October it was turned off. She was 52.

Geoff and Wendy complained to both the acute and mental health trusts. They detailed “atrocious blunders” and “a catalogue of mistakes and errors made by staff at all levels [which] finally resulted in Carole’s death. Carole died needlessly. We were all so shocked as we all knew it shouldn’t have happened,” said Wendy.

They were ultimately vindicated when the parliamentary and health service ombudsman ruled that Carole’s death had been avoidable. “Had the care and treatment Miss Foster received overall not fallen so far below the applicable standards, it is highly likely that her death could have been avoided,” said a 65-page report. It revealed a series of life-threatening mistakes.

The ombudsman also ruled: “Her legal rights were not properly considered by the [mental health] trust, and if they had been her care and treatment might have been better planned and delivered, which might have resulted in a different outcome for her.”

Mencap believes one of the most shocking aspects of Carole’s care was the lack of understanding at both the trusts involved that her pain from her untreated gallstones, rather than her bipolar disorder, was why she was so distressed while in hospital. Instead the Pennine Care Trust said Carole was attention seeking.