An elderly patient was cared for for almost a week without the staff noticing that the person had not had any bowel movements. When the severe constipation was finally discovered, the patient was too ill for surgery and died within a day.

Region Kronoberg has filed a Lex Maria report after a death where the region’s own investigation points to several deficiencies in nursing care.

The patient, who was elderly and had impaired cognitive ability, was admitted to a ward due to severe back pain that could no longer be managed at the person’s residence. According to Region Kronoberg, the nursing staff did not gather additional information from other sources, which meant that important care-related information about the patient was missed. Documentation was also inadequate.

No One Reacted to Lack of Bowel Movements

During the hospital stay, the primary focus was on treating the back pain. At the same time, it was not noticed that the patient had not had any bowel movements.

It was only after almost a week that the patient’s condition clearly deteriorated. The person became increasingly agitated, developed chest pain, and began vomiting. When the abdomen was examined, it was found to be distended, and a subsequent X-ray revealed severe constipation.

By that time, the situation had become so serious that medical treatment was no longer considered possible. The patient was also deemed too frail for surgery. Within a day, the patient passed away.

According to the region, the cause of death was assessed to be pneumonia that arose as a result of the constipation and the severe vomiting caused by the condition.

Routines Changed After the Death

Region Kronoberg has, after the incident, reviewed several parts of the nursing process and identified areas where routines need to change.

Actions taken include revised checklists, improved staff introduction, internal training initiatives, and a review of existing guidelines. The region also plans to broadly introduce handheld documentation directly into the medical records system.

The chief physician has now handed over the case to the Health and Social Care Inspectorate (IVO), in accordance with Lex Maria.

A Lex Maria report must be submitted when an event has led to, or could have led to, a serious adverse event in healthcare. IVO will then assess whether the provider’s investigation and actions are sufficient.