YORK Hospital bosses have revealed a raft of measures taken to try to prevent other patients experiencing the unnecessary pain and hunger suffered by a patient in 2020.

The move comes after the Parliamentary and Health Service Ombudsman called for an action plan to be drawn up to ensure failings in Jacqueline Penrose’s care did not happen again.

The Press reported in February how the Ombudsman said the hospital failed in its assessment and management of Mrs Penrose’s pain before the 64-year-old Stamford Bridge woman died of a tear in her oesophagus after an endoscopy.

It said there were delays in giving her pain relief- and at times she wasn’t given it despite reporting pain- and staff also failed to provide nutritional support in line with relevant guidance, there were failings in the completion of a death certificate and the hospital failed to continue prescribing a drug, lansoprazole, reducing her chance of a successful outcome.

Now chief nurse Heather McNair has written to Mrs Penrose's husband Michael to say significant changes had been made and to outline key improvements to pain management, nutritional support and record keeping.

She said York and Scarborough Teaching Hospitals NHS Foundation Trust had implemented a nutritional support improvement plan, was seeking to implement a competency assessment for nursing staff to ensure good practice and had employed a 'Nutrition Nurse' to drive forward improvements.

It was committed to the 'objective assessment and management of pain,' and was participating in the 'Tendable Quality Reporting Audit' system which gave valuable insights into care provided and highlighted areas for improvement.

It had also formed a working group to review the stopping of medications such as lansoprazole and made changes in the writing of death certificates.

She said Mr Penrose had requested a face-to-face meeting but she did not think it would be either 'appropriate or helpful,' given that the complaints process had concluded.

The trust said it was sorry for the unnecessary distress caused to Mr Penrose, his wife and their family, and reiterated its apology unreservedly for any failings, and said it had been in regular contact with Mr Penrose to listen and learn more about his concerns about his wife’s care.

Mr Penrose said: "When I read the report, my first thoughts were: If they have put these measures in place now, what was there before?

"I'm at a loss to know whether the systems they had in place before were fit for purpose, and who was in place before this new position was created. These are things I need to discuss with the CEO but he is still adamant he is not going to see me."

He said staff at the hospital 'should be doing the job they were supposed to be doing, treating people with care and as individuals.'