The health ombudsman has ruled that West Herts Hospitals NHS Trust failed two of its patients who then later died.
In the first case, an older man named in the report as Mr N, was discharged from hospital without being assessed to determine if he could cope at home.
He had been admitted in early 2013 complaining of shortness of breath, coughing up fluids and feeling confused.
After seven days in hospital it was decided that he was well enough to be discharged and the consultant requested that he be seen by the physiotherapist and the occupational therapist to establish whether he was able to manage at home. This never happened.
The man was readmitted to hospital eight hours after leaving complaining of vomiting blood. He died nine days later.
The Parliamentary and Health Service Ombudsman did not agree with Mr N’s wife that he was discharged prematurely but did conclude that the trust had failed because therapists did not access Mr N before he was discharged.
In another case it was found that staff should have carried out a more thorough assessment into the possibility that a woman who had blood in her stools had internal gastrointestinal bleeding.
No immediate action was taken to address the woman’s bleeding and the day after it was noticed there was a severe drop in her blood pressure.
She deteriorated over the following week and died.
It was unlikely that the drop in her blood pressure was preventable even if action had been taken when the blood was first recorded, said the ombudsman.
The new Parliamentary and Health Service Ombusdman report said that too many unresolved complaints are being taken to the adjudicator, which could have been resolved by public services locally.
This means that people are left waiting longer for answers and service improvements are delayed.
Ombudsman Julie Mellor said: “Many people complain about public services out of a sense of public duty, because they don’t want what happened to them or their loved one to happen to someone else.
“In many of the complaints we see, the organisation complained about has done the right thing to put things right. But too many people aren’t getting the answers to what went wrong from the organisation they complained about.”
When complaints are upheld, the ombudsman makes recommendations for organisations to put things right.