A medical practice in the Ipswich area

3. Mr R complains about the care and treatment his father, Mr O, received from the Practice between October 2019 and January 2020. Specifically he says:

• the Practice failed to diagnose gangrene or provide appropriate treatment for an abscess on his toe

• the Practice did not refer him to hospital soon enough

• the Practice did not make records of appointments he had in October 2019

• nurses at the Practice did not communicate with GPs about the worsening state of his toe.

4. Mr R also complains about the care and treatment his father, Mr O, received from East Suffolk and North Essex NHS Foundation Trust (the Trust) between December 2019 and March 2020. Specifically he says:

· the Trust failed to diagnose gangrene soon enough or provide appropriate treatment for an abscess on his toe

· the Trust delayed operating on his toes until early March despite diagnosing gangrene in January 2020

· when the Trust operated to remove his toes in March 2020, it did not respond to the results of a scan from February 2020 and clear the arteries in his legs below the knee

· it was family members who had to alert a consultant at the Trust to the scan results in March 2020 following the removal of Mr O’s toes

· he had to have a second operation which was not successful because the procedure to clear out his father’s arteries did not happen at the same time as the amputation of his toes

· in March, when the Trust rushed him to another hospital from the current one he was at, Mr O was not covered up enough and a family member had to ask for blankets.

5. Mr R also complains the Trust did not tell him his father had COVID-19 when he died, and he only found this out when the Trust would not allow the funeral director to collect his father’s body from the mortuary. He also says the Trust did not inform him his father died of COVID-19 pneumonia rather than pneumonia and he found this out when NHS England investigated his concerns with his father’s GP Practice.

6. Because the Practice did not provide appropriate treatment and professionals did not share information, Mr R says his father’s foot became worse and meant he had to have his toes amputated. Mr R says his father died as a result.

7. Because of the lack of appropriate treatment and information sharing, Mr R says he has suffered from the distress of wondering how much this contributed to his father’s death. He also suffered from the distress of seeing his father’s condition worsen.

8. Because the Trust did not diagnose gangrene soon enough or provide appropriate treatment for an abscess on his father’s toe, Mr R says his father’s foot became worse and led to him having his toes amputated. Mr R says his father died as a result.

9. Because the Trust delayed operating on his father’s gangrenous toe, Mr R says this allowed his condition to significantly worsen and meant he had to have his toes amputated. Mr R says his father died as a result.

10. Because the Trust did not respond to results of a scan, Mr R says his father suffered complications requiring further surgery. He also says his father had to have his leg below the knee amputated. Mr R says the complications and combination of three operations in a week killed his father.

11. Because of the way his father was treated by the Trust, Mr R says he has been left feeling devastated. He says his mental health has been severely affected and he has felt bitter and angry.

12. Because the Trust did not inform him his father had tested positive for COVID-19 and his death was due to COVID-19 pneumonia, Mr R says this has added significantly to the distress he feels.

13. Because he was not covered up enough, Mr R says his dad was very cold.

14. Mr R would like an apology and an acknowledgement from the Trust. He would also like financial compensation.

16. The law (the Health Service Commissioners Act 1993) says we cannot investigate a complaint where a person has the option to take legal action, unless we consider this is unreasonable in the circumstances. We have discussed this with Mr R to understand his circumstances and the outcomes he wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

17. Mr R complains his father suffered an avoidable death because the Practice and the Trust failed to diagnose how serious his condition was. In the case of the Trust he also complains it made a mistake during an operation. As a result, we consider Mr R has a potential clinical negligence claim available to him.

18. When we spoke to Mr R about his complaint in October 2021, he told us as an outcome he would like some financial compensation, even though he considered an apology and acknowledgement from both organisations to be the most important outcome. In a follow up email, he confirmed he would like enough financial compensation to cover his mum’s care for the rest of her life.

19. During our phone call, Mr R told us he had not approached any legal representatives about the possibility of taking on his case. He explained as a family they had talked about this but had decided to come to us. He told us he may look at legal action if the complaint brought to us was unsuccessful.

20. In an email to us in October, Mr R explained he had not approached any legal representatives because of the costs involved. He also confirmed he felt unable to take legal action because of the pressure this would put on his elderly mother who would need to be questioned about the complaint. He explained ‘she will not be up to that’.

21. The amount of financial compensation wanted by Mr R is significant. Care for his mother for the rest of her life could amount to a sizeable amount per week, over a long period of time. We do not award compensation in the same way as a court does. It is unlikely we would be able to achieve the amount sought. Furthermore, even if we were to find failings linked to the injustice claimed at investigation, it is also unlikely we would make a recommendation to cover the care costs of Mr R’s mother.

22. Mr R has told us the costs involved in taking legal action would prevent him looking into this. We consider this is not a strong reason without him exploring the different legal routes potentially available to him. There are free legal advice services available such as Action Against Medical Accidents (AvMA). Alternatively, he could approach a no-win no-fee solicitor.

23. Before we could consider this complaint further, Mr R should make enquiries about any available legal action. If this proved to be unavailable he could come back to us with evidence to show the enquiries he had made.

24. Mr R also told us he did not want to take legal action because of the pressure this would cause his mother. While we fully appreciate Mr R’s mother is elderly and he wants to protect her, there is no reason why he could not take the complaint to a legal representative in the same way as he has brought it to us.

25. Additionally, if Mr R were to take legal action, he would have a legal professional working for him who could assist with any stress brought about by the legal process and offer targeted advice. As an organisation, we are unable to offer such a service as we are impartial. It might be less stressful to pursue the matter with a legal representative.

26. We respect Mr R has told us an apology and acknowledgement are the most important outcomes in relation to this case. Although the courts are limited in the sorts of redress they can offer and most redress is financial, they can make recommendations alongside financial remedy. Therefore, we cannot assume Mr R will not achieve remedies such as an apology and an acknowledgement through legal action as a by-product of the process.

27. Furthermore, if Mr R were to return to us after successfully taking legal action, we could consider if there is anything that the court has not looked at and potentially achieve an apology and acknowledgement at that point.

28. Because there is a potential legal course of action available to Mr R and we think it is reasonable for him to explore legal options, we have decided to take no further action.

1. We have carefully considered Mr R’s complaint about a medical practice (the Practice) in the Ipswich area and East Suffolk and North Essex NHS Foundation Trust (the Trust). We are very sorry to hear about the events leading to his father undergoing a series of operations at the Trust and his death in March 2020. We appreciate how upsetting a time this was for his father and all the family. We also recognise Mr R and his family continue to suffer from the distress they experienced.

2. We consider Mr R could take legal action on the matter he has brought to us.