Sandwell and West Birmingham Hospitals NHS Trust

3. Mr R complains that the Trust did not give his father, Mr A, the correct pureed food during his time in hospital from 30 August to 16 September 2021, and this led to the pneumonia that caused his father’s death.

4. Mr R says the loss of his father is immeasurable. He says his grieving process was much harder than it needed to be as he had to relive the experience in complaining to the Trust. Mr R adds that he has been left with unresolved anger due to the Trust not stating how his father contracted pneumonia or taking accountability for his death.

5. Mr R would like to address whether the food his father ate in hospital caused his pneumonia. Mr R seeks an apology and service improvements to prevent this from happening to another family.

6. Mr A arrived via ambulance at the Trust’s Emergency Department on 30 August 2021. The Trust says in its complaint response that Mr A arrived with symptoms that suggested a stroke. He was at the hospital from 30 August to 16 September. On 16 September the Trust discharged him to respect the family’s wish that he be able to die at home.

7. On 1 November 2021, Mr R complained to the Trust via email. He raised numerous areas of concern about the treatment and care given to his father during Mr A’s stay in hospital from 30 August to 16 September 2021.

8. On 28 March 2022, the Trust contacted Mr R with the outcome of its complaint investigation. The Trust responded to each of the points Mr R raised.

9. The Trust said the medical care given was appropriate but other aspects of care were lacking. This included nursing staff not routinely completing Mr A’s food diary. The Trust apologised for this while noting the medical records said he was helped with his oral intake on the days when the food diary was not completed.

10. Mr R went back to the Trust with his outstanding concerns. On 18 May 2022, the Trust referred Mr R to us as it felt it had no information to add. On 23 May 2022, Mr R complained to our office.

12. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. Having followed this process, we found no signs anything went wrong.

13. Mr R complains the Trust gave his father, Mr A, incorrect food during his stay in hospital and this led to the pneumonia that caused his death. Mr R believes the Trust did not give his father the pureed food he needed. Mr A was in hospital from 30 August to 16 September 2021.

14. In its complaint response, the Trust said there were days when it did not complete the food diary. It apologised for the food diary not having been completed between 6 September and 9 September 2021. The Trust said it had identified no specific learning regarding this issue. However, it added the Trust has made documentation a learning priority since Mr R made his complaint.

15. Our clinical adviser said the medical records show the Trust followed the Trust Guidelines. Our clinical adviser noted both the medical and nursing teams made referrals to the Speech and Language Therapy (SALT) team whenever there was a change in Mr A’s condition. This is in line with the Trust Guidelines. Our clinical adviser also confirmed SALT completed frequent swallowing assessments, documenting recommendations in Mr A’s notes.

16. As the medical records show, shortly after Mr A was admitted, SALT carried out an assessment and recommended a Level 4 Pureed diet. SALT completed further reviews on 10 September 2021 and 13 September 2021 because Mr A’s condition had got worse.

17. In its complaint response, the Trust apologised that Mr A’s food diary had not been filled in on each day. Our clinical adviser noted this fact but added that, where available, the information states Mr A received the correct Level 4 Pureed food.

18. The medical records show the Trust ordered the correct Level 4 Pureed food as part of the recommended dysphagia diet (a diet designed for those who have trouble swallowing). Mr A was also able to feed himself at the beginning of his stay in hospital. The medical records show Mr A was maintaining fluids and diet and say ‘patient is a puree diet with nil assistance’.

19. Our clinical adviser confirmed there is no information in the medical records to suggest the Trust gave Mr A incorrect food. The food diary was not filled in for each day. However, whenever it was, the correct food is listed. As stated in the Trust’s response, there are entries in Mr A’s notes stating he received help with his oral intake on the days when the food diary was not completed.

20. Our Principles say an organisation should be open and accountable when explaining decisions and actions made. Our Principles also say to base decisions on available evidence and accept responsibility and apologise when necessary. The Trust’s response is based on the available evidence in Mr A’s medical records.

21. The Trust has accepted that there were days when no one completed Mr A’s food diary and someone should have done this. The Trust has kept to our Principles by clearly explaining what happened and by apologising for not completing the food diary in full.

22. Mr R complains the Trust gave his father incorrect food and this led to the pneumonia that caused his death. There is no sign of a failing in this aspect of the complaint. The medical records show the Trust ordered the correct Level 4 Pureed food and gave this to Mr A during his stay. Although there were days when the food diary was not completed, the records do not show that the Trust ever gave incorrect food. As our clinical adviser stated, SALT carried out assessments when necessary and the Trust noted and acted on any recommendations.

23. It is our role to be impartial and transparent in explaining our decision. We hope Mr R understands the reason for that decision. We appreciate how difficult it has been for Mr R to speak about the events described in this complaint and we are sorry for any disappointment our decision causes.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr R’s complaint about Sandwell and West Birmingham Hospitals NHS Trust (the Trust). We have seen no sign anything went seriously wrong with the food the Trust gave to his father, Mr A.

2. We understand the events that caused Mr R to complain are very important to him. We recognise the impact the events had on both him and his father. We accept that the loss of his father in September 2021 is immeasurable. We offer our sincere condolences for his loss.