KCH Trust between 14 October 2019 and 22 November 2019
15. Mrs C was admitted to KCH Trust on 14 October 2019 with high blood sugar, confusion, difficulty eating and vomiting. The records show the KCH Trust clinicians diagnosed her with diabetic ketoacidosis (DKA, a complication of diabetes caused by increased levels of a chemical called ketones in the blood which causes excessive thirst, frequent urination, fatigue and vomiting), acute kidney injury (AKI) due to dehydration, and a chest infection. Her early warning scores in the records at this time show Mrs C was very poorly when she was first admitted to KCH Trust.
16. The records show KCH Trust clinicians at first treated Mrs C with fluids and antibiotics. Her son told the clinicians about her swallowing problems and asked whether they may be a result of pressure from the outside of her oesophagus (food pipe) caused by a tumour. To look into this further, the acute oncology team recommended a CT scan of her chest, abdomen and pelvis to be done once her kidney function and overall condition was good enough to allow it to be done safely.
17. The records show that following Mrs C’s admission, KCH Trust nursing staff also noted she was having difficulty swallowing her tablets and she was bringing up her food. The nursing staff also noted she had lost weight. On 16 October 2019, KCH Trust’s speech and language therapist reviewed Mrs C due to her ongoing swallowing problems and recommended referring her to the gastroenterology department if her swallowing problems and vomiting continued.
18. KCH Trust’s consultant oncologist (a doctor who treats cancer) reviewed Mrs C a day later. The oncologist again noted her swallowing difficulty and wrote down that she was not suffering with pain or mucositis (inflammation in the oesophageal lining). The oncologist also recommended the gastroenterology team review Mrs C and think about carrying out either an endoscopy (where a camera is inserted into the oesophagus) or a barium swallow (a special type of X-ray test that allows the doctor to take a close look at the back of the mouth, throat and oesophagus) to help diagnose the cause of her swallowing difficulties.
19. The records show the hospital discharged Mrs C after treating her for her DKA, chest infection and AKI. From the information in the records it seems at the time of Mrs C’s discharge that KCH Trust’s gastroenterology department had not reviewed her, and the Trust had not done a CT scan or made any outpatient plans to further look into her difficulty swallowing.
20. Mrs C went to her outpatient appointment with her oncologist at GST Trust on 29 October 2019. The record of this appointment refers to her recent admission to KCH Trust and Mrs C’s reports that the pain she had experienced swallowing since her radiotherapy treatment had eased but she still had difficulty swallowing and a cough which produced a lot of sputum (phlegm). The oncologist at GST Trust referred Mrs C for a barium swallow to look into a possible stricture (abnormal narrowing) in her oesophagus and a CT scan to find out about the possible treatment options.
21. On 16 November 2019, KCH Trust again admitted Mrs C with low blood sugar and transient loss of consciousness (blackouts). The KCH Trust clinicians treated her for her low blood sugar and an ongoing chest infection. The records show she was taking oral antibiotic medication before this admission to treat her cough and chest infection. The records show the clinicians changed this to intravenous antibiotic medication (medication that is given directly into the vein via an injection or a drip).
22. On 20 November 2019, KCH Trust discharged Mrs C with oral antibiotic medication. The records show that KCH Trust clinicians raised no concerns about eating and swallowing difficulties during this second admission. Mrs C went to an outpatient appointment at GST Trust on 22 November 2019 for her barium swallow and CT scan. The clinicians at GST Trust looked at the results of these tests on 26 November 2019 and found the perforation in her oesophagus.
Failure to identify perforated oesophagus & Failure to investigate coughing and swallowing problems and decision to discharge Mrs C
23. These two points of complaint are closely linked and we have addressed them together.
24. Mr C says KCH Trust failed to find out that his wife had a perforated oesophagus despite her complaining of difficulty swallowing from 14 October 2019. Mr C says after her admission on 14 October 2019, KCH Trust planned to look into her coughing and swallowing problems but failed to do so and instead discharged her on 18 October 2019 without carrying out these investigations.
25. During Mrs C’s first inpatient stay at KCH Trust from 14 October 2019 to 18 October 2019, Mrs C's family and several health professionals said multiple times that Mrs C was having great problems with her swallowing. The records show this was so bad she had been losing weight and having difficulty taking her medication.
26. Three different healthcare professionals, including a consultant oncologist, who reviewed Mrs C during this admission, recommended either an opinion from a gastroenterologist or a CT scan of her chest to look into her swallowing difficulties. The medical team overseeing Mrs C’s care at KCH Trust did not write these opinions down in the records and they did not request the specialist reviews and tests, either on an inpatient or outpatient basis.
27. The GMC guidance says: ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
· adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
· promptly provide or arrange suitable advice, investigations or treatment where necessary
· refer a patient to another practitioner when this serves the patient’s needs.’
28. Our gastroenterologist adviser said it is impossible to know exactly when the perforation in Mrs C’s oesophagus happened but if it was present during this first admission, the recommended investigations would probably have found it. The records show Mrs C clearly had her swallowing problems during this first admission. In line with the GMC guidance, KCH Trust should have asked for a further opinion from its gastroenterology team or for further tests such as a CT scan or barium swallow to look into Mrs C's symptoms before she was discharged.
29. Our surgeon adviser said radiotherapy can cause oesophagitis (inflammation of the oesophagus) and stricture, which can then go on to cause a perforation. This is a rare but known risk. This is supported by the Cancer Research UK publication about the impact of radiotherapy, which says:
‘There is a very small risk of damage to the oesophagus which can cause an ulcer or hole to develop, that may need surgery.’
30. Our surgeon adviser said Mrs C’s symptoms of swallowing difficulty and vomiting could have also been explained at the time by the DKA and chest infection the KCH Trust clinicians identified. In light of these other health concerns, it would have been understandable that the clinicians did not think of a perforated oesophagus as the cause of her swallowing difficulties during this period.
31. However, our surgeon adviser agreed that, as the medical team overseeing Mrs C’s care at KCH Trust did not carry out the recommended further tests before it discharged her, it is not possible to say when the perforation happened.
32. We carefully looked at the complaint from Mr C, the records and the advice from our advisers. We found KCH Trust did not provide Mrs C the appropriate tests, or plans for tests, for her swallowing difficulties despite the recommendations of several of KCH Trust’s own healthcare professionals. We think even if KCH Trust’s clinicians did not think a perforation was causing her difficulties, Mrs C had symptoms serious enough to arrange further tests before they discharged her.
33. We cannot say when Mrs C’s oesophagus became perforated, and for this reason we cannot say that it should have been diagnosed and treated during this admission. However, we found KCH Trust should have looked into her symptoms further during this admission, and not doing so has left the family not knowing whether the perforation was already there and whether Mrs C could have got treatment at this earlier point. This is a great injustice for the family.
34. Once it received Mr C’s complaint, KCH Trust carried out a serious incident investigation. The report from this investigation says:
‘In the case of this patient, there were outstanding investigations and concerns to consider which were overlooked in favour of discharging the patient home. It is not possible to know at what stage the patient developed the perforated oesophagus; whether there may have been a stricture present at this stage which predisposed to a perforation or whether a small perforated had already developed. The absence of any gastrointestinal investigations at this stage meant that the patient was discharged home without a clear cause of the difficulty swallowing.
The specialty advice given by the oncology team and concerns raised by the family about the patient’s difficulty in swallowing were not acted upon.
Unfortunately, these factors led to (Mrs C) being discharged on 2 occasions without having had the necessary investigations to identify the cause of her swallowing difficulties. The diagnosis of a perforated oesophagus was finally made at GST Trust on 22 November, two days after her second discharge from the [hospital]. We are deeply sorry for this oversight and for the delay in (Mrs C’s) diagnosis and for the distress and suffering that this has caused to (her) family.’
35. About the root cause of the failings, KCH Trust’s serious incident investigation report says:
‘1. Focus on early discharge from the acute frailty ward and a belief that the patient was too unwell to undergo further investigation led to non-adherence to specialty advice and discharge without a cause for the patient’s swallowing difficulties.
2. Unavailability of patient’s usual consultant at GST Trust led to delay in acting on concerns raised by lung cancer Clinical Nurse Specialist and family, regarding patient’s swallowing difficulties.’
36. In light of the failings it had identified, KCH Trust made the following recommendations:
‘1. Education and Training on the diagnosis and management of Diabetic Ketoacidosis must be implemented for medical and nursing staff within the Emergency Department.
2. Findings of the report must be fed back to the Department of Geriatrics for reflection on balancing appropriate investigation and reduction in length of stay and acting on specialist advice.
3. Specialty advice must be verbally communicated to the parent teams as well as being recorded in the notes, whenever possible.
4. Findings of the report to be shared with GST Trust for reflection on providing continuity of care.’
37. We do not uphold a complaint if we see the organisation has already identified the failings and taken appropriate action to address them and make sure the risk of further cases is reduced. We have seen KCH Trust’s serious incident investigation identified failings in the care provided to Mrs C during this admission consistent with the failings identified during our investigation.
38. In its serious incident investigation report, KCH Trust accepts the failings and that they likely delayed Mrs C’s diagnosis of a perforated oesophagus. As a result, KCH Trust has apologised to the family for the impact this has had and made improvements to its service.
39. Our principles of good administration state:
‘Putting things right
When mistakes happen, public bodies should acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.
Putting things right may include reviewing any decisions found to be incorrect; and reviewing and amending any policies and procedures found to be ineffective, unworkable or unfair, giving appropriate notice before changing the rules.’
40. Our principles for remedy state:
‘Putting things right
Where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately. Remedies should also be offered, where appropriate, to others who have suffered injustice or hardship as a result of the same maladministration or poor service.
There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service. Remedies may be financial or non-financial.
An appropriate range of remedies will include:
· an apology, explanation, and acknowledgement of responsibility · remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these · financial compensation for direct or indirect financial loss, loss of opportunity, inconvenience, distress, or any combination of these.’
41. To resolve his complaint, Mr C asked KCH Trust to accept the failings in his wife’s care and apologise for the impact they had. He asked KCH Trust to think about the care and treatment it provided to his wife and make improvements to make sure similar incidents do not happen in future. We think the action KCH Trust took following its serious incident investigation is in line with Mr C’s requested outcomes.
42. We think the action KCH Trust took to uphold the complaint, accept and apologise to the family for the impact the failings had and make significant service improvements is in keeping with our principles. For this reason, we do not think any further action is needed to address the complaint.
Decision to transfer Mrs C to GST Trust on 22 November 2019
43. The records show KCH Trust discharged Mrs C on 20 November 2019, and we have addressed this discharge above. We found no evidence to show Mrs C stayed in the care of KCH Trust after 20 November 2019 or that she was transferred from KCH Trust to GST Trust on 22 November 2019. For this reason, there is nothing further we can say about this specific point of complaint.
GST Trust between 22 November 2019 and early January 2020
44. Mrs C went to an outpatient appointment at GST Trust on 22 November 2019 for a CT scan and a barium swallow to look into the cause of her swallowing difficulty. The report of the CT scan of her chest, abdomen and pelvis says:
‘Oesophageal rupture, likely secondary to radiotherapy. There is a wide necked posterior oesophageal rupture, approximately 2 cm in craniocaudal length at the level of T5/T6, with oesophageal content seen lateral to the vertebrae bilaterally at this level. The patient is undergoing a water-soluble contrast swallow today (same as a barium swallow), which will further delineate the location/extent of the oesophageal leak. Discussion with interventional radiology is recommended as this patient likely requires an oesophageal stent.’
45. The report of the barium swallow says:
‘Pooling of contrast around likely defect in mid oesophagus - no active leak demonstrated’
46. The clinicians at GST Trust looked at the results of these tests on 26 November 2019. As they found the perforation in Mrs C’s oesophagus, GST Trust admitted her. The records show the GST Trust clinicians decided Mrs C should remain nil by mouth (where no oral food or fluid is provided) to lower the risk of a leak into her chest or abdominal cavity from the perforation.
47. GST Trust’s radiology team reviewed Mrs C and thought about whether her perforation could be treated with an oesophageal stent (a tube that is surgically placed in the oesophagus to keep the passage open while covering the perforation until it heals). However, the records show GST Trust’s radiology team decided against using a stent as they felt it would not remain in place and would instead fall into her stomach, causing additional problems.
48. GST Trust’s nutrition team looked into whether to give Mrs C intravenous feeding due to her being nil by mouth. GST Trust’s nutrition team started Mrs C on total parenteral nutrition (TPN - a method of feeding that provides nutrients in a special formula directly into the bloodstream). GST Trust’s gastroenterology team also reviewed her at this point to think about an endoscopy to look at the size of the perforation in her oesophagus. GST Trust’s gastroenterology team decided against doing an endoscopy as they felt it would risk worsening the perforation.
49. The records show that on 28 November 2019, Mrs C had a raised temperature, and GST Trust clinicians started treatment with intravenous antibiotics and arranged blood tests. GST Trust’s surgical team reviewed Mrs C on 29 November 2019, and they decided to continue treatment with TPN to keep Mrs C nil by mouth, and to continue to treat her with intravenous antibiotics.
50. Mrs C’s blood tests were returned on 3 December 2019 and found E. coli bacteria.
GST Trust’s infectious disease consultant reviewed Mrs C and changed her antibiotic medication to treat these bacteria. This consultant also recommended an MRI scan (magnetic resonance imaging, a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) of Mrs C’s thoracic spine (the middle section of her spine) due to her complaints of back pain and because the position of the perforation might raise the risk of infection in the spinal vertebrae (the small bones that form the spine) and discs next to the perforation.
51. GST Trust clinicians performed an MRI on 4 December 2019, which identified T4-5 discitis (infection of the space between the fourth and fifth discs of the middle section of the spine). The report of the MRI scan said:
‘T4-5 discitis secondary to irritation from subjacent oesophageal rupture. No discrete paraspinal collection or cord compression. Patient mobile on the ward. Discussed at upper GI multi-disciplinary meeting and advised to continue conservative treatment (no operation or stent) with antibiotics, nil by mouth and TPN.’
52. GST Trust held a further upper GI (gastrointestinal) multi-disciplinary meeting on 11 December 2019 to talk about Mrs C’s condition and treatment plan. The records show GST Trust clinicians decided to do a further barium swallow. They carried out the barium swallow on 12 December 2019, which confirmed her perforation was still there and that they could not be completely sure there was not a very small leak at the site of the perforation. The records show GST Trust clinicians decided Mrs C should have nasojejunal (NJ) nutrition (where nutrition is fed through a tube from the nose directly into the small intestine) to lower the risk of a leak from the perforation.
53. GST Trust inserted an NJ tube on 13 December 2019 and Mrs C’s TPN was stopped. The records show GST Trust clinicians planned to carry out regular barium swallows every ten days until the perforation had healed. The records show GST Trust clinicians planned to slowly get Mrs C back to normal eating once the perforation had healed. The records show GST Trust clinicians planned regular spinal MRI scans during this period to keep an eye on the healing of the perforation.
54. GST Trust performed an MRI scan on 14 December 2019, which showed damage to the vertebra close to the oesophageal rupture and a partial compression of her spinal cord. GST Trust clinicians talked about the findings of the MRI scan with the neurosurgery department at KCH Trust who recommended Mr C be put on ‘lie flat bedrest’ and have her spine supported with a brace and support with log rolling (a technique for moving a patient while keeping their spine straight) when repositioning. The records show the neurology team at KCH Trust felt surgery to treat her spinal problems would not be appropriate given her symptoms and as she was suffering with infection.
55. On 19 December 2019, GST Trust’s specialist spinal doctor reviewed Mrs C and recommended they continue to treat her conservatively (without surgery). Mrs C’s condition worsened later that day and she started having weakness in her lower legs. GST Trust’s oncology team talked about her condition with KCH Trust’s neurosurgery department, which again recommended she not have neurosurgery at this time due to the risks posed by her condition.
56. GST Trust held a spinal multi-disciplinary team meeting with four spinal consultants and a musculoskeletal radiologist (a specialist who diagnoses conditions of the bones, joints and soft tissues) on 20 December 2019. The specialist clinicians recommended keeping a close eye on Mrs C’s neurology (functions of the brain, spinal cord and nerves) and ask for a further review with the spinal team if any worrying symptoms developed of if her condition worsened.
57. GST Trust talked about Mrs C’s condition with KCH Trust’s neurosurgery department again. The records show KCH Trust’s neurosurgery department felt Mrs C would not benefit from neurosurgery on her spine as they did not think the damage she had suffered by this point could be reversed. They also thought such surgery would put Mrs C at risk due to her infection and oesophageal rupture. The family asked for a second opinion and this request was passed on to St. George’s University Hospitals NHS Foundation Trust.
58. Mrs C’s condition continued to worsen and she was admitted to GST Trust’s critical care unit with hypotension (low blood pressure) and suspected septic shock (a dangerous drop in blood pressure caused by sepsis). GST Trust’s critical care team treated her with intravenous noradrenaline (a stimulant drug for the treatment of dangerously low blood pressure). The records show a repeat MRI scan identified a slight worsening of her spinal infection, which was continuing to compress the vertebrae in her spinal cord.
59. On 21 December 2019, GST Trust got the second opinion from St. George’s University Hospitals NHS Foundation Trust, which agreed Mrs C would not benefit from neurosurgery. GST Trust again talked about Mrs C’s condition with KCH Trust’s neurosurgery department due to the reduced strength and sensation in her legs. The records show KCH Trust advised that reduction in strength and sensation should not change Mrs C’s treatment at this point. A further MRI scan showed the infection around her spinal cord had got bigger and recommended a CT scan to look into this further.
60. GST Trust carried out a CT scan on 28 December 2019, which confirmed an ‘interval increase in size of the bilateral paravertebral and right paratracheal collection’ (an increase in the fluid beside the infected area of the spine and throat caused by the infection). GST Trust talked about this with the KCH neurosurgery department, which advised again that the risks of the surgery was greater than the possible benefits due to her condition and ongoing infection.
61. The records show Mrs C had an increase in temperature and a worsening of her respiratory function (the process whereby the body takes up oxygen and expels carbon dioxide) on 30 December 2019. The records show that in late December 2019, Mrs C had developed respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide). GST Trust discussed her condition with its thoracic surgery department (the department that performs operations on organs in the chest), which advised that although it was technically possible to drain the infected fluid, surgery would put Mrs C at high risk without any benefit, as it would not cure the infection, only drain the built-up fluid.
62. GST Trust talked about Mrs C’s condition with its upper gastrointestinal surgeon, who again advised a stent would not be appropriate due to the risk of it moving and falling into her stomach and causing a further blockage. The records show the upper gastrointestinal surgeon advised Mrs C’s perforation may not now heal by itself as it had not done so up to this point, and there was no further treatment that could be given at this time for the perforation.
63. The records show in early January 2020, GST Trust clinicians placed Mrs C on ventilation (a breathing machine that keeps the lungs working) and discussed what care was available to her at this point with her family. Mrs C was taken off ventilation the next morning as she had responded well. However, her condition worsened in the afternoon. The records show Mrs C did not recover from her illness and she sadly died a day later.
Failure to put in place an adequate care plan to treat her perforated oesophagus once it was identified in the scan of 22 November 2019 & Failure to provide any care and treatment for her perforated oesophagus for several weeks after it was identified on 22 November 2019
64. These two points of complaint are closely linked and we have addressed them together.
65. Mr C says GST Trust failed to put in place an adequate care plan to treat his wife’s perforated oesophagus once it was identified. He says it failed to give her any care and treatment for her perforated oesophagus for several weeks and instead told the family it would heal on its own.
66. Oesophageal perforation is a rare and possibly life-threatening condition that has a death rate of over 20%, as reported in the NLM guidance. Our surgeon adviser said a contained oesophageal perforation (where fluid does not drain out of the oesophagus) would likely heal on its own if the inflammation and any infection is treated and nutrition supported. During this period, care would be conservative, and supportive and non-operative management would be appropriate.
67. The WJES guidance supports this view and states:
‘Non-operative management (NOM) of Esophageal Perforation (EP) can be considered in stable patients with early presentation, contained esophageal disruption, and minimal contamination of surrounding spaces if highly specialized surveillance is available.
Patients eligible for NOM should be kept on nil per os (nil by mouth), administered broad spectrum antibiotics (aerobic and anaerobic bacteria). Early introduction of nutritional support by enteral feeding or total parenteral nutrition is essential for esophageal healing. Endoscopic placement of a nasogastric tube is recommended.’
68. Our surgeon adviser said the treatment for perforated oesophagus is to support the patient with nutrition and fluid and to treat infection to let the perforation heal on its own. Treatment may include a stent, but this would need abnormal, ‘rugged’ tissue in the oesophagus that could hold the stent in place. Where the inner lining of the oesophagus is otherwise normal, as in Mrs C’s case, a stent may not stay in place, and a stent that slips from its intended position can block the oesophagus or stomach.
69. Our surgeon adviser said in some cases, a perforation may not heal on its own and it is not possible to know when this will happen. The records show that prior to her admission, Mrs C’s immunity had been weakened by her previous cancer, radiotherapy and other serious medical conditions. In light of her previous medical history, it is reasonable to think that Mrs C was at a higher risk of her perforation not healing on its own, and also at a higher risk of dying.
70. Our surgeon adviser said there is no evidence in the records to show the decision not to go ahead with surgery (either to place a stent in her oesophagus or to treat her spinal infection) was inappropriate. Mrs C’s perforation seemed to be contained (fluid from the leak did not spread freely throughout her chest cavity), so there seemed to be no need for immediate emergency surgery. Also, her other health concerns, most importantly her infection, meant that any surgery would have been very risky for her. Our surgeon adviser said there is no evidence in the records to show the doctors could have given Mrs C different treatment during this period that may have improved her chances of recovery.
71. We carefully looked at Mr C’s complaint, the advice we got, the relevant guidance and the information in the medical records. The care plan GST Trust clinicians put in place was supportive to let the perforation heal on its own. This treatment included antibiotic medication to help with infection, support to keep up nutrition and regular monitoring through MRI and CT scans.
72. The GST Trust clinicians carried out many appropriate tests and scans during this period to always keep an eye on the size of Mrs C’s perforation and the complications that developed. The evidence also shows they looked for further advice and clinical opinions from specialist departments whenever Mrs C’s condition changed and acted on the advice they got. The records show many talks between the oncologists, surgeons and neurosurgeons from both Trusts during this period and give detailed reasons for the clinicians’ decisions.
73. We understand why Mr C and his family thought the Trust had not done enough, and we understand his view that there should have been more treatment to help his wife recover from her illness. We found the care plan GST Trust put in place and the care and treatment it provided were in keeping with the WJES guidance and the GMC guidance. We found GST Trust clinicians acted in line with GMC guidance in looking for further expert opinions when thinking about all the treatment options available to Mrs C at each stage of her illness.
GST Trust changed its view in December 2019 that the perforation was not expected to heal
74. Mr C says GST Trust clinicians told him his wife’s perforation would heal on its own. Mr C says GST Trust changed its view in late December 2019 and told him the perforation was not likely to heal on its own. Mr C says this meant he lost a lot of time which he could have spent looking for different care and treatment. He says by the time the Trust told him it would not heal on its own it was too late to look for different care and his wife died a few days later.
75. The records support Mr C’s view and show that by late December 2019, the GST Trust clinicians found that Mrs C’s perforation was not healing on its own and her overall condition was worsening. We do not think this change of view was inappropriate or a sign that the care and treatment provided up to that point was lacking.
76. As we have said about the previous points, oesophageal perforation would be expected to heal on its own. The treatment plan would be to support the patient with nutrition and fluid and to treat infection while the perforation heals. However, in some cases, the perforation may not heal on its own and it is not possible to know when this will happen.
77. As we have said earlier in our report, we found the care and treatment provided by GST Trust clinicians during this period was in keeping with the WJES and GMC guidance. We found no evidence to show there were any other options for different treatments either earlier in her care or at this late stage.
78. We accept Mr C’s account of this period and we can understand why he believes the care and treatment was lacking and that more could have been done to help his wife recover. We accept how distressing this incident was for him and his family and the deep impact Mrs C’s death has had.
79. We found Mrs C’s death was due to the nature and progression of her condition and not due to any failings in the care the Trusts provided. We found no evidence to show the Trusts missed an opportunity to provide more care and treatment that would have prevented Mrs C’s death.