Walsall Healthcare NHS Trust

3. Miss N and Mrs N complain the Trust ignored, did not examine, and did not provide appropriate treatment for Mr O’s oral mass between 16 January and 19 January 2022.

4. Miss N says Mr O died after his admission to the Trust and this caused her severe, ongoing grief.

5. Mrs N says she now avoids health services as she has lost faith in them. She says a year later she is still very shaken up and distressed by what happened.

6. Miss N wants service improvements and financial compensation. Mrs N wants an apology from the Trust because she feels its complaint response was untruthful.

7. Mr O was admitted to hospital on 16 January. Nursing staff found blood in his phlegm when suctioning.

8. While in hospital, Mr O was treated with antibiotics and intravenous fluids (IV fluids are liquids injected into a patient’s veins through a tube to maintain hydration).

9. The speech and language therapy team (SALT) reviewed Mr O three times before he was discharged to the care home on 19 January, with a diagnosis of community-acquired pneumonia.

10. On 21 January, Mr O was readmitted to the hospital because care home staff noticed he was eating less and had a swollen mass in his mouth.

11. Mr O sadly died in February 2022.

14. The law says we cannot investigate a complaint where a person has, or had, the option to take legal action, unless we consider this is, or was, unreasonable in the circumstances.

15. We have discussed this with Miss N and Mrs N to understand their circumstances and the outcomes they want. We do not consider whether legal action would succeed but whether it would be a reasonable option to take.

16. There is a three-year time limit for most clinical negligence claims. Miss N and Mrs N became aware of the issues when Mr O was discharged on 19 January 2022. This means they are likely still within the three-year time limit and have the option of taking legal action.

17. Miss N says the Trust did not address the oral mass Mr O was admitted for, even though it was visible to the naked eye. She explains she saw Mr O less than a week after he was discharged and the mass was large.

18. She explains, as a doctor, she knows a tumour could not have grown that quickly and not be visible. She feels unless SALT did not open his mouth during examination, it would have been impossible to not see the mass. She believes the Trust either lied about its examination, or it did not even quickly examine him.

19. Mrs N says Mr O was admitted because he could not swallow. She says when he was discharged the care home staff were only told about community-acquired pneumonia and treating this with oral antibiotics, but there was no mention of an oral mass.

20. Miss N and Mrs N feel the Trust’s negligence caused unnecessary suffering and left him struggling to breathe and talk, and with significant pain. They feel if the Trust had done something about the oral mass, Mr O would not have died so quickly and the family would not be experiencing ongoing grief and distress.

21. They are looking for around £30,000 in financial compensation and service improvements to make sure this does not happen to other patients.

22. Taking this into account, it seems they could pursue a clinical negligence claim against the Trust to achieve the outcomes they want. While a court cannot specifically recommend service improvements, this may be a by-product of a successful legal claim.

23. Miss N and Mrs N have not suggested or raised any concern with taking legal action and have agreed to do this. They are within the three-year limit to pursue a legal claim and in our view, it would not be unreasonable for them to take legal action. If legal action does not achieve all the outcomes they want, they can bring the complaint back to us. By law, a person should normally complain to us within 12 months of when they first became aware of a problem. We can put the time limit to one side if we think there is good reason to. We will consider any previous decisions we have made, including deciding legal action should be pursued. If we consider there are unexplained delays in bringing the complaint back to us, we are less likely to put the time limit to one side. For this reason, we recommend they return to us as soon as possible if they want to.

24. We acknowledge how important this complaint is and recognise this has been an exceptionally difficult time for Mr O’s family.

1. The Parliamentary and Health Service Ombudsman has carefully considered Miss N and Mrs N’s complaint about Walsall Healthcare NHS Trust (the Trust). We are sorry to hear about the experience Mr O (their uncle and brother) had and we do not underestimate how challenging it is for his family to revisit the care of a loved one. We recognise they have been through a difficult and distressing time.

2. We think Miss N and Mrs N could take legal action on the matter they have brought to us. For this reason, we have decided to take no further action.