University Hospitals Birmingham NHS Foundation Trust

4. Mrs O complains on behalf of her sister about the care and treatment she had from the Trust in April 2020. She says:

• the Trust gave Mrs E end of life medication that was not appropriate for her condition • Mrs E had kidney failure and the Trust prescribed too high a dosage of medication • a ReSPECT form (Recommended Summary Plan for Emergency Care and Treatment) was put in place on 4 April without discussing this with family • the Trust diagnosed Mrs E with encephalitis (inflammation of the brain) without doing any tests • the Trust told her it would arrange a third resolution meeting. but it did not.

5. Mrs O said her sister died because of the Trust’s actions. Mrs O said if the Trust had not given end of life medication, her sister would still be alive. Mrs O said the Trust wrongly diagnosed Mrs E with encephalitis to justify the end-of-life medication. Mrs O said Mrs E was diagnosed with kidney failure and should have had her medication halved but this did not happen and this also contributed to her death. Mrs O said her sister’s death has devastated her and her family and rips them apart every day. Mrs O said the Trust refusing to arrange a third resolution meeting caused her more upset and left her with unanswered questions.

6. Mrs O would like an apology, acknowledgement of failings and a financial payment.

7. Mrs E had a background of advanced liver disease and poor renal (kidney) function.

8. Mrs E was admitted to the Trust on 4 April 2020. The Trust said Mrs E was unresponsive and had aspiration pneumonia (where contents from the stomach or mouth enter the lungs causing infection). Mrs E was reviewed by the critical care team and was moved to the acute medical unit. On admission, Mrs E was also swabbed for COVID-19 and got a positive result on 5 April.

9. On assessment on 4 April, the Trust said Mrs E had a GCS (Glasgow Coma Scale assesses the level of consciousness and awareness) score of nine (the highest score is 15 and indicates full alertness). This means Mrs E had low responses to sound, movement, touch and eye opening. Mrs E was diagnosed with an acute kidney injury (AKI) stage three. AKI stage three is when the kidney is unable to function properly and can lead to complete kidney failure.

10. A ReSPECT form was completed on 4 April and documented Mrs E was for ward-based care only. A ReSPECT form is a treatment plan for a person’s clinical care in a future emergency when they do not have capacity to make or express choices. The Trust gave Mrs E IV (intravenous meaning through the veins) fluids, antibiotics, morphine (a strong opiate painkiller) and midazolam (to treat severe agitation).

11. Mrs E was reviewed by the gastroenterology team (who specialise in the digestive system) on 5 April. The team noted Mrs E was very unwell, had low blood pressure and was delirious (confused) and agitated.

12. On 8 April Mrs E’s dose of midazolam was reduced as her kidney function was getting worse. Mrs E sadly died shortly after this.

13. Mrs O complained to the Trust on 8 July 2020 and got its final response on 6 June 2023.

14. Mrs O went to the first resolution meeting with the Trust on 19 April 2022 and the second on 17 March 2023. Mrs O asked for a third resolution meeting on 25 September 2023 and the Trust declined this request on 29 September.

Events in April 2020

17. The law gives us the power to investigate complaints and says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to.

18. This complaint falls outside of our time limit. We have set out below why we think this is the case. We discussed with Mrs O the reasons why she could not come to us sooner. We have also considered the time the Trust took to deal with her complaint.

19. We think Mrs O would have reasonably known she was unhappy with the Trust’s care at the time of the events in April 2020.. Mrs O said that on 8 April the palliative care nurse told her Mrs E was on a higher dose than she should have been.

20. Mrs O complained to us on 7 October 2023. This makes Mrs O’s complaint about two years and six months out of time.

21. We looked at the reasons for delay and whether they are enough for us to put our time limit to one side.

22. Mrs O made her complaint to the Trust on 8 July 2020. We appreciate Mrs O made her complaint quickly after Mrs E’s sad death. Mrs O asked for a resolution meeting to discuss her concerns and this went ahead on 19 April 2022. We understand one year and nine months is a long time to wait for a meeting.

23. We asked Mrs O if she was able to explain the gap between July 2020 and April 2022. Mrs O explained during this time she was waiting for the Trust to arrange the meeting.

24. We also asked the Trust if it could give evidence of what was happening during this time. The Trust said Mrs O asked for the complaint to be put on hold while she was dealing with a complaint on behalf of her father. The Trust said Mrs O also asked it to allow her time to look through her sister’s medical records.

25. We can see that on 10 July the Trust sent a letter to Mrs O saying it noted her request for the meeting to be arranged once she had reviewed the medical records. In the letter the Trust asked Mrs O to contact it once she was ready for the meeting to be arranged. The Trust also advised that due to the COVID-19 pandemic there was a delay in having face to face meetings. We can see Mrs O contacted the Trust in October 2021 to say she would like the resolution meeting to be arranged.

26. We asked Mrs O if she could confirm when she received Mrs E’s medical records and what was happening during this time. Mrs O said she asked for the medical records in July 2020 and got these the next month. Mrs O said she asked for a face-to-face meeting and the Trust told her this would have to wait due to the COVID-19 pandemic. Mrs O said she was waiting for the Trust to give a date for the meeting and this was the cause of the delay.

27. We appreciate reading her sister’s medical records would have been extremely difficult and distressing. We think 14 months is a substantial length of time to read through medical records and contact the Trust.

28. On 21 October 2021 the Trust requested availability from the relevant staff needed to attend the resolution meeting. The Trust said in February 2022 it had arranged a meeting for 8 March but due to COVID-19 restrictions, only one other family member could attend.

29. The Trust said Mrs O did not agree to this and the meeting was arranged for 19 April in a larger room so more family members could attend. We appreciate six months is a long time to wait. We took this into consideration when looking at the time limit.

30. It is important to note that at this time Mrs O’s complaint was already one year out of time. It seems the main delay was between August 2020 and October 2021. In this time, we can see the Trust was waiting for Mrs O to ask it to begin the process to arrange a meeting.

31. Mrs O has not given us any more information that would explain why she was unable to contact the Trust until October 2021.

32. On 5 August 2022, the Trust sent its summary of the first resolution meeting to Mrs O. We think four months is a long time to take to send a summary and we took this into account when considering the time limit.

33. Mrs O emailed the Trust on 22 September 2022 saying she would like another meeting because the summary was not an accurate statement of what was discussed. The Trust arranged a second resolution meeting for 17 March 2023.

34. We asked the Trust if it could give evidence to explain the delay between September 2022 and March 2023. The Trust sent an email to Mrs O on 5 October asking her to send her concerns. The Trust said once it had this information it would contact the relevant departments. On 18 November Mrs O emailed the Trust and said she was still going through the questions for the meeting.

35. On 12 December the Trust contacted Mrs O to ask if she had formed her questions. The Trust explained its deadline to reply to her complaint in three months (22 December) would pass because she had not given any details for it to address. The Trust said it would not be able to give a new date for handling her complaint once this deadline had passed.

36. On 14 December Mrs O emailed the Trust saying she had not been told about a deadline. She also said she was forming questions for a meeting about her father’s care and dealing with both complaints at the same time was traumatic. Mrs O said she would send the questions by the end of January.

37. On 13 February 2023, Mrs O sent the Trust her questions for the meeting. The second resolution meeting was held one month later, on 17 March 2023. We do not think a month was too long to wait for a meeting.

38. We asked Mrs O if she was able to explain the delay between September 2022 when she requested a second meeting, and February 2023 when she sent her concerns to the Trust. Mrs O said she and her two cousins who attend the meetings with her, all had separate two-week holidays (making up six weeks of the delay). Mrs O said she and her cousins were also meeting up once a week to read through the resolution letter and prepare the questions.

39. We appreciate this and excluding the six weeks, we think three months is a long time to prepare follow-up questions for the Trust. In September 2022 Mrs O told the Trust she was unhappy with its summary letter. We think five months is a long time to take to tell the Trust she was unhappy and then to give it her questions.

40. The Trust sent its final response on 6 June 2023, including a detailed summary of the last local resolution meeting. On 25 September Mrs O contacted the Trust and explained she was not happy with any of the answers. She said she would like another meeting.

41. On 29 September the Trust emailed Mrs O and said it would not be able to hold another meeting and advised her to contact us. Mrs O came to us on 7 October.

42. We asked Mrs O if she was able to explain the gap between March and September 2023. Mrs O said she was on holiday for two weeks and was also very upset after getting the Trust’s letter.

43. We have considered the reasons Mrs O gave us. We understand she has been through a difficult and emotional time. Our decision in no way takes away from this.

44. Firstly, there is a very large gap from when Mrs O first took her complaint to the Trust in July 2020 to when she contacted it in October 2021 to ask for a meeting. Mrs O said this was due to her reading her sister’s medical records. We think 14 months is an excessive amount of time to read medical records and Mrs O could have returned to the Trust earlier.

45. Secondly, we think five months is a long time to take to form questions for the meeting. We have considered the six weeks that Mrs O and her cousins were on holiday, but we still find three months a long time to get questions ready.

46. Overall, we do not have good reason to put our time limit to one side.

Resolution meeting

47. Before we decide if we should do a detailed investigation of 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. We have done this and have not seen any signs that something has gone wrong.

48. Mrs O said during the resolution meeting on 17 March 2023 the Trust told her she could have a third meeting if she was still unhappy. Mrs O said the Trust told her it would try and arrange for her sister’s doctor to attend the third meeting. Mrs O said the Trust lied to her by telling her she could have a third resolution meeting and then refusing when she requested one.

49. Our Principles says organisations should make it clear to complainants when they have given their final response to a complaint. It also says organisations should provide clear and accurate information about the next stage of the complaint process. This is so the complainant is clear about what to do next if they are unhappy.

50. From the complaint file we can see Mrs O first complained on 8 July 2020 and asked for a face-to-face meeting. Mrs O had a meeting with the Trust on 19 April 2022 and the Trust sent its summary of this on 5 August. In this letter the Trust said its local resolution was complete and directed Mrs O to us.

51. Mrs O returned to the Trust on 22 September saying she was not happy with the summary. Mrs O said she would like another meeting before bringing her complaint to us.

52. Mrs O emailed the Trust seven questions and asked for the chief pharmacist to attend the meeting. The meeting was held on 17 March 2023 and the second summary letter was sent on 6 June. The letter said local resolution was complete and directed Mrs O to us.

53. Mrs O contacted the Trust on 25 September saying the answers in the summary letter were different to what was said in the meeting. Mrs O asked for a third resolution meeting saying she had been told before she could have one if she was still unhappy. She asked for a member of the palliative care team and a doctor who looked after Mrs E to come to the meeting.

54. On 29 September the Trust said it would not be able to arrange another meeting or to re-open Mrs O’s complaint. The Trust advised Mrs O to contact us and provided our website and advice line details.

55. We understand it would have been distressing for Mrs O to be told she could have a third meeting and for this to be withdrawn.

56. Mrs O was not bringing any new concerns to the Trust and had asked for the same seven points to be re-addressed. The Trust had already arranged two meetings and Mrs O wanted to discuss the same seven points at a third meeting. Based on this we think it was reasonable for the Trust to say local resolution was complete as it had nothing more to add.

57. We have seen no sign that the Trust has not acted in line with our Principles when handling the complaint. It told her when its process was complete, directed her to us and provided our website and advice line details.

58. We understand the emotional impact Mrs O told us this had on her. We are very sorry for any further distress our decision will cause.

1. We have carefully considered Mrs O’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust).

2. Mrs O’s complaint about the care and treatment given to her sister, Mrs E, in April 2020 falls outside of our time limit. We have considered the reasons why the complaint was not made to us sooner and have not seen good reason to put the time limit to one side and investigate further.

3. We have considered Mrs O’s complaint that the Trust would not arrange a third resolution (complaints) meeting. We have not seen any sign that anything went wrong with its decision.