County Durham and Darlington NHS Foundation Trust

3. Mrs H complains about what happened in October 2022. She complains:

• her father-in-law was given medication orally even though he was nil by mouth (NBM) • about poor communication saying a sheet of paper was stuck above her father-in-law’s bed with a handwritten note of ‘NBM’ that was not easy to see • the Trust did not administer a rotigotine patch (treatment for Parkinson’s disease) when he was nil by mouth • he was not given his Parkinson’s medication and a dose was missed • there is no record of his end-of-life medications • about poor or no record keeping during the changeover from handwritten to electronic records • about poor information on the reason for his death • the death certificate was issued despite raising concerns with the ward and medical professionals that he may have been fed when nil by mouth • about poor complaint handling.

4. As a result of the above, Mrs H says:

• her father-in-law got aspirational pneumonia (a type of lung infection) and Parkinson’s disease and then died • her mother-in-law is distressed and is struggling financially because she was dependant on her husband.

5. Mrs H wants an apology, acknowledgement of failings, service improvements and a financial payment.

7. The Health Service Commissioners Act 1993 (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. We have discussed this with Mrs H to understand her circumstances and the outcomes she wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

8. Mrs H told us she spoke to a solicitor at a large law firm who said they would not be able to take the case on. She then spoke to another solicitor at a smaller firm who has made an application to get her father-in-law’s medical records and is considering whether she has a claim for clinical negligence. She told us the law firm is looking at all the care and treatment her father-in-law had including the parts she has complained about to us. Her solicitor is reviewing the whole file with a view to considering what parts they can take forward for legal proceedings.

9. As Mrs H is currently exploring whether she has a legal claim and because compensation, along with a direct apology, are key outcomes she is looking for we think legal action is the most appropriate route for Mrs H.

10. After legal action is complete, if Mrs H has any outstanding outcomes that have not been achieved, she can return to us with her complaint. Mrs H should return to us as soon as possible, as we usually only consider complaints made to us within a year of when someone becomes aware of a problem. Taking legal action will not act against Mrs H as long as she returns to us quickly. This applies to the issues that happened within a year of her knowing she had reason to complain.

11. Mrs H mentioned that some of her concerns date back to around three years ago, that is why she has not raised these issues with us. We would like to highlight that we usually only consider concerns that have been raised with us within a year. In certain circumstances, we can set this time limit to one side, but we would need to discuss the reasons for not bringing the concerns to us sooner in detail.

12. If Mrs H does take legal action, we would need to wait for this to conclude before we consider if any issues are outstanding.

13. We appreciate how distressing the events have been and continue to be for Mrs H and her family and are grateful to her for bringing her complaint to our attention.

1. We have carefully considered Mrs H’s complaint about County Durham and Darlington NHS Foundation Trust (the Trust). Mrs H told us that a law firm is considering whether she can make a clinical negligence claim. We think this is the most appropriate way forward based on the impact claimed and outcomes she wants.

2. We are very sorry to hear that Mrs H’s father-in-law died and acknowledge the distress she and her mother-in-law have experienced because of her complaint. We hope Mrs H finds our decision helpful.