North West Anglia NHS Foundation Trust

3. Mrs P complains about the Trust’s communication during her husband’s in-patient stay in June 2022. She says she had no communication from the Trust about her husband’s decline and unresponsive episode.

4. Mrs P says that due to the poor communication she was unable to be with her husband at the end of his life.

5. Mrs P says it was a terrible shock to find out her husband had died but to also find out he had died some time before and she had not been told.

6. She says seeing her husband in bed has affected her physical and mental health and she is waiting to see a consultant because she is finding it difficult to sleep.

7. Mrs P would like service improvements to make sure of better communication between staff and patients.

8. Mr P had many existing serious conditions including chronic kidney disease, chronic obstructive pulmonary disease (COPD) affecting his breathing, a heart condition (aortic stenosis) and he previously had a stroke.

9. Mr P was admitted to hospital due to a feeling of congestion on his chest and he was short of breath.

10. The Trust transferred him to the cardiac unit two days later.

11. Three days after this, a nurse attended to Mr P in the early hours of the morning and found him to be unresponsive.

12. Mr P was reviewed by the duty doctor an hour later and he was noted to be alert and well.

13. On the same day at 11am, Mr P fell from his chair.

14. At 2pm, Mr P had an unresponsive episode, he did not regain consciousness and he sadly died.

20. The Trust said it should have contacted Mrs P after her husband became unwell early in the morning. The Trust apologised for this.

21. Mr P’s medical records say that during a routine nursing check at around 2am, the Trust noticed Mr P was not responding and his body was stiff. It goes on to say that after two minutes and without any specific treatment, he woke up and said he had been in a deep sleep.

22. After this Mr P’s observations were checked including his blood pressure, blood sugar, pulse and oxygen saturation. All of these showed as normal. Mr P was also put on hourly rounding, which means he was attended to every hour and assessed for pain management, any needs were met and he was offered food and water.

23. Our physician adviser says taking observations after an unresponsive episode is what is expected and as all Mr P’s observations were normal, it suggests nothing bad happened. Our physician adviser also added the Trust acted correctly by alerting the duty doctor and waiting for them to review Mr P.

24. Mr P’s medical records show that when he was reviewed by the duty doctor at 3am he was alert and well.

25. Mr P’s medical records also show that between 2am and 2pm his observations on the hourly nursing rounds were mostly normal. In particular, the records note that at 10.21am Mr P was sat up, alert and orientated. At 12.30pm he was alert but was escalated to a doctor because his blood pressure was low. The last check was done at 1.30pm and his blood pressure had improved, he had a drink of water, his observations were normal and there were no further concerns.

26. Our nursing adviser said Mr P’s death at 2pm was a sudden event.

27. When Mr P was admitted to the Trust he was in his eighties. His medical records show he had full capacity and was able to contribute fully during medical and nursing assessments. The records also show the Trust updated him fully on his care and treatment the day after he was admitted.

28. Mr P’s medical records show he had no concerns with communication and was independent. It is also recorded that Mr P had his mobile phone with him to contact family himself.

29. We have seen no evidence of the Trust communicating with Mr P’s family from when he first arrived to 2.15pm on the day he died. But, our nursing adviser said Mr P was happy to receive updates himself and this is documented throughout his stay. They explained any updates to the family would have been made after getting consent from Mr P.

30. The NMC guidance says:

‘provide information and explanation to people, families and carers and respond to questions about their treatment and care and possible ways of preventing ill health to enhance understanding… share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand.’

31. We think the Trust was communicating with Mr P directly about his care and treatment throughout his stay. We also think that after the potential unresponsive episode at 2am, Mr P appeared well, orientated and alert both immediately after this episode and every hour up until 2pm. In line with NMC guidance, we do not feel there was a reason for the Trust to contact Mrs P. This is because there was no evidence of a severe decline in Mr P’s health until just minutes before his death.

32. We have seen no evidence that anything went seriously wrong. We do not uphold this complaint.

33. We understand how difficult it will be for Mrs P to read how quickly her husband declined. We hope she is reassured that there was no obvious cause for concern up until shortly before he died. We also understand how upsetting it was for Mrs P to arrive at the Trust but not be able to see him in his last minutes of life.

1. Mrs P has raised concerns that the North West Anglia NHS Foundation Trust (the Trust) did not tell her about her husband’s unresponsive episode in June 2022. We have not seen any failings with the Trust’s communication with Mrs P about this episode. We do not uphold the complaint.

2. We would like to thank Mrs P for bringing this complaint to us as we recognise how hard this has been for her. We also recognise how difficult it is for Mrs P because even though she was at the Trust, she was unable to see her husband before he died. We hope our findings answer her questions about why she could not be with him at the time of his death.