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Sheffield Teaching Hospitals NHS Foundation Trust

P-002507 · Statement · Decision date: 19 March 2024 · View Sheffield Teaching Hospitals NHS Foundation Trust scorecard
Complaint (AI summary)
Miss E complained the Trust gave her mother an iron infusion too quickly, which she believed worsened her mother's pulmonary fibrosis and led to an earlier death.
Outcome (AI summary)
The complaint was closed. The ombudsman found no evidence that the Trust did anything wrong when administering Mrs E's iron infusion.

Full decision details

The Complaint

3. Miss E complains the Trust gave her mother an iron infusion too quickly on 7 March 2023.

4. Miss E thinks the speed of the iron infusion made her mother’s pulmonary fibrosis (a condition where the lungs are scarred and the lung tissue thickens making it harder to breathe) worse. Mrs E became very unwell and died a few months later. She thinks her mother died sooner than she should have.

5. Miss E wants the Trust to make service improvements.

Background

6. Mrs E attended the Trust on 7 March 2023, for an outpatient iron infusion. She returned home the same day, saying she felt unwell. She was unable to eat.

7. She continued to feel unwell and was later admitted to hospital. Sadly, Mrs E died a few months later from pulmonary fibrosis.

Findings

11. The Trust’s complaint response says it gave Mrs E her iron infusion in line with recommended guidelines and timings.

12. It apologised that Mrs E experienced muscle pains and her mobility got worse. It said muscle pain is a known, but uncommon side effect of an iron infusion. It explained it had not given the infusion too quickly.

13. It also said staff completed observations after the infusion and Mrs E did not complain of feeling unwell before she was discharged home.

14. The BNF guidance says that 1g iron infusion should be given over at least 15 minutes.

15. Mrs E’s medical record shows the Trust gave the infusion at 11.40am and took her observations at 12pm. This is a period of 20 minutes, so it seems the Trust gave the infusion in line with BNF guidance. Our adviser did not raise any concerns about the timing of it.

16. The BNF guidance does not say that an iron infusion should be avoided when someone has pulmonary fibrosis. There is nothing in the BNF guidance to say that more care should be taken for older patients.

17. We can see no evidence that the Trust did anything wrong because the Trust gave the infusion in line with guidance.

18. We appreciate the distress Miss E experienced when later her mother’s health got much worse. We do not underestimate how difficult this will have been for her. We also recognise how hard it can be to make a complaint, so we thank her for bringing her complaint to us.

Our Decision

1. We have carefully considered Miss E’s complaint about the care Sheffield Teaching Hospitals NHS Foundation Trust (the Trust) gave to her mother, Mrs E. We are very sorry to hear about Mrs E’s death and we recognise this caused Miss E great distress and upset.

2. Having considered all the information we do not think the Trust did anything wrong when giving Mrs E her iron infusion. We explain our decision below.

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