King's College Hospital NHS Foundation Trust

3. Mr R complains about the care and treatment the Trust gave to his mother, Ms R, in March 2023. Mr R complains:

• Ms R was prematurely discharged on 10 March despite not being medically fit to go home • Ms R was discharged while unable to walk unaided with a Zimmer frame leaving Mr R having to lift her into his car from her wheelchair • Ms R was not tested for COVID-19 when discharged despite it being present on the ward • staff failed to regularly communicate with him about his mother's progress • staff failed to appropriately manage Ms R's oxygen levels • staff provided incorrect information in the complaint response about when palliative and end-of-life care was discussed between Mr R and staff • staff placed him under unnecessary stress by asking him to agree to palliative care and end-of-life care • the Trust has given conflicting information about whether antibiotics were restarted or if they had not been stopped at all • the Trust has not provided the medical data he asked for • the Trust could have helped Ms R to accept food much earlier than when she did.

4. Mr R believes that if Ms R’s discharge had not been rushed on 10 March, then staff would have realised that Ms R was not well and given her a COVID test. He states this would have led to earlier treatment for the COVID she later got and could have prevented her death. Mr R believes Ms R would have recovered if doctors had not rushed to giving palliative and end-of-life care.

5. Mr R says he and his children and another grandchild of Ms R have lost the time they should have been able to spend with Ms R. He believes Ms R suffered unnecessarily due to the care and treatment given.

6. Mr R would like a review of what happened and for the Trust to apologise. He also wants a financial payment.

7. This is a brief background, we have not included all details.

8. Ms R was admitted as a patient on 1 March 2023. The Trust says Ms R was being treated for a chest related infection as well as hypothermia, acute dehydration and abnormal electrolytes.

9. Ms R had a full course of antibiotics and had improved by 7 March. The Trust says that plans for discharge went ahead as doctors felt Ms R was medically fit for discharge. Ms R was assessed by occupational therapy as well as physiotherapy before being discharged on 10 March.

10. Ms R attended the Trust’s emergency department on 13 March and was readmitted to hospital. Mr R complained to the Trust on 14 March. Ms R died later that month of COVID pneumonia.

11. Mr R raised more complaint points on 27 March. The Trust replied on 11 August but Mr R did not feel that this addressed all the points of his complaint. Mr R brought his complaint to us on 4 January 2024. The Trust sent the final complaint response on 21 March 2024.

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. We have discussed this with Mr R to understand his circumstances and the outcomes he wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

15. From talking to Mr R, we recognise the strength of feeling he has and how he thinks there has been clinical negligence. The outcomes he wants are a financial payment, an apology and a review of what happened. Mr R has made clear that he is unable to give a figure for the amount of payment he would like, but he would want it to be the highest amount possible. The outcome a court can give is mainly financial but a review of what happened as well as an apology can be achieved as by-products of a successful legal claim.

16. Our guidance on financial remedy includes our severity of injustice scale. The scale helps us to make fair and consistent recommendations and to set how seriously someone has been affected against a level on the scale. The levels are linked with a recommendation for payment ranging from £0 to £10,000. We discussed the amounts on our scale with Mr R and he said he would like to try and achieve the highest amount possible through a legal claim. This amount goes beyond our scale. We are very unlikely to award the same amount as a court.

17. We think Mr R could make a clinical negligence claim.

18. We have gone on to explore with Mr R if it is reasonable for him to take a legal route. When considering reasonableness, the factors we take into account are based on the individual circumstances of a complaint.

19. Mr R made clear that he would like to take legal action. He explained he had made his complaint to us to try and get a response from the Trust to his full complaint. The Trust had since replied on 21 March 2024 which led to him review his next steps.

20. Mr R also explained he would look to take legal action on a ‘no-win, no-fee’ basis given the high costs associated with a legal claim. Mr R also explained he would begin contacting solicitors shortly.

21 .In summary, we think it is reasonable for Mr R to take a legal route because he has expressed an interest in this and we have not seen anything to show it would not be reasonable for him to explore this.

22. Some of the points of Mr R’s complaint like the communication issues would not be considered as part of a clinical negligence claim, so a court may not look at them. But, it is clear from speaking to Mr R that the main focus of his complaint is the lack of care and treatment which he feels led to his mother’s avoidable death.

23. If there are any outstanding outcomes that cannot be achieved by the legal claim or Mr R would like us to look at issues separately after legal action has finished, he can bring the complaint back to us to consider further. We explained to Mr R the time limit for bringing a complaint to us.

24. We have provided Mr R with the details of different organisations like AvMA and Advocate who can provide help in making a legal claim.

25. We recognise the impact these events had on Mr R and his family and how difficult it has been for him to speak about.

1. We have carefully considered Mr R’s complaint about King's College Hospital NHS Foundation Trust (the Trust). We think Mr R could take legal action on the matters he has brought to us.

2 .We recognise the grief Mr R has experienced with the death of his mother and understand his concerns that her death might not have happened if she had been given the appropriate care and treatment.