Stockport NHS Foundation Trust

4. Mrs O complains that when her mother, Mrs E, was a patient in the Trust staff did not notice her condition was deteriorating and that she had symptoms of COVID-19. She says it was only when she pointed it out on 10 November, that staff took any action.

5. She says staff then also delayed her mother's test for COVID-19, which delayed her treatment for this, and affected her chances of survival.

6. She also complains that on the evening of 15 November, staff would not allow the rest of the family to stay with her mother. She says staff must have known her mother was dying and despite this, made most of the family leave. She says this was meant she was alone and had no support in her mother’s last hours and when she died.

7. She says this was a horrendous and traumatic experience which still haunts her. She says she has sleepless nights due to these events and still feels broken by what happened, having days where she cannot stop crying. She says she now takes anti-depressants and has been referred to a counsellor as she is not coping.

8. In bringing the complaint she wants the Trust to make changes to make sure this does not happen to anyone else and to make a financial payment to her.

9. Mrs E was discharged from hospital on 27 October 2022 and readmitted the following day when she became unwell again. She was found to have heart failure, her kidneys were not working properly, and she had a urinary tract infection.

10. On 10 November, when Mrs O raised concerns about her mother’s condition staff tested her for COVID-19. Unfortunately, this test was not labelled correctly and therefore it could not be processed. The test was repeated the following day and a positive result returned on 13 November.

11. On 15 November, doctors spoke to the family explaining that Mrs E was deteriorating and looking more unwell each day. However, they were still actively treating her infection with antibiotics.

12. Very shortly afterwards, in the early evening, Mrs E condition deteriorated. Doctors spoke to the family again explaining she was at high risk of further deterioration. They planned to continue treating her but would consider care to keep her comfortable (rather than treat her condition) if she was not improving.

13. Only a few hours later staff noted Mrs E appeared to be deteriorating further, as her breathing had become shallow and her blood pressure was low. Sadly, Mrs E died very shortly afterwards.

Deterioration and symptoms of COVID-19

17. Before we decide if we should conduct 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 found any indications that something has gone wrong.

18. GMC guidance says doctors should adequately assess a patient’s condition by taking account of their symptoms and arranging appropriate investigations and treatment where necessary.

19. We can see that when she was readmitted on 28 October, Mrs E had fast atrial fibrillation, which is an irregular and fast heart rate. She had heart failure (a long term condition where the heart cannot pump blood around the heart properly). She was not drinking fluids and her kidneys were not working well. Staff treated her for a urinary tract infection, giving her fluid and antibiotics.

20. Doctors suspected she had a problem with her adrenal glands (glands above the kidneys that produce various hormones) so prescribed steroids and gave her fluids and antibiotics. When tests showed she had C-difficile, bacterial infection in her bowels, doctors took advice from microbiology.

21. Our adviser said Mrs E was gradually deteriorating during this admission. They said this scenario is sadly not uncommon in frail elderly patients where there is gradual multi organ failure. They said the records indicate staff carried out comprehensive investigations, sought appropriate advice and offered appropriate treatment.

22. In line with GMC guidance, if there were signs or symptoms of sudden deterioration, doctors would be expected to respond accordingly. We have seen no signs of sudden deterioration that needed exploring further, or that any gradual deterioration was not recognised.

23. We have next looked at whether Mrs E had signs or symptoms of COVID-19 during that time. The NHS website explains the symptoms of COVID-19 are very similar to symptoms of cold and flu.

24. We have seen no record of Mrs E having such symptoms. She did not have a cough or high temperature. The records show on 7 November, Mrs E’s chest was clear. On 8 November, an x-ray showed no changes in the lung since her admission. On 9 November she was alert, bright, her chest was clear, and she was not short of breath. Even in the morning of 10 November her chest was clear.

25. In the afternoon of 10 November, Mrs O visited her mother and raised concern that she was more confused and drowsier, was coughing and was complaining of a headache and sore throat.

26. A doctor examined Mrs O and noted she was coughing and appeared uncomfortable. In line with GMC guidance, at this point there were symptoms that required investigation.

27. We can see the doctor then planned a COVID-19 test. We have seen no earlier signs prior to this point to repeat the COVID-19 test.

28. This means we have seen no indications of failings in the care provided to Mrs E in this respect and will take no further action.

Delayed COVID-19 test

29. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right.

30. The Trust has acknowledged that the COVID-19 test referred to in paragraph 28 was incorrectly labelled and therefore could not be processed.

31. The records show the test was repeated the following day and on 13 November, the result was confirmed as positive for COVID-19. If it had been done correctly on 10 November, it is reasonable to assume it would have returned on 12 November. This means there was a one day delay in staff knowing Mrs E’s COVID-19 status. We have therefore considered if this had any impact on her clinical condition.

32. The records show that after the positive result was known, the medical team sought advice about appropriate treatments for COVID-19 for Mrs E.

33. As Mrs E’s oxygen levels were not low, she did not require oxygen or dexamethasone (a type of steroid which is used when people with COVID-19 need oxygen). Unfortunately, as she had liver function and kidney failure, she was not eligible for anti-viral treatment. Even if Mrs E’s positive COVID-19 result had been available a day earlier, she would still have been unable to have such treatment.

34. This means we have seen no indication the processing failure in the COVID-19 test had any clinical impact on Mrs O. We hope this reassures Mrs O about the delay that occurred.

Visiting

35. It is clear from our conversations with Mrs O how traumatic it was for her to be alone with her mother when she died. We are very sorry to hear about this experience.

36. Mrs O told us that in the evening of 15 November, when the family was at her mother’s bedside, a nurse insisted only two relatives could remain with Mrs E and that the others must leave.

37. The Trust has apologised for the manner of the nurse who explained the visiting regulations in place at the time. However, Mrs O’s complaint is about the decision to restrict visiting to two relatives.

38. In line with our process at paragraph 29, we have therefore considered if there are indications such a decision led to Mrs O being alone when her mother died, and the significant distress this caused her.

39. Mrs O has told us that although most of the family left the hospital on request of the nurse, she and Mrs E’s grandson remained. This was a decision agreed by the family as he had travelled the furthest to visit.

40. Sometime after, the grandson needed to leave the hospital after spending time with his grandmother. At that stage, Mrs O was alone with her mother. However, as the Trust had allowed two relatives to be present, another could have joined her.

41. This did not happen, and we do not know the reasons for this. To be clear, we in no way criticise Mrs O or her family for this. We do know that Mrs E sadly deteriorated very quickly during the evening of 15 November.

42. As there was the option for another relative to replace the grandson at the bedside, we cannot link Mrs O being alone with her mother with any failure by the Trust around visiting. For this reason, we will not consider this part of her complaint further.

43. In summary, we have decided not to do a detailed investigation of Mrs O’s complaint. We recognise this was a very important concern for Mrs O and we thank her for taking the time to bring it to us.

1. We have carefully considered Mrs O’s complaint about her mother’s care at the Trust. We are sorry to hear how much these events have affected Mrs O and that they continue to affect her wellbeing so much.

2. Having considered the complaint, we have seen no indication the Trust missed earlier signs of deterioration or symptoms of COVID-19. We have seen no indication the error in processing the COVID-19 test had any clinical impact on her mother. We are unable to link the significant distress Mrs O sadly experienced when she was alone as her mother died with her complaint about the Trust’s visiting restrictions.

3. This means we will not investigate the complaint further.