University Hospitals Coventry and Warwickshire NHS Trust

3. Mrs G complains about aspects of the care and treatment the Trust gave to her sister, Miss O, across three hospital admissions between 9 November 2022 and 23 December 2022. Specifically, she says:

• the Trust failed to investigate and properly treat a suspected blockage caused by a hernia on 9 November 2022 • the Trust did not remove the fluid it found in Miss O’s right lung on 9 November 2022 until 7 December 2022 • the Trust discharged Miss O on 13 November 2022 with an infection from an unknown cause • the Trust discharged Miss O on 17 November 2022 less than 24 hours after experiencing a stroke and did not put the appropriate care plans in place • the Trust failed to properly assess Miss O’s dietary requirements during her hospital admissions and meet her nutritional requirements appropriately • the Trust failed to proactively provide her with important updates relating to Miss O’s care and treatment as agreed.

4. Mrs G says Miss O’s respiratory problems were allowed to worsen and she became hungry and malnourished. She says this contributed to Miss O developing infections, experiencing several strokes, and her subsequent deterioration and death. She says she and her family have been left significantly distressed and unable to find closure.

5. Mrs G would like the Trust to acknowledge and apologise for its mistakes, and make a financial remedy payment of at least £25,000. She would also like the Trust to make systemic improvements.

6. On 9 November 2022, Miss O went to hospital, following a consultation with her GP, because she had stabbing pains on her right side. The Trust performed a CT scan and while it could find no evidence of what may be causing the stabbing pains, it found evidence of fluid in her lung. She was admitted to hospital the same day.

7. Miss O was treated for an infection, and she received intravenous (IV) antibiotics during her admission, and was later discharged on 13 November 2022. On 16 November 2022, Miss O was admitted to hospital due to confusion and slurred speech. Mrs G was told the following day Miss O had suffered a stroke and she was discharged.

8. On 22 November 2022, community nurses caring for Miss O became concerned about her condition at home. She was taken to hospital via ambulance and admitted again. The Trust suspected Miss O had aspiration pneumonia (an infection in the lungs caused by bacteria that has leaked into the lungs from the stomach or mouth). On 28 November 2022, Miss O started vomiting and it was suspected this was caused by a blockage in Miss O’s bowel.

9. On 5 December 2022, Miss O’s condition deteriorated and the Trust drained fluid from her lungs on 7 December 2022. Two days later, Miss O was transferred to the ICU and placed into an induced coma. On 12 December 2022, the Trust performed surgery on the blockage in Miss O’s bowel. However, she became unstable during surgery and was taken back to the ICU, with her abdomen left open to allow her time to heal. On 16 December 2022, the Trust closed Miss O’s abdomen via surgery.

10. Over the following days, Miss O’s condition did not improve. She suffered another stroke and had developed kidney problems. The Trust’s stroke team said Miss O would spend the rest of her life in a care home, unable to communicate, and would not be able to move unaided. On 23 December 2022, Mrs G and her family made the difficult decision to turn off Miss O’s life support. She sadly died the same day.

13. The ‘Health Service Commissioners Act 1993’ says we cannot consider a complaint where the affected person has (or had) the option to get an answer to their concerns by taking legal action, unless we consider this is unreasonable in the circumstances.

14. We are satisfied there are potential legal routes available for Mrs G to pursue her concerns through. In saying that, we have made no assessment of the likelihood of success of these, we have simply looked at whether there are any, and whether it is reasonable for her to explore them.

15. Given there are potential legal routes available, we have considered whether it was unreasonable for Mrs G to explore them. We discussed this with Mrs G to understand her circumstances and the outcomes she wants.

16. Mrs G has told us she has not spoken to a solicitor about her concerns because after the Trust had investigated her complaint and issued its final response, it directed her to us if she remained dissatisfied. As such, Mrs G said she was doing what she thought was the right thing to do. However, she says she will explore this option if we think she should do so.

17. We do not criticise Mrs G for approaching us first, after being directed to do so. We do not expect a lay person to know the law that underpins our role and accept they are likely to follow direction from the Trust.

18. Mrs G has told us aspects of the Trust’s care and treatment caused a deterioration in Miss O’s condition, including malnourishment, difficulties breathing, and several strokes. She says this led to her death. Mrs G has also described the significant emotional impact this has had on her and her family, and that she continues to be affected by the experience. Mrs G would like the Trust to acknowledge and apologise for its mistakes, make service improvements, and make a financial remedy payment in recognition of the impact arising from its mistakes.

19. There is a cause of action available in clinical negligence for the issues Mrs G has raised concerns about.

20. Generally, the main outcome for a legal claim in court is financial redress. Other outcomes in the form of apologies and service improvements may occur incidentally as a byproduct of a legal claim.

21. We know Mrs G is seeking mixed outcomes, including a financial remedy.

22. While we can make recommendations for financial remedy where we see something has gone wrong, the amounts we recommend are usually more modest than those of the courts because our approach is different to that of the courts. When we consider recommending a financial remedy, it is in relation to the impact on the complainant, whereas the legal process is more punitive and therefore, the sums are often higher.

23. While Mrs G has told us the financial remedy is not the primary outcome she is seeking, it is still important to her. She has also not told us of any reasons why she would consider it unreasonable to expect her to explore taking legal action. As outlined in paragraph 16, she has told us this is something she is willing to do.

24. With this in mind, we think the legal process is better suited to Mrs G’s desired outcomes at this time. We also recognise there is a limited time to make a legal claim (three years) and we do not want our consideration to remove that as an option when it is clear it could potentially offer what Mrs G is looking for.

25. If Mrs G is unsuccessful in her legal claim, still has outcomes the court does not achieve, or has issues that are not considered and remedied by the courts, she can ask us to consider her complaint again. If she does return to us, she should bring her complaint back to us promptly because we would need to consider our own time limits, in line with the ‘Health Service Commissioners Act 1993’.

26. We were very sorry to hear about how upset Mrs G has been and how this experience has affected her. It has clearly been difficult, and we thank her for sharing her experience. We hope this statement clearly explains why we will not be considering her concerns further at this time.

1. We have carefully considered Mrs G’s complaint about University Hospitals Coventry and Warwickshire NHS Trust (the Trust). She told us aspects of the care and treatment the Trust provided to her sister, Miss O, led to her deterioration and death. We were very sorry to hear about the impact this had, and continues to have, on Mrs G and her family.

2. We have decided not to take further action at this time because we consider it is reasonable for Mrs G to explore taking legal action for the concerns she has raised.