Guy's and St Thomas' NHS Foundation Trust

3. Mr C complains about the care and treatment his late son, Mr T received between 18 July and 9 August 2023 at Guy’s and St Thomas’ NHS Foundation Trust (the Trust). Mr C specifically complains about the following:

• Mr T was discharged inappropriately on 3 August without intravenous (IV) diuretics which were helping his recovery • The Trust did not arrange IV diuretics to be administered at home • Mr T was readmitted to the Trust on 8 August, the Trust delayed giving IV diuretics for six hours • Mr C also says there was confusion when agreeing the cause of his son’s death.

4. Mr C says the lack of IV diuretics caused his son to severely deteriorate and he believes the delay on 8 August caused his death.

5. Mr C says his son suffered ‘inhumane’ treatment and his family have been devastated by his death.

6. Mr C is looking for apologies, explanations and service improvements.

7. Mr T was a 30 year old man with severe, lifelong disabilities which mean he had an emotional development age of around eight years old. He had six life threatening conditions and lived at home where his family cared for him around the clock.

8. On 18 July 2023, Mr C received a phone call from the Trust to say his son had high infection markers and he should go to hospital. Mr T was taken to hospital where, amongst other treatments, Trust staff gave him diuretics (a drug used to reduce fluid retention). Oral diuretics were unsuccessful so Mr T’s treatment changed and he received the diuretics via an intravenous (IV) drip from 28 July.

9. The IV diuretics seemed to improve Mr T’s condition and he was discharged home on 3 August after a Covid-19 outbreak on the ward and discussion with family.

10. Mr T was unable to receive IV diuretics at home and his condition deteriorated. On 8 August Mr T’s family took him back to the Trust where he had an X-ray. This confirmed fluid had built up on his lungs. Staff prescribed IV diuretics to treat this.

11. Sadly, Mr T’s condition deteriorated and he died in the early hours of 9 August 2023.

13. Mr C told us he attended a preliminary hearing at the Coroner’s Court on 25 July 2024. The coroner intends to hold a full inquest to look at the cause of Mr T’s death. At this stage he has not been given a date for the inquest.

14. A coroner is an independent judicial officer who investigates deaths reported to them. When a coroner investigates a death, this may include holding an inquest.

15. A coroner’s role does not extend to apportioning blame for a death or considering criminal liability. However, they will comment on the cause of death, and whether any care leading up to it was in any way contributory.

16. An inquest is a limited medical and legal enquiry into the circumstances leading up to the death of the deceased. Following an investigation, a coroner also has the power to report deficiencies in service to the relevant authorities in the hope that improvements will be made to prevent future death.

17. We think it would be appropriate for us to wait until the coroner has completed their deliberations. This is because Mr C believes the care his son received at the Trust contributed to his death. In addition to this, he disputes what the Trust has said and says it has made false statements to the coroner.

18. With this in mind, we will take no further action on Mr C’s complaint until the Coroner’s Office has completed its deliberations, determined Mr T’s cause of death and, if necessary, reported any deficiencies in service it identifies.

19. Following the Coroner’s Office’s decision, Mr C may feel its findings and reported deficiencies are enough to provide closure for him and his family. If he remains dissatisfied or there are elements of the inquest that do not cover some of the issues Mr C has brought to us, he can return to us.

20. The law says we can only look at complaints if they are brought to us within 12 months of the events complained about. Sometimes, depending on the circumstance we can decide to still consider a complaint outside of this time limit if we have good reasons to do so. Therefore, if Mr C brings his complaint back to us, he should do this as soon as possible and we will consider the reasons for the complaint being outside of our time limit.

21. We understand the events Mr C complains about have had a devasting impact for him and his family. We hope the coroner’s inquest provides Mr C with the answers he is looking for. We also hope Mr C is reassured as to his next steps should he wish to come back to us.

1. We have carefully considered Mr C’s complaint about Guy’s and St Thomas’ Hospitals NHS Foundation Trust (the Trust). We acknowledge this period of time was extremely distressing for him, his family and his son, Mr T.

2. We have decided to take no further action at this time on Mr C’s complaint because the Coroner’s Office has planned to carry out an inquest into Mr T’s death. We explain the reasons for our decision below.