York and Scarborough Teaching Hospitals NHS Foundation Trust

3. Miss B complains about aspects of the care and treatment provided to her mother, Mrs A, at the Trust during two hospital admissions, from 22 March to 12 April and 14 to 27 May 2023. Specifically, Miss B says:

March admission • a small, nearly healed pressure ulcer on Mrs A’s sacrum deteriorated significantly during her hospital stay, becoming category 4 and exposing bone • an MRI scan of the hip (to see if the bone was infected) was planned but not done • effective treatment was not provided for an infected pressure ulcer or possible osteomyelitis (infection of the bone)

May admission • a do not resuscitate form listed her mother as having ‘end stage dementia’ but she did not have this

Both admissions • the Trust failed to identify her mother had delirium due to infection • the Trust dismissed her mother as ‘end of life’ on admission

4. Miss B says if the infected pressure ulcers had been appropriately treated in March, her mother may not have developed osteomyelitis. She says her mother’s discharge from hospital in March was delayed due to the planned MRI scan, but as this was not done there was a missed opportunity to diagnose and treat osteomyelitis sooner. She says if this had happened, her mother may not have developed sepsis and died. She says her mother suffered needlessly and this was distressing for her and her family to watch.

5. Miss B seeks a financial remedy for the impact of her mother’s death due to clinical neglect on her and her family. She wants to see a law put in place to ensure older people with dementia or cognitive impairment are still seen as valued members of society. She wants holistic dance therapy introduced as a therapeutic option in the NHS for older people with dementia or cognitive impairment.

6. Mrs A was admitted to Scarborough Hospital on 22 March 2023 with a urinary tract infection. At the time she had a small pressure ulcer on her sacrum which was healing. During this admission the pressure ulcer became worse, and a referral was made to a tissue viability nurse (a nurse who specialises in skin wound management). An MRI scan of the hip was also planned, but was not done.

7. Mrs A was discharged home on 11 April 2023, before the tissue viability nurse had a chance to see her. Miss B says when her mother was discharged home, the pressure ulcer had become significantly worse than it was on admission. She says if the MRI scan had been done, this may have shown osteomyelitis.

8. Mrs A was readmitted to Scarborough Hospital on 14 May 2023, with a urinary tract infection, increased confusion and lethargy. The pressure ulcer had become worse, was infected and was graded as category 4 (loss of full thickness of tissue) with exposed bone. An MRI scan of the hip was done which showed osteomyelitis. Mrs A was also diagnosed with sepsis caused by the infected pressure ulcer.

9. Sadly, Mrs A died on 27 May 2023. Her death certificate lists the primary causes of death as sepsis, osteomyelitis of sacrum and infected pressure sores.

10. An inquest was held which concluded on 18 January 2024. A narrative verdict was recorded linking the infected pressure ulcers and osteomyelitis to the sepsis that caused Mrs A’s death.

13. The ‘Health Service Commissioners Act 1993’ says we cannot investigate a complaint where a 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 have discussed this with Miss B to understand her circumstances and the outcomes she wants. Miss B told us aspects of the Trust’s care and treatment to Mrs A led to a deterioration in pressure ulcers. This led to osteomyelitis, causing sepsis and Miss B says this led to Mrs A’s death.

15. Miss B thinks if the pressure ulcers had been treated better or if the osteomyelitis had been diagnosed and treated earlier, her mother may not have died. Miss B has described the significant emotional impact this had, and continues to have, on her and her family. Miss B would like a financial remedy in recognition of the impact of the Trust’s mistakes.

16. There is a legal course of action available. Miss B could make a legal claim for clinical negligence for the issues she has raised.

17. While we can make recommendations for financial remedy where we see something has gone wrong that has had an impact on the complainant, the amounts we recommend are usually more modest than those awarded by the legal system. This is because we use a different approach to considering financial remedy.

18. When considering recommending a financial remedy, we consider the impact of any failings we find on the complainant. The legal process may also consider the impact of any failings on the person who received treatment, and so the amounts awarded are often higher than those we would recommend.

19. We do not consider whether legal action would succeed. We look at whether there are legal options available and whether it would be reasonable for the person to explore them. Miss B says she has considered taking legal action but has not yet explored this option. Miss B has told us she is willing to explore legal action and we do not consider it unreasonable for her to do so.

20. At this point in time, we are satisfied there are potential legal routes available for Miss B to pursue her concerns, which may provide some of the outcomes she seeks. As there are time limits for making a legal claim, we do not want to remove this as an option when it could potentially offer what Miss B is looking for.

21. Miss B also says she wants to see a law put in place to ensure older people with dementia or cognitive impairments are treated as valued members of society. She also wants the NHS to provide holistic dance therapy for this group of people. We are not able to achieve these outcomes and have advised Miss B she can explore legal options for these or raise them with her Member of Parliament.

22. If Miss B explores legal action and decides it is not the right course of action to take, or takes legal action and still has unresolved issues or outcomes that are not considered or remedied by the courts, she can ask us to consider her complaint again. If she does decide to return to us, she should bring her complaint back to us promptly. This is because we would need to consider our own time limits for a person to complain to us, in line with the ‘Health Service Commissioners Act 1993’.

23. We are very sorry to hear about what happened to Mrs A and how this has affected, and continues to affect, Miss B and her family. We thank her for bringing her concerns to us. We hope this statement clearly explains why we will not be considering her concerns further at this time.

1. We have carefully considered Miss B’s complaint about York and Scarborough Teaching Hospitals NHS Foundation Trust (the Trust). Miss B complained about aspects of the care and treatment the Trust provided to her mother, Mrs A, which she says led to her premature death. We were very sorry to hear about the difficult time Mrs A had and the impact this had, and continues to have, on Miss B and her family.

2. We have decided not to take further action at this time because we consider it is reasonable for Miss B to explore taking legal action on the issues she brought to us.