Cambridge University Hospitals NHS Foundation Trust

3. Miss E complains about an incident on 29 November 2022 when staff handled her sister, Miss F, inappropriately when she was asleep after being given medication to help her sleep.

4. Miss E says the inappropriate handling left her sister with marks on her skin and frightened her to the point she chose to self-discharge whilst still unwell. Miss F was so frightened to return to hospital that she did not tell her family when she felt unwell after discharge. Miss F died from sepsis four weeks later. Miss E considers her sister might not have died if the incident had not occurred as she would not have self-discharged at that time.

5. Miss E is looking for an acknowledgement of failings and a truthful explanation of what happened. She would like assurances this will never happen to another patient. She would also like a financial remedy.

6. Miss F had a complex medical history including multivisceral transplant (transplant of two or more abdominal organs).

7. In November 2022 Miss F was in hospital. Doctors wanted to do an emergency scan as they were concerned she was bleeding internally. For the scan she needed to be injected with contrast dye, which enhances the scan images.

8. Contrast dye is usually delivered via a cannula (a tube inserted into a vein). Miss F was not keen on having a cannula as this usually took multiple attempts. She agreed doctors could try if they found a vein they were confident they could use. To increase the chance of success, ward staff asked an anaesthetic doctor to come and try to insert the cannula. By the time the anaesthetic doctor arrived, Miss F was asleep.

9. Ward staff had difficulty waking Miss F. When she woke, she was distressed and asked staff to leave her alone. She then left the ward for a while. When she returned, she told the nurse in charge the staff had pulled at her clothing and ‘neck line’ (a thin tube inserted through her neck into a vein). She was very upset about the incident and spoke to another patient about what had happened.

10. The following day Miss F decided to self-discharge against medical advice. Around four weeks later, Miss F sadly died from sepsis.

12. After careful consideration, we have decided it would not be practical to carry out a detailed investigation into this complaint. We also consider a detailed investigation would not reach a satisfactory conclusion.

13. The witness statement and Trust response both confirm staff were finding it difficult to rouse Miss F from sleep. There is a difference between the witness statement and Trust response about how they tried to wake her. The witness statement describes doctors shaking her vigorously. The Trust response describes doctors gently squeezing her shoulder. We have no way of determining which account is the most accurate.

14. We recognise Miss F told the witness she was cut on her back during the incident by one of the staff’s nails. However, the witness statement does not describe the witness seeing any actions which could have caused this cut.

15. The Trust’s response explains after the incident Miss F chose to leave the ward and visit her boyfriend who was staying at accommodation on the hospital site. When she returned, she told the nurse staff pulled at her clothing and central line. The Trust say Miss F did not report the cut on her back and there is no documentation about this.

16. We see no way we could draw any kind of robust conclusion about how Miss F sustained the injury. There is no evidence to explain how this occurred, and whether this is a result of an accident, or a failing in how staff handled her. There is simply not enough evidence for us to investigate this in any meaningful way that would lead to a satisfactory conclusion.

17. We also consider we would not be able to achieve the outcome Miss E is looking for. Miss E is looking for an acknowledgement of failings and a truthful explanation. Due to a lack of evidence it is highly unlikely we would ever be able to achieve this.

18. We also do not think we would be able to achieve the level of financial remedy Miss E is looking for. She told us she was looking for a financial remedy in line with level six of our severity of injustice scale. This is because she firmly believes her sister would not have died four weeks later if the incident had not occurred.

19. We understand why Miss E feels this way and is looking for a significant financial remedy. It is highly unlikely we would ever be able to link Miss F’s death from sepsis to the incident four weeks earlier. We recognise Miss E’s account that Miss F felt she had no choice but to self-discharge against medical advice. We also acknowledge Miss E says she was too frightened to tell her family she felt unwell after discharge, because she did not want to go back to hospital.

20. As Miss F did not seek medical attention there is no evidence about her clinical condition in the days and weeks after the incident. We note that as a transplant patient Miss F was at a high risk of infection and death from sepsis, whether she was in hospital or not. We will never be able to say whether Miss F’s death from sepsis could have been avoided if the incident had not occurred and she had stayed in hospital.

21. As we will never be able to say that Miss F’s death was avoidable, we cannot achieve the significant financial remedy Miss E is looking for.

22. In summary, after careful consideration we have decided a detailed investigation into this complaint is not practical and would not lead to a satisfactory outcome for Miss E. We hope this statement clearly explains why we have decided not to consider this complaint further.

1. We have carefully considered Miss E’s complaint about Cambridge University Hospitals NHS Foundation Trust (the Trust). We recognise this complaint is important to Miss E and she remains very upset about what happened to her sister. We offer our condolences for Miss F’s sad death, and thank Miss E for taking the time to tell us about her complaint.

2. We have decided not to take any further action in relation to Miss E’s complaint. This is because there is not enough evidence to allow us to reach a robust decision about what happened, or the impact the events had. We also do not think we could achieve the outcomes Miss E is seeking. We recognise this decision is not what Miss E hoped for when she asked us to consider her complaint.