Mersey and West Lancashire Teaching Hospitals NHS Trust

3. Mrs A complains about aspect of care and treatment her father, Mr B, received from the respiratory ward at the Trust between 27 and 28 December 2021. Specifically, she complains:

• Staff did not provide appropriate care and treatment when her father was suffering from secretion. Mrs A is concerned staff did not provide her father with medication to alleviate his symptoms and only provided him with suction. She is concerned her father was left alone whilst he was suffering from secretion which led to aspiration. She explains the nurse told her this had happened and that she was unhappy with the initial treatment plan the emergency team had suggested.

• The medical emergency team and the ward manager did not escalate concerns about her father’s deteriorating clinical condition to a registrar or a senior doctor promptly. Mrs A explains her father’s NEWS score kept increasing and she feels this should have been escalated promptly.

• The medical emergency team and ward manager failed to recognise that her father was approaching the end of his life in the morning of 28 December. She is also concerned that the ward manager did not record in her father’s medical records that she had attended to her father.

• Mrs A is also concerned staff did not update her on her father’s clinical condition at all during his admission, including when her father’s condition deteriorated in the morning of 28 December.

• The ward manager did not allow her to visit her father whilst he was still alive, when she was only waiting in the family room to see him. Mrs A explains when her father died the ward manager physically blocked her and her children from visiting him in an aggressive manner, was unprofessional and unsympathetic.

• The doctor told her that her father had just died, however when she went up to see him nursing staff had already washed, changed and packed all of his belongings. Mrs A is concerned her father had aspirated and died alone. She is also concerned staff did not note her father’s time of death.

4. Mrs A explains the circumstances surrounding her father’s death have caused her and her sister significant grief and upset. She explains this impact will be everlasting and she will always remember the terrible circumstances surrounding the last moments of his life. She feels her father would not have died in such a terrible way if staff had acted appropriately. She feels the distress he suffered in his last hours could have been avoided.

5. Mrs A would like service improvements. She would also like action taken against the ward manager.

6. Mr B attended the Trust on 25 December 2021 as he was feeling unwell. Doctors in the emergency department diagnosed him with pneumonia (inflammation of the lungs usually caused by an infection in the lower part of his right lung) and emphysema (type of lung disease where the air sacs are damaged).

7. To help manage his symptoms, doctors prescribed Mr B with antibiotics, nebulisers, steroids and oxygen. On 27 December, doctors admitted Mr B into the respiratory ward for further treatment.

8. Sadly, in the morning of 28 December, Mr B began to vomit brown liquid and became seriously unwell. Doctors carried out a chest X-ray which showed increased fluid in his right lung. To help manage this, staff gave him a different antibiotic.

9. Soon after, Mr B began to suffer from airway secretion which required suctioning. This is when a small tube is used to clear the patients’ airways. Although staff were able to do this, Mr B’s condition continued to deteriorate he sadly died. Mrs A had attended the hospital to see him, however remained in the family room until after his sad passing.

11. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

12. Mrs A became aware of her concerns about the care and treatment her father received in December 2021 and May 2022 when she obtained a copy of his medical records. She approached us with her complaint on 14 April 2024, roughly one year and four months, and 11 months, outside of our time limit.

13. When considering if we can set the time limit to one side, we look at any delays that were in Mrs A’s control, to see if she was actively seeking a resolution to her concerns. We have discussed this with Mrs A to understand why she could not act on her concerns sooner during these delays.

14. After her father’s passing, Mrs A requested a copy of her father’s medical records and attended two bereavement meetings with the Trust. As these did not address her concerns, she then raised a formal complaint on 2 December 2022. Mrs A raised her complaint with the Trust within the one-year time period set out in the NHS Complaints Regulations 2009.

15. The Trust provided its first response on 27 April 2023. Mrs A explains this response did not fully address her concerns, so she had another meeting with the complaints manager on 13 June. The complaints manager escalated her complaint onto stage two of the Trust’s complaints process. Mrs A sent a copy of her additional concerns to the Trust on 12 July.

16. Although there are some delays in Mrs A discussing her additional concerns with the complaints manager, and sending these into the Trust on 12 July, these delays are not significant. We can see she was actively pursing a resolution to her concerns during this time.

17. The Trust provided its final response on 13 October. This response signposted Mrs A to us. Mrs A then contacted us in January 2024. We asked her to complete a complaint form and we sent her a copy of this that same day.

18. In early February, Mrs A contacted us again explaining there was an error with the form. We sent her another copy that same day. Mrs A approached us with her written complaint on 14 April.

19. The delay between when Mrs A received the Trust’s final response on 13 October 2023 and when she sent us her written complaint on 14 April 2024 is significant. We have carefully considered the full reasons why she could not approach us sooner during this time.

20. Mrs A explains that that two members of her extended family were very unwell during this time and required care and treatment from hospital. She explains this was very difficult for her and caused her significant worry.

21. After this, she filled in our complaint form which was more detailed than she had expected. She explains she went through this several times with her sister, ensuring that it contained as much information as possible.

22. We recognise the events Mrs A explains would have been very difficult for. We acknowledge they could lead to a short delay in approaching us, however, six months is significant. At this stage, the Trust had already provided Mrs A with the information she needed to contact us as soon as possible. We would have expected her to approach sooner than 14 April 2024.

23. Overall, we can see there were some reasons that would have caused a slight delay in Mrs A acting on her concerns during the local resolution process, and after it ended. However, the delay after local resolution had ended was significant and appears largely avoidable. For this reason, we are unable to set the time limit to one side.

24. Sadly, this means we are unable to consider Mrs A’s concerns further. We recognise this decision will be disappointing for Mrs A. We hope we have clearly explained the reasons for this.

1. Mrs A’s father, Mr B, sadly died on 28 December 2021. We are very sorry for her loss. We know this was a very difficult time for her. We would like to thank her for taking the time to provide us with information on her complaint about his care.

2. Having carefully considered Mrs A’s complaint, we have decided we cannot consider it further because of the time that has passed since the events she complains about. We recognise our decision will be disappointing for Mrs A. We hope we have clearly explained the reasons for our decision in this statement.