Tameside and Glossop Integrated Care NHS Foundation Trust

5. Mrs N complains Tameside and Glossop Integrated Care NHS Foundation Trust’s account of service improvements in relation to the following areas does not provide sufficient assurance that would prevent recurrence:

• Missed administering three doses of Mrs H’s antibiotics which it had prescribed to treat her infection on 24 and 25 December 2022.

• Failed to ensure consultant input into Mrs H’s care on her admission over Christmas and New Year period in 2022.

• Failed to consider transferring Mrs H to ICU in December 2022 • The critical care outreach team were not the appropriate team to consider whether Mrs H should transfer to ICU on 27 December 2022 • The critical care outreach team were not available to review Mrs H on 29 December 2022 and the Trust did not take appropriate action.

• Failed to discuss Mrs H’s case with a specialist liver team when she was first admitted to ICU.

6. Mrs N says she has lost faith in the NHS due to the errors made and lack of appropriate action the Trust has taken to prevent the failings happening again. She has told us of the turmoil and unbearable pain the Trust’s actions have caused.

7. To resolve her complaint, Mrs N is seeking an apology and service improvements to ensure the Trust have learnt from its mistakes and the same failings do not happen to others.

8. Mrs H’s death was referred to HM Coroner who started an investigation on 3 January 2023. This investigation concluded on 12 June 2023. The coroner issued a prevention of future deaths report after it found that Mrs H died from the complications of elective hip surgery, where antibiotics were not always administered in line with her prescription.

9. On 22 November 2022 Mrs H became severely unwell and was admitted to the intensive care unit (ICU) with sepsis, acute kidney injury and liver failure. The ICU treated Mrs H until 26 November when she returned to the ward.

10. Mrs H was receiving treatment for cellulitis (a serious bacterial skin infection) and an ulcer on her left foot that had developed. On 16 December 2022 the Trust discharged Mrs H.

11. On 22 December 2022 Mrs H returned to the Trust with concerns about her health, she had a raised NEWS 2 score (a raised NEWS2 score indicates that a patient is showing signs of clinical deterioration and may need urgent medical attention). Mrs H was treated with intravenous antibiotics. Her liver function was deranged (not working properly), and she had acute kidney injury.

12. The coroner found that on 24 December the Trust missed giving Mrs H a dose of antibiotics and on 25 December it missed two doses.

13. On 27 December 2022 the Trust prescribed Mrs H further antibiotics as she continued to be unwell. Mrs H was reviewed by the Critical Care Outreach Team who determined an ICU referral was not indicated.

14. On 29 December 2022, the Trust changed Mrs H’s antibiotics. It referred her back to the Outreach Team, but this was unsuccessful. The team had no available staff. The coroner found there was no doctor-to-doctor assessment, no consultant review and no liver specialist advice sought or provided by the Trust.

15. Mrs H continued to deteriorate rapidly and on 31 December she was accepted by the ICU. Sadly, Mrs H died the same day.

16. In early September 2023, the Trust issued its response to the coroner’s report and provided its account of service improvements. Mrs N contacted our office shortly after with concerns the Trust had not carried out sufficient action to ensure it had learnt from its mistakes.

19. Before we decide whether to investigate a complaint, we should consider attempting a resolution where it appears that, with minimal intervention, we could achieve a satisfactory resolution outcome for the complainant.

20. Mrs N told us she remained devastated that the Trust did not issue a statement acknowledging its mistakes. Ms N told us she wanted a formal apology from the Trust which recognised the impact of its failings.

21. Our Principles for Remedy outline our expectations for organisations. We expect an organisation to acknowledge mistakes and apologise for the impact these mistakes had.

22. In October 2024 we wrote to the Trust to ask it to consider Mrs N’s request for a formal apology for the failings identified by the coroner and recognition of the impact these failings caused.

23. The Trust responded to Mrs N’s request in the same month. Within its response it acknowledged the concerns raised by the coroner and apologised for the impact this had on Mrs N’s family. It said it recognised there were elements of Mrs H’s care which could have been better, and it was sorry for this.

24. We appreciate the impact of these events on Mrs N. We are pleased to see the Trust has apologised for its actions. We consider the Trust’s apology is in line with our Principles for Remedy and what we would expect to see from an organisation when it has made mistakes. As this was one of the outcomes Mrs N wanted for her complaint to us, we think this resolves this part of her complaint.

25. As we have explained above, we may choose not to investigate a complaint if we do not think we can do a practical investigation or reach a suitable conclusion. We also consider whether there is another organisation better suited to consider a complaint

26. During our discussions Mrs N told us she is not reassured by the Trust’s reply to the coroner and the action plan it has produced in response to the concerns raised during her mother’s inquest. Mrs N told us her view that the Trust’s action plan does not fully address its failings. She said that within its action plan, the Trust has referred to keeping systems in place which failed her mother.

27. The Care Quality Commission (CQC) is an independent regulator of healthcare in England. It aims to make sure health and social care services give people safe, effective, compassionate, high-quality care and it encourages these services to improve. It inspects services and uses information provided by members of the public about their experiences of care and those of their family in its monitoring of services. It can take regulatory action when safety standards are not met.

28. Based on the outcomes Mrs N is seeking we think her complaint is better suited for the CQC. This is because the CQC can do inspections on care providers and discuss concerns or put conditions on how a service operates. These actions can result in service improvements being recommended.

29. When we investigate a complaint and find failings we will usually write to an organisation and ask it to come up with its own action plan to ensure such failings are not repeated. We also ask it to share a copy of this with the CQC to take into account in its monitoring of services. While we consider whether action plans address the failings we identified, we do not have a role in monitoring the effectiveness of action plans and we do not direct organisations to take specific improvement actions.

30. We have explained this position to Mrs N and that we are not best placed to consider her concerns about the Trust’s action plan. For this reason, it seems more suitable the CQC consider Mrs N’s concerns at this time.

31. We understand the complaint is very important to Mrs N and commend her for all her hard work pursing this. We are very grateful to her for bringing these concerns to our attention.

1. Mrs N is concerned the Trust has not taken enough action following the care and treatment it provided to her mother, Mrs H, before her death on 31 December 2022. We extend our sincere condolences to Mrs H. We recognise these events continue to profoundly affect her.

2. After careful consideration, we have decided not to consider Mrs N’s complaint further. This is because we do not believe an investigation by our Office would provide a satisfactory outcome for her.

3. The Trust has sent Mrs N a formal apology following its investigation following her mother’s death. We have seen the letter, and it provides part of the outcome Mrs N wants. We consider this partially resolves Mrs N’s complaint.

4. Mrs N has told us she is not assured by the changes made by the Trust following its investigation into her mother’s death. We have decided Mrs N’s concerns would be better considered by the Care Quality Commission (CQC). As the professional regulator for health and social care in England, the CQC is better placed to consider the systems of a Trust and whether they are sufficient in the way Mrs N seeks.