Croydon Health Services NHS Trust

5. Miss B complains about the following aspects of care and treatment her late mother, Mrs B, received from Croydon Health Services NHS Trust (the Trust) between 22 April and 23 April 2023. Miss B specifically says the Trust:

• failed to realise how serious her mother’s condition was • did not provide the appropriate monitoring and treatment for her mother’s condition • failed to keep her and her family informed of her mother’s condition and they were only informed of her death after she had died • got her mother’s diagnosis wrong as she was originally told her mother had pneumonia but on her death certificate it says sepsis.

6. Miss B feels her mother was not given the best chance of survival due to the treatment and monitoring she received.

7. She adds that her mother died alone and her and her family were unable to say goodbye to her. She says this has had a significant impact on her and her family who have to live with knowing their mother was alone when she died. She says this has caused significant distress and upset.

8. Miss B adds the Trust let both her and her mother down.

9. Miss B is looking for service improvements and a financial remedy.

10. On 22 April 2023, Mrs B was in pain and finding it hard to breath. Her family called 999 and an ambulance took her to hospital. She arrived at 7.07pm.

11. Upon arrival the Trust carried out an ECG (electrocardiogram) and prescribed oral diazepam (a relaxant), intravenous paracetamol, saline and intravenous antibiotics.

12. The Trust also completed a chest X-ray which showed evidence of a lung infection and the Trust diagnosed Mrs B with pneumonia.

13. At 6.30am on 23 April 2023, Mrs B was deteriorating.

14. At 7.58am, an emergency bell was pulled by a nurse caring for Mrs B when they noticed she was not breathing.

15. Mrs B sadly died at 8.28am on 23 April 2023.

18. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Miss B to understand her circumstances and the outcomes she wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

19. Miss B complains about the Trust’s diagnosis, its lack of recognition of the seriousness of her mother’s condition and then its failure to monitor and treat her adequately. Miss B believes her mother could have survived if the Trust had diagnosed, monitored and treated her differently. Instead, her mother sadly died.

20. We therefore consider Miss B is describing the Trust potentially failing in its duty of care to provide the appropriate care, treatment and diagnosis for Mrs B.

21. This means she may have a clinical negligence claim for the above three parts of her complaint.

22. As a resolution to this complaint Miss B is looking for service improvements and a financial remedy. In terms of how much financial remedy Miss B is seeking she has said she is looking at level 6 within our Severity of Injustice (SOI) scale. This is £12500 or more.

23. Our SOI scale is a tool we use to ensure any decisions or recommendations we make are consistent and transparent to everyone. Our scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts we would usually recommend in those circumstances. It is available on our website.

24. This is therefore a significant financial remedy.

25. Level six on our SOI says, ‘Level six cases are the most serious we see, involving profound, devastating or irreversible impacts on the person affected. This includes circumstances where the individual may be affected permanently, or where recovery is likely to take several years, and cases involving avoidable death.’

26. While we can make recommendations in our detailed investigation for financial remedies, the amounts we recommend are typically modest when compared with what can be achieved through legal action. Miss B seeks a substantial amount of money and whilst it is something we could potentially recommend, it is more likely for Miss B to receive amounts like this by going down the legal route as we do not achieve financial outcomes like the courts do.

27. Miss B has said the reason she has not sought legal advice sooner is because she wants to get the findings first so that her and her family can move on. She said she has not yet explored legal action.

28. Miss B has provided no information to suggest it is not reasonable for her to pursue a legal claim due to her circumstances or finances and she has considered the legal route is an option to her. We understand Miss B has raised concerns about whether the legal route would cost her however, this is not necessarily the case. There are multiple funding options available for legal action including no win no fee solicitors for clinical negligence claims. We have signposted Miss B to free, independent organisations which may be able to help her find a solicitor and provide information on funding options.

29. We understand Miss B is also looking for service improvements, this can be something which can be resolved in the courts. Often improvements to service can be achieved as a by-product to a successful legal action.

30. With regards to Miss B’s concerns the Trust did not keep her and her family up to date with her mother’s condition and the Trust only informed them of her mother’s death after she had died, we do not consider there is a necessarily a legal claim here. This is because the impact on Miss B was an emotional impact in that she was not able to say goodbye to her mother and now lives with knowing her mother died alone. In general, a solicitor may not take on a claim where the impact is purely distress and upset.

31. This part of the complaint is closely linked and tied in with Mrs B’s care and treatment from the Trust. Miss B complains the Trust did not appropriately monitor her mother’s condition. A court may find this extends to not acting on her deterioration and not informing family sooner. We consider Miss B should also seek legal advice regarding this element of her complaint. For us to consider whether there has been failings with the communication between the Trust and Miss B we would need to look into what care and treatment her mother received and how this impacted the communication between the Trust and Miss B. We are unable to do this when there is a legal route still available to Miss B.

32. If Miss B is unsuccessful in her claim, does not achieve all of her sought outcomes, or there are parts of her complaint on which she is unable to take legal action, she is able to come back to us. Miss B will need to be aware of our time limit if doing so.

33. We recognise the tragedy of these events and understand how difficult it is for Miss B to have unanswered questions about her mother’s final days. We thank her for sharing her personal experience with us.

1. We have carefully considered Miss B’s complaint about Croydon Health Services NHS Trust (the Trust). We consider Miss B could take legal action on the matters she has to us.

2. Miss B has raised concerns the Trust failed to realise how serious her mother’s condition was, it did not provide her mother with the appropriate monitoring and treatment and the Trust got her mother’s diagnosis of pneumonia wrong. Miss B feels due to these claimed failings her mother did not have the best chance of survival and the Trust let her mother down. Miss B is looking for service improvements and a financial remedy to resolve these matters. We therefore consider it is reasonable for her to pursue a clinical negligence legal claim at this time.

3. With regards to Miss B’s claim the Trust did not keep her or her family informed of her mother’s condition, we do not think she has a clinical negligence claim as usually such claims do not cover solely emotional impacts. However, as this element of the complaint is so closely linked to Mrs B’s care and treatment, we consider Miss B should also take legal advice regarding this.

4. We are saddened to hear of this tragic event and understand how well-loved Mrs B was. We would like to offer our sincere condolences to Miss B and her family.