University Hospitals Birmingham NHS Foundation Trust

6. Dr Y complains about the care provided by the Trust to Mr Z in February to May 2023. Specifically, she complains:

• at the start of Mr Z’s admission, the Trust overdosed him with warfarin despite the correct medication dose being provided • the Trust moved Mr Z to a new ward in the middle of the night • the Trust did not assist Mr Z to get to the toilet and left food out of reach at meal times • Staff checked his continence pad when he was sleeping without asking Mr Z first • the Trust did not investigate what caused Mr Z’s fall or his recurrent postural drop • at the start of Mr Z’s admission, the Trust delayed repeating the International Normalised Ratio test (INR) to check how long it was taking his blood to clot despite Dr Y requesting it in AMU (Acute Medical Unit) every day • the Trust prescribed Tramadol, despite Dr Y explaining her father did not tolerate it and that it affected his INR • The Trust did not ensure Mr Z had his inhaler and when he had chest pain, nobody came to assist him • The Trust did not take action when Mr Z was racially abused by other patients.

• the Trust delayed providing Mr Z with a cardiology review until 14 March, despite Dr Y requesting a regular review • a nurse at the Trust shouted at Mr Z and told him to shut up at night • a nurse ignored an anaesthetist’s notes about Mr Z’s fluid input/output after surgery, and did not take action about fluids when she told Mr Z’s family she would • on 4 March, the Trust failed to determine Mr Z’s hip X-ray showed the neck of his femur was affected, and a hip CT scan should have been requested • on 4 March, the Trust’s on-call registrar refused to review Mr Z despite the fluctuating Glasgow Coma Scale (GCS) (a scale used to describe the extent of impaired consciousness after a trauma), reduced urine output and significant hypotension • the Trust failed to investigate her father’s left side and leg for several days after his hospital fall, despite Dr Y’s requests • the Trust suggested a move to a rehabilitation bed before Mr Y was medically optimised • the Trust did not complete a diet record when it said it would • towards the end of Mr Z’s admission, the Trust treated him palliatively. Due to this Dr Y took her father to another hospital and admitted him under his previous cardiologist. Dr Y said the cardiologist managed to medically optimise him and stabilise his blood pressure.

7. She said the failure of the Trust to investigate why Mr Z fell or suffered recurrent postural drop meant the Trust did not provide the treatment he required.

8. The Trust’s lack of assistance for Mr Z to get to the toilet caused injury to Dr Y’s back when she assisted him herself. She also says it caused trauma to Mr Z’s urethra when he stepped on his catheter. He also became distressed when a staff member tried to check his continence pad when he was sleeping.

9. Mr Z could not eat his meals because food was out of reach. He also became distressed when he had a long wait to be assisted to the toilet as he feared soiling himself. His family lost faith in the Trust when it said it would keep a diet plan and it did not weigh him for almost a week and only family members updated the diet sheet.

10. Mr Z experienced distress and chest pain when he could not have his inhaler. He called Dr Y to ask for her help but when she phoned the ward she received no response, which added to their worry and distress.

11. The Trust’s lack of action against patients racially abusing Mr Z caused distress to him and his family.

12. The failure of the Trust to complete a cardiology review meant the Trust did not manage Mr Z’s heart disease, angina symptoms and orthostatic hypotension. This meant his preparation for surgery was impacted. Orthostatic hypotension is also known as postural hypotension and is a form of low blood pressure that happens when standing after lying or sitting down.

13. The Trust provided medication and overdoses provided to Mr Z which caused fluctuating cognition, his blood pressure, and his INR to be affected. This contributed to his fall and led to him suffering a left hip fracture and significant left shoulder displacement. Mismanagement of Mr Z’s blood pressure led to increased risk of falls.

14. The failure of the Trust to identify a hip fracture in an X-ray and its failure to investigate Mr Z’s left side pain for several days led to a delay in the fracture and displacement being identified. This left Mr Z in severe pain. It also caused distress and worry when the Trust wanted to move Mr Z to a rehabilitation bed before Dr Y believed he was medically ready for this.

15. These failings led to a slower recovery time in the NHS and led to Dr Y’s decision to transfer to private care. Dr Y said as they needed to take her father to Manchester to be privately treated, he lost the rehabilitation bed and funding. Dr Y said her father spent £30,000 on private medical, rehabilitation and care costs.

16. Dr Y told us these events have been very distressing for her and her father. She said her long COVID-19 symptoms have been adversely affected by the stress of these events. Dr Y also suffers flashbacks and significant anxiety.

17. She told us her everyday functioning and her work have been significantly affected by these events. She has said that she has PTSD symptoms when receiving Birmingham area calls. This is because the Trust uses the same area code.

18. Dr Y said the Trust has not addressed the consequences of its failings on Mr Z and his family. She has asked the Trust to complete an action plan to address the failings. Dr Y has requested financial remedy to reimburse Mr Z’s private care fees, her loss of earnings, and private therapy costs.

19. Mr Z had a thirty-year history of cardiac needs and needed warfarin (a treatment to prevent blood clots). On 27 February 2023, Mr Z fell at home. He banged his head and injured his left shoulder.

20. At hospital, the Trust undertook a CT scan (computed tomography), which is a type of scan that uses X-ray and a computer to create detailed images. This confirmed Mr Z had a shoulder fracture.

21. Mr Z remained in hospital. While on the ward, Mr Z fell. He fractured his hip, and his left shoulder was ‘significantly displaced’. The Trust diagnosed this four days later. The Trust later told Mr Z he would need surgery on his shoulder.

22. Mr Z also had recurrent episodes of chest pain whilst in hospital, but Dr Y says nobody tended to him to assess this and provide his GTN spray (glyceryl trinitrate, used to treat angina).

23. The Trust decided Mr Z was to be given palliative care (a form of care to alleviate pain and other symptoms as you approach the end of life). Dr Y decided to transfer him to another hospital on a private basis to receive care from doctors who knew Mr Z’s medical history.

26. 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 Dr Y 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 explore.

27. When considering Dr Y’s complaint, it appears there may be a legal remedy available to her through the courts. This is because she believes the Trust failed to provide Mr Z with sufficient care and treatment to manage his conditions. She says the hip fracture led to significant changes in Mr Z’s mobility and contributed to a later fall and his death in October 2023. She believes the Trust’s failure to investigate and treat Mr Z’s conditions appropriately resulted in prolonged pain and distress to Mr Z

28. Given Dr Y’s complaint, it appears she may have a claim for clinical negligence in relation to the clinical issues she has raised. This is because Dr Y believes the failings in the care and treatment provided by the Trust to Mr Z resulted in an injury to him, and that this later contributed to his death. We have gone on to consider whether it looks like legal action could achieve the outcomes Dr Y is seeking.

29. As an outcome to her complaint, Dr Y has told us she is seeking a financial remedy and service improvements. When we explored this further, Dr Y told us she is seeking around £30,000 in private care fees for Mr Z. She is also seeking a financial remedy to cover private therapy fees for herself, and loss of her own earnings.

30. While both we and the courts could potentially recommend a financial remedy, the courts may achieve an amount closer to what she is seeking. We recognise the court may not be able to consider the financial impact to herself or any family members.

31. Dr Y also wants service improvements including staff training programmes to counteract ageism in the NHS and staffing level improvements. While the courts cannot order changes in processes or procedures, these things may occur incidentally, as a by-product of a legal claim.

32. Whilst we can ask the Trust to consider service improvements, it would be for the Trust to decide what improvements it thinks it should make. While we can make recommendations to the Trust, we cannot recommend service improvements across the whole of the NHS.

33. In summary, it appears legal action may be able to achieve a financial remedy closer to what Dr Y is seeking. Neither we, nor the courts, could recommend the widespread service improvements Dr Y is seeking, although we could make recommendations to the Trust, which the courts cannot. We have suggested Dr Y may want to contact NHS England or her local member of parliament (MP) to explore the widespread changes to the NHS she is seeking further.

34. It appears both we and the courts appear to be able achieve a mix of the outcomes Dr Y is seeking. We have also considered whether there would be any barriers to her pursuing legal action.

35. We understand Dr Y has been speaking to a legal adviser about her complaint. We understand she has been told that it may take some time to reach a decision about whether legal action can be pursued, and that it may take several years to pursue this.

36. We also understand that legal action may not be able to consider all of the issues Dr Y has raised. For example, Dr Y’s complaint about the Trust moving Mr Z to a new ward late at night, about staff attitude, or the Trust’s failure to take action when other patients were abusive. It also may not be able to achieve the outcomes she is seeking in recognition of the impact these events had on her.

37. We considered whether we could consider any issues not covered by the legal action, or the complaint in relation to Dr Y’s own impact as a separate complaint whilst she explores legal action.

38. After careful consideration, we do not think we could consider the complaint solely in relation these issues while any legal action is ongoing. We think that considering these issues now could potentially impact the court’s consideration of Dr Y’s complaint, as the same issues would need to be considered concurrently.

39. It may also result in us having to consider the same complaint twice, but for impact to Dr Y and Mr Z separately. We do not think this would be proportionate.

40. We recognise Dr Y is concerned about the length of time her legal adviser has told her it may take to consider her complaint. It told her it will take around six months to decide whether to proceed with legal action, and a further two to three years if legal action is pursued.

41. It appears that there would be no barriers to Dr Y exploring legal action at this time. In summary, it appears Dr Y may be able to pursue legal action in relation to the majority of issues she has brought to us. Legal action may be able to achieve some of the outcomes Dr Y is seeking, and there are no barriers in Dr Y exploring this.

42. We recognise the courts may not be able to consider all of the concerns Dr Y has, or order all of the outcomes she is seeking. She can return to us if following legal action if she has outstanding outcomes which the court was unable to order, or if the court was unable to consider parts of her complaint. Dr Y can also return to us if she finds she is unable to pursue legal action.

43. We have made Dr Y aware of our time limits, as we are unable to investigate complaints brought to us 12 months after someone has become aware of the problem. We can put this time limit to one side if we think there is a good reason to do so. We advised her to return to us as soon as possible after legal action has been exhausted. This is because we would need to consider our time limits.

44. We recognise it has been difficult for Dr Y to share these upsetting events, so we are grateful to her for taking the time to do so. We wish her the best with the next steps of her complaint.

1. We have carefully considered Dr Y’s complaint about University Hospitals Birmingham NHS Foundation Trust’s (the Trust’s) treatment of her father, Mr Z. We were saddened to hear Mr Z died before the complaint could be concluded.

2. We believe there may be a legal remedy available to Dr Y in relation to Trust’s care and treatment of Mr Z. Having discussed this with Dr Y, we have seen nothing to suggest it would not be reasonable for her to pursue this.

3. We understand Dr Y has already begun liaising with a legal adviser about the complaint. We understand Dr Y’s legal adviser told her that the court system would only consider impact to Mr Z, and not third parties such as family members. It would also not recommend service improvements, which we know Dr Y is keen to be considered. We are also not able to achieve all of the outcomes Dr Y is seeking, which we have explained below.

4. While a legal remedy may not exist for all Dr Y’s concerns, or be able to achieve all of the outcomes sought, the events and any potential impact appear linked to the events the courts may consider. Because of this, considering these issues now may potentially impact the court’s consideration. We therefore should wait for the courts to complete its consideration before we consider any remaining parts of the complaint, or any outcomes the courts were not able to recommend.

5. We appreciate these events are difficult for Dr Y and her family to talk about, so we thank her for sharing her concerns with us.