James Paget University Hospitals NHS Foundation Trust

4. Mrs A complains about the communication from a consultant nephrologist, employed by the James Paget University Hospitals NHS Foundation Trust (the Trust). She specifically complains that after her husband, Mr A, was admitted to one of the Trust’s hospitals on 19 June 2023, the consultant did not communicate effectively and discuss the treatment options with her family during her husband’s final hours.

5. She says that this caused her family immense distress during an already difficult time, and her husband lost the opportunity to opt for a peaceful and palliated experience in his final hours.

6. Mrs A would like the Trust to acknowledge what went wrong and take steps to prevent this happening again.

7. Mr A was a gentleman in his 50s who, sadly, died in the intensive care unit (ICU) of a hospital run by the Trust on 22 June 2023. This was following an emergency admission to hospital on 19 June.

8. Mr A had a long-term condition that required at-home dialysis. He became overloaded with fluid in June, leading to an admission an Emergency Department (ED), run by the Trust, on 19 June. He received care in the ED between 19 and 21 June, and Mrs A was happy with the care provided.

9. On 22 June Mr A was transferred to the Trust’s ICU for continuous dialysis. Both his wife’s account and the Trust’s responses reflect he was very afraid at this time, and he began to panic when the staff tried to provide treatment in the ICU. This was very distressing for both Mr and Mrs A. The Trust’s staff sedated Mr A in order to proceed with treatment.

10. Mr A died shortly after this intervention and Mrs A has been very distressed at how afraid he was during his final moments. She says that although she always knew her husband’s life expectancy would be lower due to his long-term condition, his final moments should not have been so distressing and frightening for him.

11. Mrs A complained to the Trust about what happened and is satisfied with the responses regarding the ICU care. However, she remains unhappy about the response from the consultant nephrologist who was in charge of her husband’s care.

13. The Health Service Commissioners Act 1993 gives us the power to investigate complaints about NHS service providers, including NHS Trusts and third-party service providers. Whilst individuals can be named in complaints, our work must focus on the organisation. We cannot make findings about individuals’ professionalism or comment on issues that should be considered by the individual’s regulatory body, such as their conduct or fitness to practice concerns.

14. When a complaint comes to our service, we must consider whether we should investigate the matter(s) further. To ensure we do this consistently, we outline how we consider complaints in our Service Model Guidance. We follow this guidance for each case that comes to our service.

15. Our Service Model Guidance says that we must consider what action has already been taken to resolve the complaint and what we could likely achieve as an outcome before we investigate the matter.

16. Mrs A undoubtedly had an incredibly distressing experience in the final hours of her husband’s life. She raised a complaint with the Trust on 8 September 2023, outlining the following concerns:

• the consultant nephrologist caring for her husband communicated poorly with both of them and did not explain the treatment options available • the consultant nephrologist attempted to obtain consent from her husband when he did not have mental capacity due to his critical condition • the staff had to restrain her husband to sedate and treat him whilst in the ICU and the consultant nephrologist made an inappropriate comment to her and asked her to leave the room • her husband’s last conscious moments were of panic and fear, and he should have been given options for a peaceful, palliated, and dignified death.

17. The Trust held a local resolution meeting with Mrs A on 2 November, but the consultant nephrologist was unable to attend. He, therefore, wrote to Mrs A on 1 November to respond to her concerns. This letter outlined his account of what happened and apologised for any ‘misunderstanding’.

18. Mrs A attended the meeting on 2 November, and a written investigation statement was sent to her on 6 December. This letter outlined the following:

• Mrs A felt the issues with the ICU treatment had been fully resolved by the meeting • she had outstanding questions for the consultant nephrologist • that the doctor in the meeting agreed that Mr A’s last moments should have been handled differently • the doctor in the meeting agreed that the options should have been discussed with the family, instead interpreting her statement that she wanted ‘staff to do their best’ to help Mr A as wanting active treatment instead of palliative care • the consultant nephrologist, who was not in attendance, was not under the impression that the family wanted palliative care • the consultant nephrologist felt he had communicated effectively • the Trust apologised that Mrs A was not given sufficient time to consider the options available.

19. Following this meeting and correspondence, Mrs A is satisfied that most of the issues have been resolved. However, she is unhappy with the response from the consultant nephrologist. She maintains he did not communicate effectively with her and is unhappy that he has not apologised for his communication during this very difficult time.

20. We have considered what we could potentially achieve for Mrs A if we were to investigate her complaint.

21. We cannot recommend that the nephrologist apologise to Mrs A. This is because our powers limit us to investigating the Trust, not the individuals employed by the Trust. We could only recommend that the Trust apologise, which it has already done.

22. We recognise that Mrs A feels very strongly about the conduct of this individual. Complaints of this nature, when they relate to the actions of a registered professional, should be considered by the professional’s regulatory authority.

23. Because we cannot achieve the outcome Mrs A is looking for, we are not taking further action on her complaint. This decision makes no comment on the merits of her complaint, or of the outcome she is looking for.

1. We have carefully considered Mrs A’s complaint about James Paget University Hospitals NHS Foundation Trust (the Trust). We were very sorry to learn about how distressing these events were for her family.

2. Mrs A’s experience in the final hours of her husband’s life was incredibly distressing and she continues to be dissatisfied with the consultant nephrologist’s response to her complaint about his communication.

3. We are not taking further action on this complaint because we cannot achieve what Mrs A is looking for. Specifically, we cannot recommend that individuals apologise for their individual actions because our powers limit us to investigating NHS Trusts, not the individuals employed by them. We can also only make recommendations that NHS Trust take action to put things right.