Northern Care Alliance NHS Foundation Trust

4. Ms J complains the Trust did not identify her sepsis in a timely manner and planned to send her home with painkillers after she attended the Emergency Department on 3 April 2024. She is also unhappy she was not told what was wrong with her when the Trust contacted another hospital trust to transfer her there.

5. Ms J says she has lost faith in the Trust and her experience of needing critical care has had a lasting impact on her daily life. She is more concerned about her health and wellbeing so has reduced her working hours, socialises less than she used to, and experienced panic attacks and nightmares.

6. Ms J would like the Trust to acknowledge its failings, apologise and improve its service. She would also like us to consider making a financial recommendation.

7. Ms J attended the Emergency Department at one of the Trust’s hospitals in April 2024. She had been experiencing pain in her right flank (between the rib and hip) for several hours that afternoon. We recognise Ms J disputes some of the Trust’s records, including those about her pain score and pain relief.

8. The National Early Warning Score (NEWS) is a tool used to detect and respond to clinical deterioration in adult patients. Six physiological parameters are included in the scoring system. The score allocated reflects if the observations are in the normal range (scoring 0) or outside of this (scoring 1-3). The Trust has a policy which sets out when it should record NEWS and the escalation process.

9. The Trust suspected Ms J had a urinary tract infection (UTI) and planned to send her home with antibiotics. After tests, it arranged to transfer her to a different hospital trust.

Diagnosis of sepsis

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong and if so, what impact this had.

14. The Trust’s policy says ‘Patient observations in A&E should take place every hour for the first four hours, after which NEWS2 frequencies should be applied. However, if on initial observations patient has a trigger score, observations must be recorded [as set out in the policy].’ Observations should then be recorded four-hourly if NEWS is under 5.

15. We can see the Trust did not act in line with the policy, it did not carry out hourly observations. The Trust’s response acknowledged this. It registered Ms J at 1759 and triaged her at 1859. The first entry on the NEWS chart is a score of 1 at 0037 that night. The timeframe is an indication of a failing.

16. In line with the Trust’s policy, the next observations should have been at around 0430. This did not happen. We can the Trust reviewed Ms J after 0340 when there was no indication she was critically unwell. We can see the observations took place at 0630, approximately two hours after they were due. The Trust says they took place at 0530 and Ms J’s NEWS was 1.

17. We are unable to say exactly when Ms J’s sepsis developed but based on the available information, it is very unlikely the delayed in carrying out observations made a difference. The Trust gave Ms J fluids and antibiotics quickly when abnormal observations were seen. We hope this reassures Ms J about the care she received.

18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right.

19. We raised what we had seen with the Trust. It told us it is happy to send a letter of apology to Ms J and is happy to meet with her to discuss and explore her experience with relevant staff. We consider this an appropriate resolution in the circumstances, in line with what our NHS Complaint Standards about taking action to put things right.

Plan to discharge

20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong here.

21. Doman 1 of ‘Good medical practice’ cover providing good clinical care and using resources effectively. It says doctors must propose any investigation or treatment based on their assessment and clinical judgement of the patient. They must take account their responsibilities to patients and the wider population.

22. Our adviser explained based on the older NEWS score, it was reasonable for the Trust to consider sending Ms J home with painkillers and antibiotics as she did not appear to be acutely unwell.

23. The Trust gave her pain relief, saw if she improved and using clinical judgement based on its assessment at the time, planned to send her home on that basis. When she did deteriorate, the Trust changed the plan.

24. The Trust acted in line with the GMC guidance so we cannot say there are signs something went wrong here.

Communication

25. Ms J does not recall the Trust telling her that she needed to be transferred elsewhere because of how serious her clinical condition was. We have not found any indications that something has gone wrong in relation to this.

26. Doman 2 of ‘Good medical practice’ says doctors must communicate sensitively and considerately. The must give patients the information they want or need in a way they can understand. This includes information about their condition and treatment options.

27. The information documented suggests the Trust acted in line with the GMC guidance. The Trust’s records indicate it informed Ms J of the transfer but that does not guarantee she took in what she was told. It is possible the situation Ms J was in may have made it difficult for her to absorb information discussed with her at the time, or affected her recollection of what she was told. We cannot say this is an indication of a failing.

28. We were pleased to hear Ms J was ultimately able to receive the treatment she needed. She has described the lasting impact of the experience on her family, which we appreciate our investigation will not change.

29. Overall, we have seen no reason to investigate the concerns Ms J brought to us further. We would like to thank her for bringing the complaint to us and we hope we have reassured her about the care she received.

1. We have carefully considered Ms J’s complaint about the Trust. We understand she remains concerned about the care she received and the Trust’s communication when she was unwell in hospital.

2. We have seen no indication anything went seriously wrong in relation to parts of Ms J’s complaint, around communication and a plan to discharge her. In relation to the Trust’s diagnosis of sepsis, we have decided there may have been a short period for it identify it sooner. We cannot link what we have seen to the impact Ms J felt this had.

3. We have decided the Trust has already done enough to put this right following our intervention. We hope this decision statement will help Ms J understand how we reached these conclusions.