Warrington and Halton Hospitals NHS Foundation Trust

4. Mrs R complains about the poor handover of care she says the Trust provided to her late husband, Mr R. Mrs R says the Trust failed to ensure it safely handed over care and management of Mr R’s gallbladder drain to the district nursing team from another local trust in March 2021.

5. Mrs R also complains when she raised concerns about her husband’s drain with the Trust in late March 2021 the Trust did not act on this as it should have, so the drain was not removed until 12 April 2021.

6. Mrs R says if the Trust had handed over care of the drain properly and removed Mr R’s drain sooner, he would not have developed infections, and his death would have been avoided. She told us the Trust’s actions caused her husband to suffer in pain unnecessarily.

7. Mrs R told us of the grief and suffering she is still experiencing because of the Trust’s actions. She has told us the Trust’s actions have had a lasting impact on her own health and wellbeing due to the loss of her husband.

8. Mrs R would like service improvements to avoid this happening to others and an apology.

9. Mr R was admitted to the Trust on 14 February 2021 and diagnosed with inflammation of his gallbladder, which was caused by his gallbladder not functioning properly or emptying as it should.

10. The Trust found Mr R was not suitable for surgery to remove his gallbladder, so it inserted a temporary cholecystostomy drain on 19 February 2021 to remove bile. The Trust discharged Mr R on 11 March 2021 to the care of the district nursing team provided by a different hospital trust, about whom Mrs R has not raised any complaint with us. Mr R was residing in a care home at this time.

11. At the end of March, Mr R raised concerns with his GP that his drain did not appear to be working. The GP noted the district nursing team advised Mr R to contact the Trust, but the Trust signposted Mr R to his GP.

12. On 9 April Mr R’s care home contacted the Trust to ask it to remove his drain after he had ongoing pain to the area.

13. The Trust explained it is the district nursing team who are responsible for removing drains in the community. The care home wrote to the district nursing team via a referral and asked it to remove Mr R’s drain.

14. The district nursing team responded the same day and said it did not remove drains. The care home attempted to contact the Trust again via telephone but did not receive a response. It sent a request to a pharmacy for an urgent medication order and asked the on-call doctor to attend to Mr R. The on-call doctor said they were not able to review Mr R that afternoon due to a heavy workload.

15. On 12 April Mrs R took her husband back to the Trust’s Accident and Emergency (A&E) department. Mr R attended complaining of pain to his drain site that had persisted for several weeks. The Trust admitted Mr R and his records show the Trust removed his drain shortly after he was readmitted.

16. On 21 April 2021 Mr R sadly died, with his cause of death noted as hospital acquired pneumonia (lung infection) and vascular dementia (a type of dementia caused by reduced blood flow to the brain), and previous ischaemic stroke (a stroke caused by a blockage in a blood vessel in the brain).

Handover of Mr R’s gallbladder drain

21. Mrs R says the Trust failed to safely handover the care of her husband’s gallbladder drain to the district nursing team. She told us she is concerned the poor transfer of care meant her husband did not get the treatment he needed.

22. The GMC guidance (section 44 and 45) says clinicians must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. When clinicians delegate the care of a patient, they must be satisfied the person providing the care has the appropriate qualifications, skills and experience to provide safe care for the patient.

23. As we have explained in the background to this case, the Trust inserted a temporary drain to help remove Mr R’s bile on 19 February 2021. It said the drain needed to remain in place for 8 weeks. On 11 March the Trust discharged Mr R to the care of the district nursing team with a plan to remove Mr R’s drain in mid-April.

24. Our adviser has explained the type of drain Mr R had was complex and, because it is a specialist drain, its use is commonly overseen by a surgical team, even after a patient’s discharge from hospital. They explained whilst there is no specific guidance relating to management of the drain, it is most in keeping with the GMC guidance to arrange some form of imaging prior to the removal, which cannot be done in a community setting. Our adviser told us it would not generally be in keeping with the GMC guidance to entirely hand over management of a cholecystostomy drain to community care, including the decision to remove it, which needs to be done in a hospital setting.

25. We found no evidence in Mr R’s records the Trust continued to care for him and his drain through its surgical team after his discharge. We can see the Trust’s referral to the district nurses asked the team to take over monitoring of Mr R’s gallbladder drain. We can also see from Mr R’s records the Trust said the district nurses were responsible for removing Mr R’s drain, after his care home contacted it to arrange its removal.

26. We cannot see evidence in Mr R’s records the Trust arranged a clear plan to follow up on Mr R’s drain and remove it as and when needed. We have not found evidence in Mr R’s records the Trust maintained oversight of his drain or supported the district nursing team in monitoring this.

27. We consider this a failing. Our current thinking is the Trust did not act in line with the GMC guidance mentioned in paragraph 23. We consider the Trust should have provided oversight of the management of Mr R’s drain, including in the community setting. We go on to consider the impact this had in a further section of this report.

Failure to act on concerns about drain

28. Mrs R told us that in March 2021 she raised concerns with the Trust about the functioning of Mr R’s drain and it not removing further bile. Mrs R says her husband had developed severe pain in his drain area and suspected he had an infection. In April 2021 Mrs R took her husband back to the Trust after she became concerned about his condition. She did not think the Trust had done all it should have when she raised her concerns in March. Mrs R says if the Trust had acted on her concerns about Mr R’s drain, his death may have been avoided.

29. We have carefully reviewed Mr R’s medical records and noted his GP reviewed him in late March due to concerns about his drain’s functionality. The records indicate that the GP was aware the district nursing team had attended to Mr R and advised him to contact the Trust regarding the drain’s performance. After Mrs R spoke with the Trust, she was advised to contact Mr R’s GP.

30. Mr R’s GP advised that his drain should be reviewed by the team who inserted it at the Trust. The GP contacted Mr R’s surgical team, who said since the drain was due to be removed in mid-April, it had no concerns that further action was needed at that time.

31. We cannot see evidence in Mr R’s records the Trust carried out any review of Mr R and his drain at this time.

32. Our adviser told us discomfort at a drain site is common and usually due to skin irritation. They explained that it could, however, be due to a complication with the drain, such as a bile leak. While there is no evidence of this in Mr R’s notes, we understand from our adviser it should have still prompted a review by the Trust's surgical team, as it would have been in line with the GMC guidance section 15b to have done so. We understand from our adviser it would not be reasonable to expect a district nurse or a GP to assess a patient for potential complications of a drain placed into an organ, given their respective roles. This means the Trust should have arranged for Mr R to have a clinical assessment when concerns were raised about the drain in March.

33. GMC guidance section 15b says clinicians must provide a good standard of practice and care. If assessing, diagnosing or treating patients they must promptly provide or arrange suitable advice, investigations or treatment where necessary.

34. Mr R’s records do not show evidence the Trust cared for Mr R in line with GMC guidance, or that it took the opportunity to review Mr R in March when concerns were first raised about the functioning of his drain. We consider this a failing.

35. As we have found failings in the issues Mrs R has brought to us, we have considered the likely impact they caused.

36. Mrs R told us if the Trust had acted appropriately regarding Mr R’s drain, including removing it when she raised concerns, his death could have been avoided, and he would not have had to suffer in pain. She also described the devastating impact of losing her husband on her own wellbeing.

37. Having considered the evidence available to us, including our independent clinical advice, we can see it is unlikely the failings we have found caused a clinical impact to Mr R. This is because we have not seen that the lack of handover led to a missed chance for further treatment. Our adviser explained that the clinical evidence available shows Mr R’s worsening health was not caused by any issues with the drain or its management.

38. Mr R’s records show that while the Trust removed his drain shortly after he was readmitted in early April, it noted no problems with the drain that needed addressing. Our adviser explained, as there is no evidence of serious issues with Mr R’s drain or drain site, it is likely his pain was due to local skin irritation.

39. We understand from our adviser that patients who have the type of drain Mr R had, which was due to frailty, sadly have high death rates usually because of their underlying health issues rather than problems with their gallbladder. Our adviser explained the drain Mr R had can safely be left in place for several months and it is often safer to delay removing the drain rather than taking it out too early. We have not seen anything within the clinical evidence and advice available to us that suggests the failings we have identified contributed to Mr R’s lung infection.

40. Our adviser explained Mr R’s previous gallbladder issue may have made him weaker and his health more vulnerable, but there is nothing to indicate this contributed to his later diagnosis of pneumonia. It is clear from Mr R’s records his decline was related to a chest infection and not a further infection of his gallbladder or drain. Considering this, we have not seen anything to suggest that the failings we have identified caused or contributed to Mr R’s death, nor that it would have been avoided if those errors had not taken place.

41. We recognise these events and the loss of her husband had a significant impact on Mrs R’s emotional wellbeing. Mrs R has told us she is still experiencing grief and suffering due to the loss of Mr R. She has explained the lasting impact the Trust’s actions have had on her own health and wellbeing. We recognise this must have been an extremely difficult time for her and that she has been deeply affected by the death of her husband.

42. Whilst we have not seen that Mr R’s death would have been avoided, we have considered the emotional impact to Mrs R. We consider that if the Trust had acted as it should have in monitoring Mr R’s drain, Mrs R may have had the information she needed to fully understand her husband’s clinical situation and so her frustration and distress at believing her husband was not receiving care he needed could have been avoided. We do not underestimate how difficult it must have been to navigate the worries she had about her husband and his drain, and we have thought about what would put things right.

1. We consider there were failings in relation to the actions the Trust took after giving Mr R a temporary cholecystostomy drain (a tube inserted into the gallbladder to drain its contents). We do not consider this had a poor clinical impact on Mr R or would have changed the sad outcome in this case but if those failings had not happened, Mrs R may have had the all the information she needed to understand the clinical situation, and her concerns about Mr R’s drain may have been prevented.

2. We partly uphold the complaint and have made recommendations for the Trust to apologise to Mrs R and put an action plan in place to prevent the failings we have identified from happening again.

3. We were sorry to hear about the circumstances that led to Mrs R bringing her complaint to us. We understand her husband’s sad death caused her much distress. We hope our work provides a resolution to her concerns.

43. In considering our recommendations, we have referred to our Complaint Standards. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

44. Mrs R wants the Trust to apologise for its mistakes. Mrs R also wants the Trust to implement service improvements.

45. Our Standards say if failings are found which have had an impact of any kind, the first step is to provide a meaningful apology. They also say to put things right, organisations may consider revising policies and procedures to stop the same thing happening again, and training or supervising staff.

46. In its responses, the Trust has apologised for the lack of advice and support it gave regarding Mr R’s drain. It has not apologised for the poor handover of care or its lack of review of Mr R’s drain when concerns were raised about this.

47. We recommend that within two months of receiving this report the Trust acknowledges the mistakes we have identified and apologises to Mrs R. We also recommend that within three months of this report the Trust creates an action plan with the input of its patient safety specialist which sets out how it will consider the failings we have identified and take steps to improve its services so those failings do not reoccur. The Trust should share a copy of this action plan with this Office, Mrs R, NHS England and the Care Quality Commission (the CQC).

48. We recognise that the circumstances of this case have been, and continue to be, very distressing for Mrs R. We hope our investigation and views help to reassure Mrs R on these matters. We also hope this report provides some reassurance that changes will be made.