Harrogate and District NHS Foundation Trust

5. Mrs H complains about the following aspects of care the Trust provided to her husband, Mr H, between June 2023 and January 2024: • doctors treated Mr H’s pneumonia with antibiotics in June 2023. Mrs H says this likely caused the clostridium difficile (Cdiff) he was later diagnosed with in July • the codeine phosphate given to Mr H in November affected the rate Cdiff could be expelled • Mr H suffered a fall while in the Emergency Department (ED) on 22 December • no faecal transplant operation (stool from healthy donor introduced into the patient’s colon) took place despite two previous episodes of Cdiff. This limited Mr H’s chances of making a recovery • Mr H was wrongly discharged on 20 December with Cdiff, worsening colitis and while still in severe pain. Mrs H says her husband’s death could have been avoided had he remained in hospital • Mr H was discovered on his side, with no pillows, his face very bloody and sore from an ill-fitting non-invasive ventilation (NIV) mask on 27 December. This occurred despite repeated requests from Mrs H for the mask to be changed.

6. Mrs H is devastated to lose her husband. Further upset and distress has been caused by the poor care her husband received prior to his sad death and the belief his death could have been avoided. Mrs H adds that she has also been financially impacted by her husband’s death which has put increased strain on her.

7. Mrs H wants the Trust to acknowledge its errors, apologise for them and make service improvements. She also wants the Trust to pay her a financial remedy.

8. Mr H had visited the Trust previously in relation to problems with his swallowing and speech. Doctors believed Motor neuron diseases (MND) was the cause of these symptoms. MND is a life-shortening disease which causes muscle weakness.

9. On 21 November 2023 Mr H was admitted to hospital with to bowel problems, including Cdiff infection and colitis (inflammation of the colon). Cdiff infection is caused by bacteria in the colon and can lead to severe diarrhoea and colitis. Doctors discharged Mr H on 20 December as they considered him medically fit.

10. Mr H deteriorated and was taken back to hospital on 22 December. He sadly died from aspiration pneumonia on 27 December.

13. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider it is (or was) unreasonable under the circumstances.

14. Mrs H tells us her husband sadly died in December 2023 because of the poor treatment he received. Mrs H explains her husband may have survived had the Trust provided timely and correct treatment.

15. Alongside the great emotional impact Mrs H suffered as a result of her husband’s death she also says she now earns around £20,000 less a year, which has put strain on her ability to run her household. Mr H’s death has clearly had a significant financial impact upon Mrs H.

16. We understand Mrs H has spoken with Action Against Medical Accidents (AvMA). AvMA is a charity who support people by giving advice and information when they have suffered harm in the NHS.

17. Mrs H tells us she discussed those concerns, set out in ‘the complaint’ section of this statement, with AvMA including a key element of her complaint which is not set out in this statement. We have not listed this in our statement as it does not appear the Trust has responded to it yet.

18. Mrs H says the Trust’s doctors misdiagnosed her husband with MND. She says this diagnosis clouded the real cause of her husband’s dysphagia (problems swallowing).

19. She suspects her husband’s primary hypothyroidism (where the thyroid gland does not make enough hormones) may have been the cause of his dysphagia. She further explains an adenoma (benign tumour) discovered on his parathyroid gland (small gland in the neck which plays a crucial role in regulating calcium in the body) may have caused his primary hypothyroidism.

20. Mrs H says the Trust did not thoroughly explore this and may have missed an opportunity to save her husband’s life.

21. We understand Mr H sadly died of aspiration pneumonia, so any misdiagnosis or treatment relating to his ability to correctly swallow may be significant alongside the other concerns she has about his care and treatment in November and December 2023.

22. AvMA provided Mrs H with the contact details for three solicitors firms it felt may be able to help her. We understand Mrs H has not yet contacted them.

23. Mrs H says AvMA felt her case was ‘serious but complicated’. Mrs H also recently told us she obtained further information from the Trust which she felt ‘may assist solicitors in assessing what appears to be a complicated case.’

24. We think Mrs H should seek some independent legal advice in the first instance. This is because she has clearly suffered a significant financial impact as a direct result of her husband’s death.

25. Mrs H has not indicated there are any barriers to her seeking legal action and already started her enquiries prior to contacting our Office.

26. Mrs H is a dependant and may, for example, be able to make a claim under the Fatal Accidents Act 1976 (FAA). The FAA allows dependents to seek compensation for the loss of a family member who may have wrongfully died because of poor care and treatment. This claim can include where someone was financially dependent on the person who died.

27. Mrs H tells us she is at level five or six of our SOI, so is potentially seeking a significant financial remedy from our Office.

28. We recognise Mrs H also seeks service improvements, an acknowledgement of errors and an apology. We appreciate legal action cannot directly achieve these other outcomes.

29. If someone seeks a mix of outcomes, some of which they cannot achieve through legal action, we still consider if it is appropriate for someone to pursue legal action. We do not consider whether legal action would succeed, only whether it would be a reasonable option to explore.

30. Outcomes like acknowledgement of errors, an apology and service improvements may also be achieved indirectly through legal action. While a court cannot typically recommend such outcomes, an organisation may take those actions proactively to avoid similar legal claims in future.

31. Based on what Mrs H told us, it is clear financial remedy is important and has had a significant impact upon her. We appreciate she has been through a traumatic experience, and we do not wish to add to this. We must, however, consider whether we may be doing Mrs H a disservice if we took on her complaint at this stage. It may be that the legal route is better suited to achieve the financial remedy she seeks.

32. After careful consideration, we have decided it is reasonable for Mrs H to seek some independent legal advice in the first instance. We think it is important for Mrs H to be fully aware of what legal action may be able to achieve for her, particularly in light of the financial impact she describes.

33. We recognise the two elements of Mrs H’s complaint concerning her husband’s fall in the ED on 22 December and the problems with his NIV mask on 27 December may not have a legal route open to them. This is because those elements may not be directly linked to his claimed avoidable death.

34. We have carefully considered this, and decided it is not proportionate to consider those two elements in isolation.

35. Mrs H could come back to us if solicitors decline to consider her claim or if they were unable to achieve all the outcomes she wanted. If Mrs H chose to do so, we would need to carefully consider at that stage whether it was appropriate for us to look into her complaint. We may also need to review any correspondence she received from those solicitors.

36. It is also important to stress that if Mrs H wants to come back to us following her legal enquiries, she must do so without delay. Should Mrs H delay in coming back to us, it may mean we cannot consider her complaint.

37. We hope we have clearly explained our thinking.

Other matters

38. We cannot see the Trust responded to Mrs H’s potentially serious allegations concerning an incorrect MND diagnosis and how this may have drawn attention away from Mr H’s adenoma on his parathyroid gland and its potential links with his primary hypothyroidism and dysphagia.

39. If Mrs H did want us to consider these matters following her legal enquiries, it would be extremely helpful to get a response from the Trust on this issue. If Mrs H would like any advice around this, she should get in contact with us.

40. Likewise, we understand Mrs H recently received further information from her husband’s medical records and discovered further issues she may wish to complain about including a potential problem with her husband’s morphine driver (a small battery powered pump which gives a steady flow of medicine).

41. Mrs H will need to put these matters to the Trust and get its response before we can consider them. We acknowledge the Trust felt there was nothing further it could add to what it had already said, but these matters appear different to those it previously considered. If Mrs H wants further advice around this, she can also get in contact with us.

1. We have carefully considered Mrs H’s complaint about the Trust. We are sorry to hear of her concerns about the care her husband, Mr H, received before he died.

2. We have decided it is reasonable for Mrs H to seek independent legal advice on her complaint. This means we cannot consider it further at this stage.

3. We recognise how deeply Mrs H has been affected by Mr H’s death and we do not underestimate how difficult it has been for her.

4. Although we are unable to look into Mrs H’s complaint at this stage, we hope this statement clearly explains the reasons for our decision and why we see it is important for her to seek independent legal advice in the first instance.