23.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 for each component of Ms O’s complaint.
Diagnosis and treatment
24.Ms O complains the Trust delayed in diagnosing and treating Mrs O’s health conditions from 3 April 2023. She says this contributed to Mrs O’s death on 30 April 2023.
25.In its complaint response of 17 January 2025, the Trust said Mrs O was treated appropriately for all possibilities and she was receiving the correct treatment throughout her admission.
26.We considered this issue with help from our physician adviser.
27.GMC guidelines set out the principles, values, and standards of professional behaviour expected of all medical professionals registered with them. Sections 15 and 16 of the guidance say doctors must: • adequately assess the patient’s conditions and where necessary examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs • provide effective treatments based on the best available evidence.
28.Mrs O was admitted to the Trust’s cardiology unit on 3 April 2023 after a fall at home. Tests showed no heart issues and Mrs O was transferred to A&E the same day. An A&E doctor examined Mrs O and said their impression was her fall was secondary to delirium from infection. They prescribed a broad-spectrum antibiotic for a presumed chest infection.
29.We can see that between 3 and 5 April the following tests and investigations were done: • electrocardiogram (a test that records the electrical activity of the heart) • blood tests including full blood count, kidney, liver, muscle breakdown, glucose, heart failure, blood clotting, heart muscle, infection markers and blood cultures • arterial blood gas • chest X-ray • urine tests • bedside echocardiogram (ultrasound examination of the heart performed at the patient’s bedside) • transthoracic echocardiogram (a more detailed ultrasound scan of the heart) • Computerised tomography scan (CT – medical imagining procedure that takes detailed pictures of the inside of the body) of the brain, neck, chest, abdomen and pelvis; and • Covid-19 and respiratory viral tests.
30.This is in line with GMC guidelines which say suitable investigations should be arranged promptly.
31.On 5 April the microbiology department reported the blood cultures confirmed Mrs O had MSSA with an unknown source. Mrs O was prescribed intravenous (IV) flucloxacillin (a first line antibiotic for staphylococcal infections, one of which is MSSA) the same day.
32.This is in line with GMC guidelines which say effective treatments based on the best available evidence should be provided.
33.An infection consultant examined Mrs O on 6 April to try and locate the source of the infection. They noted Mrs O had spinal tenderness which might be discitis (an infection of the intervertebral disc space) and made a referral for an MRI scan. Mrs O was on the appropriate antibiotics to cover the MSSA infection. The flucloxacillin was to be given for two weeks but it was noted Mrs O might need a longer course depending on the results of the investigation. In the event flucloxacillin was given until 28 April.
34.An MRI scan was done on 12 April. The scan report said the images were ‘severely degraded’ because Mrs O was unable to keep still but within those limits there was nothing to suggest discitis.
35.On 14 April a microbiologist reviewed Mrs O’s case and said the source of the MSSA remained unclear but there was a high possibility of a spinal infection. They said Mrs O should be treated for ‘complicated MSSA bacteraemia’ with four to six weeks of antibiotics, six if a bone infection was confirmed.
36.This is in line with GMC guidance which says effective treatments based on the best available evidence should be provided.
37.A CT scan was requested to help identify the source of the infection. The CT scan was done on 19 April. The scan report said there was no discitis but there was a suspicion of osteomyelitis.
38.NICE antibacterial therapy guidelines say the treatment for osteomyelitis is antibiotics, specifically flucloxacillin. The guidelines say the suggested duration of treatment is six weeks.
39.On 20 April a doctor reviewed the CT findings and said Mrs O would likely need antibiotics for six weeks. This is in line with the NICE antibacterial therapy guidelines we have referred to, and GMC guidelines which say effective treatments based on the best available evidence should be provided.
40.A second MRI was done on 22 April. The scan was abandoned because Mrs O could not keep still. The scan report said within those limitations the findings were ‘very suspicious for an infection’ in the spine.
41.We asked our physician adviser about the Trust’s investigations to try and diagnose the source of the MSSA infection, and the treatment Mrs O was given based on her symptoms. They said the Trust completed a comprehensive and informative set of investigations when Mrs O was admitted to hospital. They said more targeted investigations were then done after the MSSA was confirmed and advice was sought from specialists such as microbiology.
42.We acknowledge it would have been stressful for Ms O not to know the exact cause of her mother’s infection. We have seen no omissions by the Trust in either its attempts to diagnose Mrs O or the treatment it gave her. This is because we can see it acted in line with the GMC guidelines mentioned above. Although it could not confirm the source of Mrs O’s infection, it provided effective treatments based on the best available evidence. We have not seen any indications of failings by the Trust in this aspect of care.
43.We can see Ms O might have thought different treatments would have been available if the source of the infection had been confirmed. We hope to reassure her that we do not think the treatment would have been any different if osteomyelitis had been confirmed. This is because the treatment (flucloxacillin) would not have changed. Mrs O was being given flucloxacillin from 5 April until 28 April. Unfortunately, she did not respond to this treatment, but that does not mean it was the incorrect treatment. For these reasons we will not be considering this matter further.
MRI 44.Ms O complains the Trust delayed completing the MRI requested on (Thursday) 6 April 2023.
45.NHS England's Seven Day Services (7DS) Clinical Standards aim to ensure patients receive the same high-quality care every day of the week, including weekends, by requiring trusts to provide services seven days a week. Section 5 of the 7DS says hospital inpatients should have seven-day access to diagnostic services such as MRI, and tests and completed reporting should be available within:
• one hour for critical patients • 12 hours for urgent patients • 24 hours for non-urgent patients.
46.This means at the latest, the MRI should have been done by 7 April. It was done on (Wednesday) 12 April which was not within the 7DS standards. This indicates there was a failing.
47.We have thought about whether this had an impact on Mrs O with the help of our physician adviser. They said the MRI images were not ideal because Mrs O was unable to tolerate the scanner. They said this was an unfortunate consequence of the severity of her illness and an earlier test would not necessarily have changed this outcome. Our physician adviser explained that even if the MRI images had been clear enough for a diagnosis to be made, Mrs O’s treatment (flucloxacillin) would have stayed the same.
48.We understand why Ms O would have felt worried about the delay by the Trust in doing the MRI and why she thinks that Mrs O’s death might have been avoidable if the MRI had identified the cause of the infection. We hope to reassure Ms O that we do not think the delay contributed to Mrs O’s death and she was receiving the appropriate treatment irrespective of a formal diagnosis. For this reason, we will not be looking at this matter further.
Nutrition
49.Ms O complains the Trust failed to provide Mrs O with appropriate nutrition from 3 to 28 April. Ms O says Mrs O had lost her appetite because of her illness and nothing was done to remedy this. She says if Mrs O had not been weakened due to a lack of nutrition, she might have been able to recover from the infection.
50.In the Trust’s complaint response, it said Mrs O was assessed by a dietician on 14 and 25 April. It said Mrs O’s eating was variable and prior to being seen by the dietician, she was prescribed a nutritional supplement. It said the reason for Mrs O’s poor oral intake was delirium and infection.
51.NICE nutrition guidance says patients should be screened for malnutrition by healthcare professionals with appropriate skills and training. Hospital inpatients should be screened on admission and again weekly or when there is cause for clinical concern. Nutrition support should be considered for people who have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer. Patients should receive food and fluid of adequate quantity and quality in an environment conducive to eating.
52.The Malnutrition Universal Screening Tool (MUST) is a five-step screening tool to identify adults who are malnourished or at risk of malnutrition. A MUST score of nil indicates low risk of malnutrition in adults. This means that no immediate nutritional intervention is required. Someone who has a score of two or more is considered high risk.
53.Mrs O’s records show she was weighed and measured when she was admitted to A&E on 3 April. There is no evidence a malnutrition risk score was recorded. The Trust should also have completed weekly nutritional assessments on 10 and 17 April. As these actions were not carried out, this is not in line with the above guidance and indicates a failing in care.
54.Where we have seen an indication of a failing, we look at the impact the complainant says it caused. We must consider whether the impact is likely to have happened as a result of the failings.
55.We asked our nursing adviser about this. They said Mrs O’s weight and height when she was admitted on 3 April meant her Body Mass Index (BMI) was in the healthy range. They said it is likely a MUST score would have been O and Mrs 0 would have been low risk for malnutrition. This means no immediate nutritional intervention was required, although we can see Mrs O was prescribed a daily nutritional supplement drink from 4 April.
56.We have seen a dietician reviewed Mrs O on 14 and 25 April. On 14 April they said Mrs O’s BMI was in the healthy range. They said Mrs O should be assisted and encouraged with eating and drinking using the red tray system (the red tray is used to indicate to staff which patients need their food intake monitoring, and that they may need assistance). Nursing records show the red tray system was in place following this advice which meant Mrs O was given encouragement and assistance with her eating.
57.The nursing records show a nutritional assessment was completed on 24 April. Ms O’s MUST score was two which means she was at high risk of malnutrition (she had lost approximately 2.2kgs since 3 April). A dietician referral had already been made prior to this. The dietician reviewed Mrs O on 25 April. They recommended for ‘optimisation of nutritional status’ and Mrs O should be given encouragement and assistance to eat and her nutritional supplement should be increased to twice a day. The dietician also said Mrs O was not a candidate for a nasal gastric tube (NGT which is a method of providing nutrition and hydration to individuals who cannot consume adequate amounts of food or fluids orally). On 27 April a doctor recorded they agreed with this decision.
58.Taking into account the views of our adviser and the guidance, we consider there are some indications of failings on the part of the Trust. Specifically, it did not complete nutritional assessments on 3, 10 and 17 April.
59.We can also see from records that Mrs O’s appetite was variable throughout her admission. We think Mrs O’s reduced oral intake was likely due to her overall decline in health and ongoing infection. Whilst we have identified some potential failings in Mrs O’s nutritional care,we think that even if they had not happened, it is unlikely the Trust would have done anything different. This is because it is likely her MUST score on 3 April would not have indicated any action needed to be taken, and there is evidence she was reviewed by a dietitian on 14 April and her BMI was normal. Appropriate action was taken to assist with eating at this stage, and her nutritional supplement was increased when her MUST score was raised on 24 April.
60.We recognise how important nutrition is to a patient’s recovery. We have seen Mrs O’s appetite had fallen due to her illnesses, and the medications she was prescribed. We think if the failings in nutritional screening had not happened, it is unlikely Mrs O’s oral intake would have been any different, due to the illness she had. We are unable to link the potential failings we have seen to Mrs O’s death. Therefore, we will not consider this matter further.
61.We understand from what Ms O has told us this matter has caused her a great amount of distress during what was already a difficult time. We can see why she was concerned that Mrs O’s poor oral intake might have contributed to her failure to recover. We hope our explanation provides some reassurance to Ms O that overall measures were in place to support her mother with her nutrition.
AAU
62.Ms O says Mrs O was kept on the AAU for nine days when the maximum stay should have been two. She says Mrs O’s condition deteriorated due to the conditions in the AAU.
63.In its complaint response the Trust said Mrs O could not be transferred because there were no beds available. This was because there were patients with a higher clinical priority waiting to be admitted to the elderly care ward. The Trust apologised and said it recognised this could be very frustrating and upsetting for patients and their families.
64.The AAU is a dedicated facility within a hospital that acts as the focus for the delivery of care to patients who present to hospital with an acute medical illness. A patient admitted to the AAU will receive care that will include the necessary investigations and management required until the patient is discharged, stabilised or transferred to an acute ward, under the care of the appropriate specialist physician.
65.The GIRFT programme is a NHS England programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking, and presenting a data-driven evidence base to support change. GIRFT says ideally, the AAU should provide continuity of care for patients, up to 72 hours.
66.Mrs O was transferred to the AAU on 4 April and moved from there to an elderly care ward on 13 April. This means Mrs O should have been transferred to the elderly care ward by 7 April in line with guidance. She was not transferred until 13 April. This indicates there was a failing.
67.We asked our physician adviser about this matter. They said the 72-hour timescale is important because it allows patients to flow through the AAU and new patients who require acute medical care can be transferred in. They said that does not mean any patient who stays longer receives suboptimal care. They explained there is no reason to suggest the staff or environment on the AAU would not have been able to meet Mrs O’s care or treatment needs. Our adviser told us there are no obvious omissions in Mrs O’s care, and as we have covered above, appropriate investigations, medication and treatment was provided throughout the admission.
68.There is an indication of a failing because the Trust did not transfer Mrs O to a ward within the 72-hour timescale. We are not persuaded this had a clinical impact on Mrs O. We acknowledge the delay transferring Mrs O would have caused Ms O stress at a time when she was already worried about her mother’s health. We have also seen the Trust apologised for the delay in transferring Mrs O and explained it was due to a shortage of beds on an appropriate ward. We would not expect the Trust to do more in the circumstances. Therefore, we will not consider this part of the complaint any further.
Incident on 12 April 2023
69.Ms O says she went to the AAU on 12 April to visit Mrs O and found her naked to the waist with no covers, no curtain around her and exposed to the ward. She says there were medical supplies, packaging and trays scattered over the bed and floor around Mrs O. Ms O says the AAU ward manager spoke to her on 13 April and said there would be a full investigation, and he would get back to her but did not.
70.In its complaint response the Trust said it had been believed at the time that Mrs O’s delirium had caused the event. It apologised for the state Ms O found her mother in and the ward manager apologised for not coming back to Ms O. It said staff could not shed any further light on how the situation arose.
71.Records show Ms O spoke to a nurse in the evening on 12 April and said she was concerned that when she arrived to visit, Mrs O was not wearing any clothes, and her dignity was not being maintained. The nurse told Ms O she would highlight the matter with the ward manager the next day.
72.Ms O has shown us notes she wrote on 12 April. They say a nurse helped her dress Mrs O and apologised for what had happened. The nurse told her all staff were on a break when ‘this happened’. Ms O says she spoke to a doctor who told her Mrs O had taken her own gown off due to her delirium.
73.Our complaint standards say organisations should aim to address and resolve a complaint at the earliest opportunity. Staff should proactively respond to service users and their representatives and … deal with any complaints raised at first point of contact. The guidance also says staff who carry out investigations will give a clear and balanced explanation of what happened and what should have happened. They will reference relevant legislation, standards, policies, procedures and guidance to clearly identify if something has gone wrong. They will also make sure the investigation clearly addresses all the issues raised. This includes obtaining evidence from the person raising the complaint and from any staff involved.
74.Ms O’s notes say the ward manager spoke to her on 13 April about the events the previous day. The ward manager said he would investigate the incident. We have seen no evidence an investigation was completed. This is not in line with our complaint standards and indicates a failing occurred.
75.We have seen the Trust has already recognised this. In its complaint response it acknowledged the ward manager did not get back to Ms O with any findings from an investigation and apologised.
76.Due to the passing of time, and the limited evidence available, we do not think it is reasonable to ask for an investigation to be completed now. We think the acknowledgement of the failure and the apology is in line with our complaint standards. We do not consider there is any further action the Trust can take to put matters right. We will therefore not be looking into this complaint any further.
77.We recognise it would have been upsetting for Ms O to find her mother in the condition she was when she visited her on 12 April. We acknowledge the Trust’s failure to complete an investigation means Ms O remains concerned about this event. We can also understand why the incident made Ms O feel she needed to spend more time at the hospital with her mother. We are sorry we have not been able to provide her with closure about her concerns and understand she might be disappointed that we will not be investigating this matter further.
Communication 78.Ms O says she was told on 24 April her mother was improving but three days later was told she was not likely to recover. Ms O says her mother’s decline came as a shock and she was not able to inform family or arrange for them to visit Mrs O.
79.GMC guidelines say doctors must communicate effectively and give information in a way that can be understood.
80.A doctor (Dr S) spoke to Ms O on 24 April. Dr S’ notes say they told Ms O the MRI suggested there was infection around Mrs O’s lumbar spine area but it was improving from the previous scan. The notes say Dr S told Ms O that Mrs O’s infection markers were falling in response to the antibiotics.
81.Ms O has shown our office text messages she sent to her brother on 24 April after she had spoken to Dr S. Ms O said Dr S told her they saw no red flags to suggest Mrs O would not recover and would tell her if they did.
82.A different doctor (Dr J) then spoke to Ms O and her brother on 27 April. They told them at this stage Mrs O was very unlikely to make a full recovery and with each passing day her outcome became worse. They said the chance of death, permanent cognitive impairment and need for significant amounts of care became more likely. Dr J’s notes say Ms O and her brother were concerned about contradictory updates and Dr J apologised for ‘any uncertainty conveyed’.
83.In the Trust’s complaint response, it said Dr S apologised for giving Ms O the impression Mrs O would make a full recovery and the impact this had on Ms O and her family. It said Dr S’ communication was not as clear as it could have been. Dr S was referring to Mrs O’s infection response to antibiotics and not her overall recovery.
84.We have seen there is a difference between the information Dr S says they gave Ms O on 24 April and the understanding she took away from the same conversation. Unfortunately, based on the evidence available we cannot determine exactly what was said, as we have conflicting accounts that are hard to resolve.
85.Dr S wrote that Mrs O’s infection markers were falling. The notes did not say they told Ms O they ‘saw no red flags which suggested Mrs O would not recover’. We can understand though why Ms O might have thought Mrs O might recover from the infection if Dr S said the infection markers were falling.
86.We recognise Ms O was distressed to be told just three days later that Mrs O was coming to the end of her life.
87.The Trust accepted in its complaint response that communication on 24 April could have been clearer. This indicates there was a failing. We are satisfied the Trust has acknowledged Dr S’ communication might have been poor and apologised in its complaint response. This is in line with what we would expect to happen in the circumstances, and we will therefore take no further action.
Complaint handling 88.Ms O complains the Trust did not respond to the complaint she made on 21 March 2024 until 17 January 2025, and this added to her stress, suffering and grief following her mother’s death. In its complaint response the Trust apologised for the unacceptable delay in responding to Ms O and said it was not the standard of service it aimed to achieve with their complaint investigations.
89.We have reviewed this issue by referring to our complaint standards which set out how NHS organisations should approach complaint handling in a clear and consistent way, and the Trust’s own complaints process.
90.Our complaint standards say organisations should respond to complaints at the earliest opportunity and consistently meet expected timescales for acknowledging a complaint. They should give clear timeframes for how long it will take to look into the issues and discuss timescales with everyone involved in the complaint and agree how people will be kept informed and involved. They should provide regular updates as agreed with the parties, throughout and a final written response should be issued within six months.
91.The Trust’s own complaint process says a letter of acknowledgement will be sent to the complainant within three working days. It aims to provide a response within 35 working days or within an alternative agreed timescale.
92.On 21 March 2024 Ms O sent an email complaint to the Trust’s complaints team. It replied on 24 March and said it aimed to respond by 14 May or would contact Ms to provide an update on the expected response time.
93.Ms O sent an email to the Trust on 15 May and asked for an update because the deadline had passed, and she had not been contacted. The Trust replied on 20 May and apologised the response had been delayed and said it hoped to be able to respond by 17 June.
94.Ms O sent an email to the Trust on 18 June and asked when she would receive a full reply. She then contacted us on 11 October. We sent an email to the Trust the same day and said if local resolution had not been completed by 12 November we would consider investigating.
95.We contacted the Trust twice more, on 28 November and 23 December. The Trust sent its final response to Ms O on 17 January 2025 and apologised for the unacceptable delay in responding.
96.The Trust did not provide a response to Ms O within 35 working days, contact Ms O within an alternative agreed timescale, or within the six-month standard given in our NHS Complaint Standards. This is an indication of a failing.
97.We can see the Trust apologised for its delay in responding to Ms O’s complaint when it wrote to her on 17 January 2025.
98.We recognise how poor complaint handling can exacerbate a person’s emotions when, often, they are complaining at a time when they are already distressed. We consider the fact Ms O waited months for a response would likely have caused her frustration.
99.Before we decide whether we will conduct a detailed investigation there are a number of checks we must carry out. One of these checks is to consider where the claimed impact arising from the issues raised by a complainant falls on our ‘Severity of Injustice Scale’. This means that, in some circumstances, we will not consider a complaint because we have decided it would be more proportionate and a better use of resources to focus on issues where the impact arising from them is more significant.
100.We can see the Trust’s delay in providing a response would have been frustrating for Ms O. We do not consider it would be proportionate for us to carry out a detailed investigation about complaint handling delays. We think this would meet level two on our ‘Severity of Injustice Scale’ because this is where we place cases of poor complaint handling where there is a delay of up to around one year.
101.We do not think it is proportionate to use our resources to focus on this part of Ms O’s complaint. Therefore, we have decided to take no further action on this issue and thank Ms O for bringing it to our attention.
102.We realise how difficult and distressing the events leading to her complaint have been for Ms O. We thank Ms O for bringing her complaint to us and hope that our consideration and explanations are helpful.