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University Hospitals Coventry and Warwickshire NHS Trust

P-003762 · Statement · Decision date: 4 August 2025 · View University Hospitals Coventry and Warwickshire NHS Trust scorecard
Complaint (AI summary)
Mrs B complained the Trust failed to perform a CT scan and Echocardiogram on her mother, believing this omission led to her death a week later.
Outcome (AI summary)
The complaint was closed. The ombudsman found no indication that the Trust did anything wrong in the care provided to Mrs L.

Full decision details

The Complaint

3. Mrs B complains about the care the Trust provided her mother, Mrs L in April 2024. She complains the Trust failed to carry out a CT scan and Echocardiogram (Echo- a heart scan).

4. Mrs B says the failure to carry out these tests led to the death of her mother a week later. This has impacted Mrs B and her brothers in their grief of losing their mum. Her brother was not able to see his mother before she died, which has been distressing.

5. As an outcome, Mrs B is seeking service improvements and for the Trust to learn from its mistakes.

Background

6. This brief background is only intended to place the key events in context, not provide a full account of everything that happened.

7. Mrs L (aged 86) had a background of high blood pressure, irregular heartbeat and falls.

8. On 17 April 2024, an ambulance took her to the Trust with worsening shortness of breath.

9. Doctors that saw her on the first day suggested an Echo and a CT scan. She saw cardiology and respiratory teams on 18 April. Both teams felt her symptoms were related to a chest infection and heart failure.

10. On 19 April, a consultant saw Mrs L and felt further tests were not necessary as they would not change her management. They decided to discharge her back to her care home with oxygen, antibiotics and diuretics (tablets to remove fluid).

11. Mrs L sadly died a week later.

Findings

15. 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 the Trust did anything wrong.

16. Mrs B is concerned the Trust failed to carry out the tests it had initially planned to. She feels the Trust were unable to treat her mother properly as staff did not know exactly what was wrong.

17. The Trust explained Mrs L was treated for pneumonia and heart failure, and further tests would not have changed her management, given her condition at the time. Pneumonia is a specific type of chest infection that affects the small air sacs in the lungs.

18. On 19 April, the notes show a consultant spoke with Mrs B and Mrs L. They explained it was important to treat Mrs L’s symptoms, rather than look for more possible diagnoses as this would not help. Mrs L indicated she did not want to be in hospital and the consultant wanted to facilitate her wishes. The consultant explained Mrs L had deteriorated since the beginning of the year and was now frail.

19. GMC guidance says at section 14b: ‘You use specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which options for investigating, treating or managing the patient’s condition (including the option to take no action) are clinically appropriate.’

20. The notes indicate the Trust spoke with Mrs L about her preferences and wishes. The Trust made a decision about further tests while respecting Mrs L’s wishes.

21. Our adviser explained an Echo or CT scan would not have altered Mrs L’s management. She was being treated for pneumonia and heart failure, with oxygen, antibiotics and diuretics. All these treatments would have helped her with her symptoms of shortness of breath.

22. Our adviser also noted that exposing Mrs L to the radiation of a CT scan would be potentially harmful, if there was no deemed benefit of carrying out the scan.

23. We have carefully considered all the evidence showing what happened. This indicates the Trust acted in line with section 8.7 of the BTS guidance on pneumonia in providing Mrs L with the appropriate antibiotics, given her allergies.

24. It also acted in line with the BTS guidance on home oxygen, in particular section i20, which says Palliative oxygen therapy can be used to reduced breathlessness and improve quality of life.

25. Overall, we consider the Trust acted in line with Mrs L’s wishes and relevant guidance in not performing further tests. Mrs L was on the correct treatment for her symptoms of breathlessness. Based on this, we have seen no indications of failings and have decided not to consider the complaint further.

26. We are sorry to hear of how quickly Mrs L deteriorated when she was discharged and recognise the distress this caused her family. We hope Mrs B can be reassured the Trust has acted in line with guidance when treating her mother.

Our Decision

1. We have carefully considered Mrs B’s complaint about University Hospitals Coventry and Warwickshire NHS Trust (the Trust). We were sorry to hear of the reasons for her complaint. Mrs B told us how distressing it was to see her mother deteriorate so quickly.

2. We have considered all the available evidence, and we have seen no indication the Trust did anything wrong. We recognise the upset Mrs B and her brothers experienced, and we extend our sincere condolences on the loss of their mother.

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