South Warwickshire University NHS Foundation Trust

SWFT

4. Mrs K complains about the care and treatment SWFT provided to her father, Mr M, during a hospital admission from 14 to 19 July 2024. She specifically complains about its decision to discharge him home on 19 July 2024 without treating his obstructive jaundice.

5. Mrs K has told us her father’s condition quickly deteriorated, and he was admitted to another hospital on 25 July 2025. Mr M then very sadly died on 8 August 2024 from sepsis secondary to cholangitis.

6. Mrs K says her father’s deteriorating condition may have been picked up and treated sooner had SWFT not discharged him when it did. She believes SWFT’s decision to discharge him contributed to his death.

7. Mrs K has told us her and the family have been left devastated by her father’s death and the circumstances surrounding it. She says his death came as a shock to the family as cancer was only suspected three weeks earlier. She also says she has lost faith in this NHS due to what happened.

8. Mrs K would like SWFT to acknowledge any failings, provide explanations for why they happened and make service improvements to stop them from happening again. She would also like a financial remedy.

UHCW

9. Mrs K complains about the care and treatment University Hospitals Coventry and Warwickshire NHS Trust provided to her father, Mr K, during a hospital admission from 22 July 2024 to 8 August 2024.

10. She specifically complains the Trust delayed in treating obstructive jaundice, poorly communicated with the family and provided poor nursing care over the course of her father’s final few days. She also complains the Trust delayed in moving her father to a side room and did not tend to his body with care after he died.

11. Mr M very sadly died on 8 August 2024 from sepsis secondary to cholangitis. Mrs K says the delay in treating obstructive jaundice led to him developing an infection and ultimately his death. She believes UHCW’s delay in treating obstructive jaundice contributed to her father’s death.

12. Mrs K says her father’s death came as a shock to the family as cancer was only suspected three weeks earlier. She has told us it was very distressing for the family to witness his final few days and that it still haunts them.

13. Mrs K says UHCW’s poor communication and poor nursing care made an already distressing situation even more distressing. She has told us family members who live abroad may have been able to see him before he died had UHCW communicated better. She also says she has lost faith in this NHS due to what happened.

14. Mrs K would like UHCW to acknowledge any failings, provide explanations for why they happened and make service improvements to stop them from happening again. She would also like a financial remedy.

15. Mr M was admitted to SWFT on 14 July 2024 with a five-day history of abdominal pain, nausea, night sweats and obstructive jaundice (the blockage of bile flow from the liver to the intestines, leading to a buildup of bilirubin in the blood causing the skin and eyes to turn yellow).

16. Mr M underwent investigations, and these showed he likely had cholangiocarcinoma (cancer of the bile ducts). SWFT discharged him on 19 July 2024 awaiting the outcome of a multidisciplinary team (MDT) meeting at UHCW.

17. The MDT took place at UHCW on 22 July 2024 and recommended an internal biliary drain to relieve his jaundice (a medical procedure used to ease blockages in the bile ducts, allowing bile to flow from the liver to the small intestine), as well as biopsies and brushings.

18. Mr M was admitted to UHCW with abdominal pain and jaundice on 25 July 2024. He had an internal-external drain placed on 31 July 2024. He very sadly died in hospital on 8 August 2024 from sepsis (when the body’s response to infection causes injury to its own tissues and organs) secondary to cholangitis (bile duct infection).

21. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

22. Mrs K has told us the family has recently instructed a solicitor to investigate the concerns they have about her father’s care and treatment. As she has told us they are actively trying to pursue legal action, we will not be considering her complaint to us any further at this time.

23. Mrs K can bring her complaint back to us if legal action does not go ahead or if it does ahead but does not achieve all the outcomes she is looking for. Mrs K would need to come back to us as soon as she becomes aware legal action is not an option or as soon as the legal case concluded. This is because there is a time limit for complaining to us.

24. The law says people should complain to us within a year of when they first became aware of the issue(s) they are complaining about (date of knowledge). In this case, we think the date of knowledge would be when Mr M died on 8 August 2024. The law says we can look at complaints brought to us outside our time limit, but we need to see a good reason for any delay.

25. We could potentially consider parts of Mrs K’s complaint now. This is because legal action may not be possible for some issues, such as those where the claimed injustice is distress. This could be issues such as poor communication with the family and the way nursing staff cared for Mr M’s body after he died.

26. We think it would be better to wait and see if legal action goes ahead and, if it does, whether it puts things right for Mrs K and her family. It could also be difficult for us to consider the way UHCW communicated with the family in isolation of Mr M’s care and treatment, for example.

27. We hope we have clearly explained why we are closing Mrs K’s complaint at this stage and what she should do if she wants to bring her complaint back to us. We would like to take this opportunity to thank her for bringing her concerns to us and to wish her and her family the very best.

1. We have carefully considered Mrs K’s complaint about South Warwickshire University NHS Foundation Trust (SWFT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW).

2. We consider Mrs K could take legal action on the matters she has brought to us. Mrs K can bring her complaint back to us if legal action does not go ahead or does not achieve all the outcomes she is seeking.

3. We would like to pass on our sincere condolences for the incredibly sad loss of Mrs K’s father, Mr M. We cannot begin to imagine what a difficult time this must have been for Mrs K and her family.