12. Before we decide if we should do a detailed investigation of a complaint, we look at whether an investigation would be practical or is going to result in a satisfactory conclusion. In some cases, where there is differing information, it might not be possible to reach a clear view about what happened.
13. Miss A complained that the death of her father was caused by him eating a sandwich during a discharge assessment on 27 January 2022. She says this caused aspiration pneumonia as he was on a thick liquid diet. She explained he was not allowed he eat solid food due to the risk of food entering his lungs.
14. Miss A has supplied copies of text messages from 27 January between herself and her sister following a phone call from their father. These refer to Mr A having told Miss A that he had been asked to make a ham sandwich during the ‘fit for discharge’ assessment, which he ate.
15. Miss A says her father decided to eat the sandwich without staff asking him to do so. She said he could not believe his luck.
16. The Trust has explained that Mr A had a discharge assessment on 24 January 2022 but that this did not take place in a kitchen. It explained he did not make a sandwich and there was no ham on the ward, although bread for toast is generally available. It explained he passed the assessment but needed a stair assessment before discharge could be agreed. On 27 January, the occupational therapist (OT) saw Mr A again and confirmed he was fit to go home if he passed the stair assessment.
17. The ward notes for 24 January 2022 refer to the assessment carried out by the OT and that Mr A was able to move with help (a walking frame) and that he was able to wash and dress himself. It recommended a stool be provided to help with washing at the sink and the need for an extra bottle for urine. It said if Mr A passed the stair assessment he could go home. There is no reference to Mr A being asked to make a sandwich or an assessment taking place in the kitchen.
18. The note from the OT on 27 January repeats Mr A being fit for discharge if he passed the stair assessment. It also says that it was possible to return home if the assessment was not passed as there were alternatives to going upstairs, but that the assessment was needed before any plans were put in place. There is no reference to Mr A being asked to make a sandwich.
19. The ward notes of 25 January made by the consultant show a conversation about Mr A being on thick liquid diet. This diet allowed him to better swallow as eating normally was difficult for him.
20. It is clear the recollection of events differs about whether Mr A ate a ham sandwich while in hospital. Miss A tells us this did happen. The ward notes and record of the OT assessment do not refer to a kitchen assessment being made or to a sandwich being made and eaten.
21. The Trust says the patient kitchen where assessments took place before COVID-19 had not been reopened to allow these to take place. It also says that ham is not available on the ward, only bread for toast.
22. The consultant who saw Mr A on 25 January says he discussed diet with him, making him aware he was on diet of thick liquids only.
23. After considering the available information, as the accounts differ it is not possible to take a clear view on this.
24. There is no clear evidence to show the Trust asked Mr A to make a ham sandwich and eat this, or that there was ham available on the ward to enable this. Even if we were able to say that Mr A was able to have access to a sandwich, Miss A’s recollection of the call with her father on 27 January and the text messages exchanged with her sister show Mr A decided to eat a sandwich while knowing he was on a liquid diet and without asking staff.
25. There is likely to be no further information we could find which would allow us to reach a clear view.
26. It is not practical to investigate this further as we are unlikely to reach a satisfactory conclusion. We would be unlikely to say whether Mr A had access to solid food, and if he did, to say the Trust was responsible for his decision to eat it.
27. We thank Miss A for bringing this complaint to us and recognise the impact the loss of a loved one has had on the family. We hope she understands why we cannot take this complaint further and offer our sincere condolences for the loss of her father.