Staffing levels and monitoring Mr G while staff gave him NIV
24. In its RCA report, the Trust said staff needed to do hourly observations on acutely unwell patients in a side room receiving NIV. It acknowledged this applied to Mr G. However, staff did not do hourly observations during the night he died. It went on to explain a lack of staffing played a part in this.
25. The Trust cited the Ventilatory Management Guidance. Regarding staffing levels, the Ventilatory Management Guidance contains a section on the essential requirements for an NIV service. This says, where hospitals provide NIV treatment, they should have staffing levels above that of a general ward. This consists of one nurse for every two NIV patients.
26. The Trust acknowledged it did not have these ratios in place while Mr G was a patient, and it needed to ensure it did. Before the COVID-19 pandemic, the Trust said staff placed all its patients who needed NIV in its critical care unit. It said it changed this pathway during the pandemic to allow NIV to take place in the most appropriate setting for its patients. This included wards.
27. The Trust explained the ward Mr G was on had three nurses and two healthcare assistants on shift when he died. At the time the Trust issued its RCA report (June 2022), it found this remained the current staffing levels for an overnight shift on the ward. Because Mr G was an NIV patient, the Trust acknowledged it should have had an additional nurse on the ward during his admission.
28. The Trust added the inadequate staffing it had in place to manage its NIV patients meant nurses were not able to maintain the hourly observations they should have been doing on Mr G. It also said it delayed staff responding to Mr G’s NIV equipment disconnecting.
29. The Trust noted, when it has NIV patients on a ward, it needs to ensure it has the staffing ratios recommended by the Ventilatory Management Guidance in place.
30. We agree with the Trust that it did not act in line with guidelines on this matter.
31. In the Trust’s complaint file, we saw internal emails between its staff commenting on the staffing ratios the Trust had in place.
32. The clinical matron responsible for the ward staff put Mr G on gave details of the scheduled staffing in place. When scheduling staffing, they confirmed the Trust’s planning around this did not take account of having patients on continuous NIV on the ward. They added there should be one nurse for every two acute NIV patients, which did not happen while Mr G was on the ward.
33. So, this evidence does not show unavoidable staffing pressures, for example, through unplanned staff absence, explain the shortfall. Rather, the Trust did not plan staff rosters to ensure it had the recommended staff to patient ratios in the right places.
34. Our nurse said the Trust should have taken account of the NIV patients it had on its ward when planning its staffing levels.
35. Having considered the evidence and advice, we saw the Trust did not take account of the considerations the Ventilatory Management Guidance says it should have in planning its staffing levels. This meant it did not have the staff to patient ratios this guidance says is essential when providing care for NIV patients like Mr G.
36. Regarding the frequency of the Trust’s observations on Mr G, the NEWS Guidance says where a patient has NEWS of five or more, staff should do hourly observations on a patient as a minimum.
37. NEWS is a tool staff use to assess a patient’s breathing rate, oxygen saturation level, blood pressure, heart rate, level of consciousness, and temperature. Staff give each parameter a score between zero and three. A score of zero means the parameter is normal. Higher scores indicate the patient is more unwell.
38. Staff add up scores for each parameter to give a total score. They should add two to this score if they need to give a patient supplemental oxygen. A higher overall score means the patient is more unwell and at higher risk of deterioration.
39. Mr G’s care records show staff recorded his NEWS between five and seven in the 24hour period before he died. In these circumstances, the NEWS Guidance says staff should have done hourly observations on Mr G.
40. The Trust acknowledged, and Mr G’s care records confirm, staff did not do observations on him as frequently as this. Our nurse said they would expect to see hourly observations to meet the requirements set out in the NEWS Guidance.
41. So, having considered this evidence and advice, we saw the Trust did not act in line with the NEWS Guidance. Staff did not do their observations on Mr G as frequently as they should have.
42. We hope we have clearly explained our findings on this matter. We recognise this is a very concerning matter for Miss G, and she expected staff to regularly check on Mr G. As we saw the Trust did not act in line with guidelines, we considered the impact of these events from paragraph 57.
43. This comes after explaining our findings about the monitoring equipment the Trust had in place. We appreciate Miss G complains the lack of equipment also contributed to the delay in staff noticing Mr G’s NIV tubing disconnected from the machine supplying him oxygen.
Alarms and monitoring equipment the Trust had in place
44. We next considered Miss G’s concerns about the lack of alarms and monitoring equipment outside of Mr G’s room together. Our consideration of each issue is similar.
45. In its RCA report, the Trust referred to HSIB’s Investigations. The Trust noted HSIB’s Investigations said there is a safety risk to patients like Mr G who staff care for in side rooms. Staff cannot always observe a patient easily. This is because any bedside monitoring equipment is not visible outside their room.
46. To mitigate this risk, HSIB’s Investigations explain staff should arrange central monitoring. This is where staff observe patients centrally, for example at a nursing station, via monitors which duplicate their bedside monitor screens and alarms. The Trust added this should include alarms which detect the disconnection of a patient’s NIV equipment.
47. The Trust said it did not have such equipment in place on the ward Mr G was on. Staff could only have heard the alarms on the machine giving him oxygen in his room. Had the alarms sounded, this meant staff would not have heard them anywhere else.
48. The Trust also explained the ward had no means of displaying health indicators, like his heart rate and oxygen saturation levels, centrally at a nursing station on the ward. The only way for staff to have checked this information was from the machines and monitors inside Mr G’s room.
49. On this basis, the Trust’s RCA report said it intended to explore investing in equipment that would show a patient’s vital signs and any alerts centrally on consoles at its nursing stations.
50. We found the Trust did not have the monitoring equipment in place recommended by guidelines.
51. We appreciate the Trust referred to HSIB’s Investigations and it said it did not have the equipment in place HSIB suggested. We have not considered whether the Trust acted in line with HSIB’s Investigations. This is because HSIB had not yet published this work when Mr G was a patient. For this reason, we could not have expected the Trust to act in line with it. HSIB’s Investigations also said HSIB made no safety recommendations.
52. That said, HSIB said it supported existing guidelines about looking after acutely unwell patients outside of critical care areas, which HSIB listed. One of the recommendations HSIB listed was the Equipment Guidance. This was in place at the time of Mr G’s admission. Our nurse said this was a relevant guideline the Trust should have followed.
53. In providing care for patients needing complex respiratory care, the patient pathways section of the Equipment Guidance says:
• a patient’s oxygen saturation levels need to be clearly visible to staff, including when patients are in isolation rooms • staff should have protocols to detect disconnections from NIV equipment, which will include disconnection alarms • disconnection alarms should be audible from outside a patient’s room if staff placed them in a side room.
54. Our nurse said this meant staff should have had equipment like this in place for Mr G. This was so they could have seen vital information like his oxygen saturation levels, which might have promptly alerted them to any deterioration in his condition. They should also have had disconnection alarms which they could have heard outside of his room. For example, at the nursing station on the ward.
55. As the Trust confirmed staff did not have such equipment in place for Mr G, we can see the Trust did not act in line with the Equipment Guidance. It lacked the detectable alarms staff needed to alert them to any malfunction in the NIV equipment giving Mr G oxygen. Whether linked to an NIV equipment malfunction or something else, staff lacked the equipment that might alert them to sudden deterioration in his condition.
56. We hope we have clearly explained why the Trust did not have the monitoring equipment it should have. Alongside the failings we found in staffing Mr G’s ward and staff monitoring him, we considered the impact of these events from paragraph 57.
The impact of the failings we found in paragraphs 24 to 56
57. Miss G says, had staff monitored Mr G frequently enough and they had the correct equipment in place, he would not have died. She told us her family have had an incredibly difficult experience because he died (which we described in paragraph three).
58. We first considered whether Mr G is likely to have survived had staff acted in line with guidelines. This starts with what difference a staff response would have made to any deterioration or sudden fall in Mr G’s oxygen saturation levels.
59. Our nurse said, had the Trust arranged the level of staffing it should have, this may have given the ward the capacity to conduct hourly observations on Mr G. This would have enabled nursing staff to do observations in line with the NEWS Guidance. We appreciate the Trust said the lower staff ratios played a part in nurses not doing hourly observations.
60. Our nurse said monitoring equipment which was visible to nurses, and audible alarms warning them Mr G’s NIV equipment disconnected may have allowed them to identify:
• a reduction in his oxygen saturation levels • his NIV equipment disconnected and stopped his supply of oxygen.
61. Our nurse said this equipment may have alerted nurses to these things earlier. They added this could potentially have led to earlier intervention and escalation to give Mr G treatment.
62. Mr G’s care records show, during the evening of 5 November, he removed his oxygen mask to allow him time to eat. Staff noted he became less responsive. This indicates, even after a short period, his oxygen saturation levels fell when his NIV equipment was not supplying him oxygen.
63. Our physician also noted Mr G became dependant on NIV, and his oxygen saturation levels fell when he was without his NIV equipment for just a few minutes.
64. Given this, we found hourly observations of his vital signs were unlikely to have been frequent enough for nurses to see a sudden reduction in these levels. We also appreciate our nurse said central monitoring equipment and audible alarms were the measures likely to alert nurses to a problem like this.
65. As the main staff responsible for identifying any deterioration, we saw no reason to doubt nurses would have responded to any problems flagged by this equipment had it been in place. As this equipment would have shown nurses any sudden fall in Mr G’s oxygen saturation levels and/or his NIV equipment disconnecting, we consider nurses are likely to have responded soon after.
66. On this basis, we concluded the lack of centralised monitoring equipment and audible alarms were the main factors likely to have made a difference in allowing nurses to swiftly identify any fall in Mr G’s oxygen saturation levels and/or his NIV equipment disconnecting. Had this equipment been in place, we consider nurses could have intervened soon after such an event and escalated his care to medical staff.
67. Based on the evidence and advice we saw, we found Mr G lost the opportunity to receive such intervention. Therefore, we went on to consider what impact this may have had, including whether he was likely to have survived his admission.
68. Our physician said, even if staff continuously administered Mr G his NIV treatment, and this equipment did not disconnect, the chance of him dying during his admission was more than 50%. We recognise describing this chance in such a numerical way is likely to be difficult for Miss G to read. We explain the reasons behind this figure below.
69. Our physician said Mr G was a patient with severe COPD on NIV. He also had other risk factors which further increased his chances of dying. These other factors included:
• his long-term use of supplemental oxygen at home • his previous hospital admissions where staff treated him for respiratory failure associated with his COPD (Mr G’s care records show he had two admissions like this before his November 2021 admission) • his cor pulmonale (a type of heart failure, often caused by COPD) • his increasing degree of dependency on NIV treatment.
70. Based on all these factors, even had staff detected his NIV equipment disconnected and promptly reattached it, our physician said it was more likely than not he would have deteriorated and died during his admission. Our physician considered the Ventilatory Management Guidance, the COPD Mortality Study, and the Life-threatening Events Study in advising on Mr G’s survival chances.
71. These studies and guidelines contain complex technical and statistical evidence. As an expert in their field, we consider our physician is a suitable professional to interpret this evidence and give reliable information on how it applies in Mr G’s circumstances.
72. The Ventilatory Management Guidance referred to a study following COPD patients who survived previous hospital admissions where they had treatment for respiratory failure. Aside from the statistical information, it said, after two admissions, patients typically deteriorated. They had more severe and/or frequent COPD exacerbations leading to further hospital admissions and their death.
73. The COPD Mortality Study stated the course of COPD involves a rapid decline in a patient’s health after their second severe exacerbation of their illness. Each subsequent event is associated with high mortality rates. So, this supports our physician’s interpretation of these studies and what they indicate about Mr G’s chances of survival.
74. Our physician said prompt reconnection of Mr G’s NIV equipment may have prolonged his survival. From the day after his NIV equipment disconnected (had this not happened or staff reconnected it), they would have expected staff to start considering the trajectory of his illness, and that Mr G would likely not survive his admission.
75. Our physician said this may have then given staff the time to introduce anticipatory medicines and start endof-life care measures. This would have allowed staff to plan Mr G’s death better. For example, when staff had arranged and started end-of-life care, allow his family to come to hospital to see him and be with him when he died.
76. Having considered this information and advice, we saw Mr G was unlikely to survive his admission. However, through the Trust’s failings, he lost the opportunity to live slightly longer. This meant staff did not have the opportunity to plan later endoflife care and arrange for his family to be with him when he died.
77. We appreciate Miss G carefully told us about the impact Mr G’s death has had on her and her family. We explained these impacts in paragraph three.
78. We recognise this has been extremely hard for them. As we cannot robustly conclude Mr G would have survived his admission, or that his death was avoidable, we cannot say the failings we found at the Trust caused the family’s experience.
79. We recognise our findings that staff missed the chance to delay Mr G’s death so his family could be with him when he died are likely to be distressing for Miss G and her family. We can only imagine how difficult this will be for them to read about.
80. From paragraph 81, we considered whether the Trust has done what it should to address the impact we found.
Has the Trust remedied the impact we found (in paragraph 76)
81. Where we see failings have had an impact, we use our Principles for Remedy to determine what might put that right. We also have regard to what outcome the complainant wants.
82. Where organisations cannot return someone to the position they would have been in had the poor service not occurred, our Principles for Remedy include the things Miss G wants (which we described in paragraph five) as appropriate remedies. Therefore, we looked at whether the Trust provided these things during its complaint process.
83. To try and prevent failings happening again, our Principles for Remedy say organisations can:
• revise published material • revise procedures • train or supervise their staff • do any combination of these things.
84. To address the staffing levels the Trust’s RCA report identified, the Trust updated its procedures. It noted the staffing levels it had in place when looking after NIV patients was not in line with the Ventilatory Management Guidance.
85. The Trust shared two versions of its standard operating procedure on caring for wardbased NIV patients. This included the version it had in place when Mr G was a patient. It also shared its updated procedure following its RCA report.
86. Section 2.6.6 of the Trust’s updated procedure cited the staff to patient ratios from the Ventilatory Management Guidance. The procedure explained what ratios its wards needed to meet the requirements from this guidance. It also explained exactly how many nurses the ward needed and the corresponding number of NIV patients that managers could place on the ward to keep within the required ratio.
87. Section 2.6.1 in the updated procedure also confirmed staff needed to do the hourly observations they did not do in Mr G’s case.
88. The Trust conducted audits throughout July 2022 to check whether staff adhered to doing these observations for NIV patients. The 49 spot checks managers conducted throughout the month showed staff did observations and recorded a patient’s NEWS hourly in each observation check they did.
89. This means we saw, through revising its procedures, the Trust has put the staffing and procedures in place to now do the observations they failed to do during Mr G’s admission. Its audits show staff are now observing NIV patients at the frequency they should. This is suitable improvement action in line with our Principles for Remedy to prevent the same failings happening again.
90. In its RCA report the Trust said it was exploring investing in the alarm and monitoring equipment we saw it lacked while Mr G was a patient. The Trust updated us on this matter in early September 2025.
91. It explained it is in the process of procuring this equipment. When the Trust has found monitoring equipment that is compatible with its ventilatory equipment, it plans to buy and install it on its respiratory wards.
92. As we explained in paragraph 66, the monitoring equipment and/or alarms was the most likely thing to alert staff to what happened to Mr G. For this reason, we saw this is suitable investment which, when the Trust installs the equipment, reduces the chance of what happened to Mr G happening to another patient.
93. As the Trust has updated procedures, and it is investing in suitable equipment, we saw it has acted in line with our Principles for Remedy to make improvements. Therefore, we did not see there is further action it should take beyond what it is doing to improve its service.
94. While the Trust has taken action to improve, we cannot see it considered the impact of the failings its RCA report identified on Miss G. Its RCA report, and later responses through the complaint process, focused on explaining what the Trust did to try and prevent the failings happening again.
95. We could not see the Trust apologised for the impact we identified in paragraph 76. As this is something our Principles for Remedy say the Trust should do, we saw there is action it should take.
96. Miss G seeks a financial remedy for the impact of the events. The Trust has not yet provided one. Our Guidance on Financial Remedy, which contains our severity of injustice (SOI) scale, says a financial remedy is appropriate for the impact we identified in paragraph 76.
97. This guidance cites bereavement categories of injustice. This includes where failings meant there was a lost opportunity to better prepare for a death or for the patient’s family to be with them at the time of their death. Through the failings we found, Miss G and her family missed the chance to be with Mr G before he died. We do not underestimate how difficult this is for them.
98. Level four in our SOI scale gives the example of a patient who would not have survived their admission. However, through care failings, they lost the chance of surviving longer and they lost the chance to better plan their final days.
99. As this aligns with what happened to Mr G, the impact we identified fits into level four of our SOI scale. In these circumstances, our SOI scale says the Trust should provide a financial remedy.
100. In the recommendations section from paragraph 164, we explain what the Trust should do to address the impact we found. This also accounts for the impact we saw stemming from failings in the Trust’s complaint handling (which we explain in paragraphs 138 to 163).
101. We recognise the personal redress we are recommending will not change the distressing events Miss G experienced. We hope our recommendations help in bringing her some closure on Mr G’s death.
102. We also hope our explanations about the Trust’s improvements and its investment in equipment assures her it is acting to prevent what happened to Mr G happening to another patient. We understand this was an important outcome for her in raising her complaint.
Opportunities to visit Mr G in hospital
103. In her complaint to the Trust, Miss G said no member of staff advised her she could book a visiting slot to see Mr G in hospital.
104. In response, the Trust apologised staff did not give her information about visiting. It explained infection control regulations about visiting during the COVID-19 pandemic meant the rules on visiting changed.
105. We found the Trust acted in line with guidelines on this matter.
106. Section 10.6 in the PHE Guidance said, for hospital patients under high-risk care pathways, visiting should be limited to only essential visits.
107. Mr G’s care records show staff isolated him in a side room. This was for infection control purposes because his NIV treatment was an aerosol generating procedure.
108. On this basis, our nurse said Mr G was a higher risk patient, and only able to have essential visits. In his circumstances, our nurse explained staff could have deemed a visit essential if they saw he was approaching the end of his life, he was likely to die soon, and his family wanted to see him before he died.
109. Our physician said it is difficult for clinicians to identify when a patient with advanced COPD like Mr G is approaching the end of their life, and if they will die soon.
110. While his prognosis was poor, our physician would not have expected staff to initiate endof-life care during the period before Mr G’s NIV equipment disconnected. Had he remained on NIV therapy and not improved, from the day after his NIV equipment disconnected, they would have expected senior clinicians to recognise he was only likely to deteriorate from his illness.
111. At that point, our physician said staff might have considered end-of-life care arrangements. In commencing this care, staff could then have permitted family visits so Mr G’s family could be with him when he died as part of his end-of-life care.
112. His care records show staff did not start any end-of-life care plan. He died while they were providing treatment to try and help him recover. His death was sudden in nature given staff found him unresponsive after previously seeing him less than three hours earlier. In their entry before they found he died, while he was unwell, staff noted he was stable and tolerating his NIV treatment.
113. Having considered the evidence and advice, we could not see Mr G met the criteria from the PHE Guidance where staff should have permitted his family to visit him. We did not see staff should have commenced end-of-life care that would have triggered exceptions to visiting restrictions.
114. Therefore, we saw no failing in staff not facilitating a visit for Miss G and other family members. Sadly, the sudden nature of Mr G’s death meant this was not possible.
115. We can only begin to imagine how distressing it must have been for Miss G and her family not to have seen Mr G again before he died. We hope we have clearly explained our findings and they help bring Miss G’s family some closure on this matter.
Opportunities to visit Mr G in the mortuary
116. In her complaint to the Trust, Miss G said she called the Trust’s bereavement office on 8 November 2021. She hoped to see Mr G in the mortuary.
117. She said staff told her she could not come to the mortuary because of COVID-19 restrictions. They said she could collect his belongings later in the week. She called again on 9 November. She complained all staff allowed was a time for her to collect Mr G’s personal belongings.
118. The Trust told us, due to COVID-19, it suspended family visits to see relatives in its mortuary. This explained why staff could not offer Miss G the opportunity to see Mr G in the mortuary.
119. We found the Trust acted in line with guidelines in deciding to suspend visits to its mortuary, including the one Miss G wanted.
120. Section 2.1 in the PHE Guidance explained the principles within the guidance applied to all health and care settings to help organisations maintain services during the COVID-19 pandemic. On this basis, we saw these principles applied to the Trust’s mortuary.
121. The PHE Guidance said, to maintain services, organisations needed to continuously review ways of working based on emerging evidence, experience, and expert opinion. It acknowledged the operations in different organisations may need to differ across the UK.
122. Section three in the PHE Guidance said organisations should make health and care settings as COVID19 secure as possible. They should mitigate workplace risks. This may entail local risk assessments to manage infection.
123. The Trust told us it decided to restrict relatives visiting deceased patients in its mortuary. It did so to try and limit the risk of COVID-19 transmission to visitors and staff. This was to help it maintain its services. In the mortuary, staff focused on transferring patients to funeral directors in a timely manner to support family viewings in these places.
124. The Trust explained it operated a red, amber, green (RAG) COVID-19 alert status system. Green was the lowest status level and red the most severe level, where COVID-19 prevalence was high. At red status, the Trust said it took all the measures it devised as part of its risk assessments and continuity plans to maintain its services. One of these measures included suspending visits to its mortuary, which it decided to do.
125. The Trust’s RAG system prompted staff to consider the latest national and regional ‘R’ rate. The ‘R’ rate is a measure on how quickly COVID-19 is spreading in the population. An ‘R’ rate above one means the prevalence of the virus is increasing.
126. The Trust’s RAG system also prompted staff to review the number of COVID-19 patients they were treating in its hospital. The Trust also needed to consider its staff absence, whether this was in line with normal levels, and the number of staff off work having acquired COVID-19.
127. Each factor had certain thresholds to score amber or red status. If any factor met red criteria, this was the status the Trust’s RAG system said its hospitals should operate at. Staff should enact any measures associated with that status.
128. The Trust’s COVID-19 alert status reports from 1 and 5 November 2021 shows its hospitals were in red status at the time. These reports reviewed the latest COVID-19 data.
129. Both reports referenced the ‘R’ rate in the Trust’s region. Its region’s ‘R’ rate recently increased to between 1.1 to 1.4. This was above the national ‘R’ rate of 1.1 to 1.3 in England. This rate met amber criteria. The following other amber criteria also applied on 5 November, and the Trust had:
• one or more positive COVID-19 patients admitted to its hospital in the last 24-hour period (five patients to reach red) – the Trust recorded one • more than five COVID-19 positive patients in the hospital (20 to reach red) – the Trust had 13 • more than two COVID-19 positive patients in the hospital’s critical care unit (five to reach red) – the Trust had three.
130. The Trust also recorded a red factor. Based on the number of its staff off sick or selfisolating across the organisation, the Trust expected a significant impact on its workforce to remain in place for more than 24-hours. It could not resolve this through normal business continuity plans. The graphs on its staff absence showed staff absence at one of the highest points to date in the calendar year 2021.
131. On this basis, the Trust declared red status given the challenges it faced in certain areas of its operation.
132. We saw its RAG system indicated the Trust should have declared this red status. This meant it could impose all the measures it devised to ensure continuity of its service. This included suspending visits to its mortuary.
133. We saw the Trust devised this system and its responses to manage infection risks posed by COVID-19 in line with the principles from the PHE Guidance. Based on evidence about COVID-19 prevalence or how its prevalence impacted its operations, the Trust’s system directed staff on the mitigations they should take in the circumstances to make settings more COVID-19 secure.
134. As the Trust used this system to identify the risks and mitigations it should take, we saw no failing here.
135. Through using a system devised in line with the PHE Guidance, staff decided to suspend visiting to its mortuary. This applied when Miss G wanted to visit. We saw how this measure sought to eliminate a potential source of COVID-19 transmission which might further affect the Trust’s staff and the Trust’s ability to keep its services running.
136. We do not underestimate how upsetting it must have been for Miss G when staff told her she could not see Mr G. This must have been even more difficult given she was not able to see him in hospital either.
137. We hope we have clearly explained our findings on this matter. We hope they help her understand the reasons for the Trust suspending visits to its mortuary and the risk posed to visitors, its staff and its operations had it kept the mortuary open for visiting.
Whether the Trust did investigations about Mr G’s missing wallet and watch
138. When Miss G collected her father’s possessions from the Trust’s mortuary, she said she noticed his wallet and watch were missing. She raised this in her complaint to the Trust. The Trust agreed to search for these items when it confirmed receipt of her complaint.
139. In its response on 20 April 2022, the Trust said it was investigating the whereabouts of Mr G’s watch and wallet. It apologised about the distress this issue caused Miss G’s family. It noted she had a meeting with its operational service manager on 29 April, who would give a final update about their investigation into the items.
140. Miss G told us this meeting was informal. Staff did not record it or take minutes. She added the operational service manager did not attend, and she received no explanation why. She said a junior doctor met with her. They did not give any details about her father’s watch and wallet, and the Trust took no further action.
141. We found the Trust did not act in line with guidelines on this matter.
142. Our Principles of Good Complaint Handling say public bodies should investigate complaints thoroughly. They should be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions.
143. In its 20 April response to Miss G’s complaint, beyond the details we described in paragraph 139, the Trust gave no more information about Mr G’s missing possessions. It did not give further explanations about the investigations staff did or were doing to find them in this response.
144. Based on what Miss G told us, she received no details about this in the meeting the Trust arranged either. The operational service manager did not attend the meeting.
145. We saw emails in the Trust’s complaint file corroborate what she told us. In an email Miss G sent the Trust on 20 June, she said she met only with a doctor on 29 April. She also said the doctor could not answer her questions on the investigations into her father’s missing possessions.
146. After this, the Trust’s complaint file shows its actions were limited to sharing its RCA report. This gave findings only about Mr G’s clinical care. It gave no details about his missing possessions and what investigations the Trust did to try and find them. We saw no other record on this matter, or any written or audio evidence about the meeting Miss G had with its doctor.
147. When we confirmed with the Trust we decided to investigate Miss G’s complaint, we explained the above. We asked, if the Trust had any further information on the matter, that it share this information with us. Having made this request, the Trust was not able to send us any further information.
148. This means, having reviewed the evidence, we did not see the Trust investigated this matter thoroughly. It did not provide a response on the matter at all, despite telling Miss G it would. This means it did not account for its actions or any outcome in trying to locate Mr G’s missing possessions. This is not in line with our Principles of Good Complaint Handling.
The impact of the failings we found in paragraphs 138 to 148
149. We concluded Miss G and her family would have found the lack of investigation into Mr G’s missing possessions distressing. Especially given the Trust said it would investigate what happened to his wallet and watch. These were personal possessions of a close relative who died at the Trust.
150. As Miss G described in her complaint (paragraph four), we saw how this lack of investigation caused her family added further distress to their bereavement.
Has the Trust remedied the impact we saw (in paragraphs 149 to 150)
151. Our general approach to impact is to seek to put the person affected back in the position they would have been in had the poor service not occurred. As we saw the Trust did not investigate this matter, we considered whether asking it to reconsider this position on whether it had and should investigate may be an appropriate remedy.
152. However, the impact Miss G links to the Trust’s failure to investigate is distress she has now experienced. We also considered, given the passage in time, there is a lower chance of staff recalling the events in Mr G’s case. It seems unlikely the Trust would be able to do a meaningful investigation to establish what happened to Mr G’s possessions now.
153. As the Trust cannot return Miss G to the position she would have been in through a meaningful investigation now, our Principles for Remedy say the outcomes she wants are appropriate.
154. The Trust has not yet provided any of these remedies. It was not until we shared our findings when the Trust realised it had not responded about what happened to Mr G’s wallet and watch despite promising to investigate this matter. Therefore, we did not see it recognised this omission or the impact we saw this had on Miss G and her family.
155. This means we did not see the Trust acted to learn from this oversight and make improvements to prevent an event like this happening again. It did not address the impact on Miss G’s family through any apology. Our Principles for Remedy say these are actions the Trust should take.
156. The Trust has not considered or provided a financial remedy in recognition of this impact either. This is something, as we explain in further detail below, our Guidance on Financial Remedy says is appropriate.
157. Our SOI scale includes a bereavement category where a person is experiencing bereavement, and poor complaint handling at the organisation made this worse. In cases where the organisation’s complaint handling is very poor in these circumstances, our SOI scale says this impact fits into level three of our SOI scale. Our SOI scale says an organisation should pay the person affected a financial remedy in these cases.
158. We consider what happened to Miss G and her family fits with these criteria and is an example of very poor complaint handling. This is because:
• the Trust said it would investigate what happened to Mr G’s wallet and watch • it did not share the outcome in its written response and set up a meeting to discuss this instead • the member of staff responsible for sharing information on this matter then did not attend, and the Trust gave no explanation why • the Trust did not give Miss G any information on this matter in the meeting • the Trust made no further reference to the matter after that.
159. Putting ourselves in her position, we can imagine this made Miss G feel as though the Trust was not taking this matter seriously and dismissing her and her family. In the context of their bereavement, we can understand this added to the distress they experienced.
160. We also considered whether the impact we can see matches more severe criteria in level four of our SOI scale. This includes cases where the organisation’s complaint handling was particularly poor and impacted the family’s ability to find closure.
161. Miss G has not said the Trust’s handling of her complaint on this issue impacted on her family’s ability to find closure on events in Mr G’s care or death. This issue is about what happened to his possessions. This means the impact we saw here fits into level three of our SOI scale.
162. We hope we have clearly explained why the Trust did not take the action it should have to address the impact we saw on this matter. From paragraph 164 we explain the recommendations we have made so the Trust addresses this impact.
163. We understand our recommendations will not change the experience Miss G had. We hope they help in bringing her closure on what happened.