19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have seen the Trust has already done enough to put right the impact of these events. We will explain how we came to this conclusion.
Appropriate Medical Treatment 20. Mr N says if the Trust had treated his father appropriately on the first attendance on 3 September, then his father would not have subsequently suffered for a further four days. He would have been provided treatment and would not have had to attend the Trust ED on a further two occasions.
21. Mr O, first attended ED with shortness of breath, fever (38.7°C), AF (atrial fibrillation – irregular heartbeat) and a heart rate of 147 bpm (beats per minute). He was assessed several hours later and discharged with antibiotics for a suspected chest infection. Blood results were said to be within normal range.
22. He returned to ED on 4 September with cough, chest pain, and confusion. AF was again noted on ambulance ECG but had reverted to sinus rhythm (normal heart rhythm) by the time of assessment in ED. A consultant reviewed him and discharged him with a different antibiotic.
23. On 5 September, Mr O attended ED a third time with fast AF, fever, and diarrhoea. He was assessed, referred to the Acute Medical Unit (AMU), and admitted.
24. Our adviser noted the initial presentation on 3 September may have indicated sepsis, given the fever, raised heart rate, and new AF. NICE Guideline NG51 on suspected sepsis recommends early recognition and management, including face-to-face assessment and prompt treatment.
25. The second attendance was appropriately reviewed by a consultant in line with RCEM guidance for unscheduled returns.
26. The third attendance resulted in admission following appropriate referral. Overall, we see there was a potential missed opportunity to recognise and treat sepsis during the first visit.
27. We considered what should have happened if sepsis had been recognised during the first visit on 3 September. We can see Mr O was assessed, investigated, and treated with antibiotics. Although the records do not explicitly document ’query sepsis’, the actions taken including antibiotic prescription, blood tests, and chest imaging were consistent with NICE Guideline NG51, which outlines best practice for recognising and managing suspected sepsis.
28. Mr O’s medical presentation during the second and third attendances were assessed by appropriate medical staff, including consultant involvement. This resulted in further investigation, treatment, and eventual admission. We acknowledge Mr N’s concerns about the impact of delayed treatment.
29. When considering complaints, we assess what should have happened against what did happen. We do this by using relevant guidance as our benchmark. In this case, the treatment provided fell within the guidelines. We have seen the care given at each attendance was in line with relevant guidelines, and as such we will not be taking further action. We hope our explanations provide some reassurance to Mr N.
Personal Care 30. On 6 September 2022, Mr N’s mother found Mr O in soiled bedding. According to the complaint letter, Mr O had repeatedly pressed the call bell, but no staff attended. Mr N’s mother cleaned Mr O without assistance from nursing staff. A similar incident is said to have occurred on 7 September 2022.
31. In email correspondence dated 6 September 2022, Mr N reported this to the Trust promptly after learning of the incident and noted that his mother had taken photographs of the situation.
32. Mr N expressed serious concerns regarding the delivery of fundamental care, as well as the impact on his father’s privacy and dignity.
33. The Trust said, upon receiving the information, the matron and interim director attended to speak with Mr O and his wife. In its first written response dated 19 January 2024, the Trust apologised and explained that documentation showed personal care had been provided. The Trust also outlined service improvements, including the installation of a new call bell system.
34. In its second response dated 27 August 2024, the Trust reiterated its apology but noted that it could not comment further on the records due to differing accounts of what occurred. In its final response dated 16 December 2024, the Trust again apologised and acknowledged that the situation fell below its expectations, stating there was no excuse for what had happened.
35. It is difficult to determine from the records exactly when Mr O may have been left unattended. On 6 September 2022, a note at 03:23am records Mr N speaking to the ED sister about cannulation, which was then attempted. Nurses documented blood tests at 4:51am and 5:40am, indicating that a nurse or health professional was physically present. At 6:17am, blood results were received, and an instruction was added by a doctor to administer co-amoxiclav (an antibiotic), which may have been a remote clinical decision. Nurses took bloods again at 7:14am, and nursing records have been completed hourly.
36. Based on this, it is unclear how staff may have missed Mr O’s need for the toilet or failed to respond to the call bell for an extended period. It was explained in the Trust responses it may have been that the bell did not sound, or the light may not have illuminated outside of the side room, which would have alerted staff. The Trust also explained there is no way for the bell to be turned off without physically entering the room.
37. On 7 September 2022, records show hourly checks except between 2:00am and 6:00am, where no entries appear. At 8:00am, nurses documented that Mr O was sitting up for breakfast, and at 11:00am he was assisted with personal care. It is possible then that he was left for a considerable period during the early morning hours.
38. The NMC Code states that nurses must deliver the fundamentals of care effectively, including nutrition, hydration, bladder and bowel care, physical handling, and maintaining clean and hygienic conditions. NICE guidance also advises that healthcare professionals should regularly review patients’ personal needs, including continence, hygiene, and comfort.
39. We do not dispute the lived experience of Mr O and his wife, and we acknowledge the distress this situation would have caused. The Trust has accepted responsibility, issued apologies, and implemented service improvements, including a new call bell system.
40. While the records show regular nursing entries and clinical activity, there are gaps. The Trust’s own responses acknowledge that standards fell below expectations.
41. The Care Quality Commission has been made aware of the incident and will oversee the implementation of improvements. Given the Trust’s acknowledgement, apology, and actions taken, we will not take any further action on this issue.
Accurate Records 42. Mr N says his father’s medical records are inaccurate. The records show a doctor saw his father at 1:36am on 6 September 2022. Mr N says this is incorrect, as family members were present at the time and no doctor attended.
43. At the Local Resolution Meeting (LRM) on 22 August 2023, a doctor explained that some clinicians had written notes before seeing patients and may have become distracted, resulting in inaccurate timestamps.
44. At the time of the complaint, the Trust reminded doctors to document patient interactions only at the time of examination.
45. GMC guidance states that when doctors assess, diagnose, or treat patients, they must promptly provide or arrange appropriate advice, investigations, or treatment.
46. We understand Mr N’s concerns about inaccurate record keeping and recognise the potential for this to have been a wider issue before the EPR system was introduced. We have no recorded precedent of similar concerns about this Trust.
47. We acknowledge Mr N, and his family were able to identify the inaccuracies because they were present at the time. Mr N raises concern for patients who do not have family members present to advocate for them. We are only able to comment on the complaint Mr N has made on behalf of his family.
48. We agree that the documentation error was unacceptable. However, the Trust has taken steps to prevent recurrence by implementing the EPR system.
49. Our Standards require organisations to provide fair and accountable responses and to take action to ensure learning is used to improve services. In this case, we consider that the Trust has met this requirement, and we will take no further action on this issue.
Delays in ED 50. Mr N said Mr O’s treatment was delayed when he attended the Emergency Department (ED) for the third time on 6 September 2022. He believed this was due to inaccurate record keeping and a delay in inserting a cannula, which led to Mr O being left in an uncomfortable, inappropriate room and receiving delayed care.
51. Mr N felt other patients were prioritised over his father and that treatment only began after he raised concerns with the nurse in charge. The Trust later acknowledged that the ED process should have been explained more clearly and expressed regret that Mr N and his family felt overlooked during this time.
52. Mr N also asked the Trust to provide staffing levels for 5 and 6 September 2022. The Trust apologised for not being able to meet this request, explaining that staffing figures alone would not accurately reflect how the department was functioning at the time.
53. The Trust accepted that Mr O had been placed in a hot, windowless room and acknowledged the discomfort this caused. It has since made improvements to patient spaces.
54. In relation to the delay in treatment, our adviser confirmed that a junior doctor documented a clinical plan at 01:36am on 6 September 2022, which was followed. However, the plan was not implemented immediately due to difficulties with cannulation, which was necessary to administer intravenous fluids. A nursing note at 03:23am shows the staff nurse apologised to Mr N and documented issues with cannulation. Bloods were eventually taken at 04:51am.
55. The Trust acknowledged the failed cannulation attempt and confirmed that the nurse involved had been reminded of the correct procedure. It also spoke to all staff involved in Mr O’s care to reinforce the importance of compassion, empathy, and kindness.
56. GMC guidance states that doctors must promptly provide or arrange suitable advice, investigations, or treatment when assessing patients. Similarly, the NMC Code requires nurses to practise effectively and preserve safety, including maintaining accurate records and delivering timely care.
57. We understand Mr N’s concerns about the delay and the impact on his father’s comfort and dignity. Although the clinical plan was documented, the delay stemmed from procedural difficulties with cannulation rather than record inaccuracy. That said, the documentation may have caused some confusion about the timing of the physical review. Delays that affect patient comfort are unacceptable and can have serious consequences.
58. In this case, there were no clinical implications for Mr O. The Trust has acknowledged the issue and taken steps to prevent recurrence. These include implementing a new electronic patient record system, providing staff training on cannulation and escalation, addressing staff attitudes, and improving patient rooms.
59. These actions meet the standards we expect from organisations responding to complaints and learning from them. We do not consider further action is necessary.Complaint handling 60. Mr N told us it took nearly two years to receive a formal response to his complaint, during which he and his family felt dissatisfied and frustrated. He believed the Trust delayed its response until it had resolved the complaint issues.
61. Part of the delay stemmed from difficulties accessing Mr O’s medical records, which prevented Mr N from submitting a complete complaint. The Trust later acknowledged this and confirmed it has provided training to its ‘Access to Records’ team.
62. Mr N repeatedly chased the Trust for a local resolution meeting, which was consistently delayed. He raised further concerns in emails but felt these were not adequately addressed. He also sought specific answers from individual staff members and questioned whether the Trust had fulfilled its duty to report the incident to the CQC.
63. The Trust apologised and explained it has introduced a new complaints process. It confirmed that a Datix report had been entered and that this fulfilled its duty of candour by logging concerns with the CQC.
64. Throughout the complaint, the Trust provided explanations and apologies for delays but did not offer a clear timeline for resolution. NHS Complaints Regulations require organisations to respond as soon as reasonably practicable and to notify complainants if a response cannot be provided within six months. Our Principles of Good Complaint Handling also emphasise promptness, transparency, and keeping complainants informed.
65. Although the ED matron and interim hospital director personally apologised to Mr N’s parents shortly after the incident, the formal complaint process was significantly delayed. Mr N experienced long gaps in correspondence and was not given a clear timeframe for when to expect a response.
66. As a result, Mr N and his family were unable to get answers from key staff members, some of whom had left the organisation by the time the complaint was addressed. The Trust could have prevented this by responding more promptly.
67. We recognise that external pressures, including industrial action, affected the Trust’s ability to manage complaints and meetings. We also understand the Trust delayed its first response in January 2024 to ensure it was accurate and reflected appropriate learning.
68. The Trust explained it had sought advice from Employment Relations but confirmed that no formal HR or disciplinary investigation was initiated. It did review the complaint issues internally.
69. The Trust should have communicated when service improvements were planned and how they would be implemented. This would have helped build trust and demonstrate transparency earlier in the process.
70. This highlights the importance of clarity in complaint responses. When information is presented in a way that leaves room for interpretation, it can lead to confusion and undermine confidence in the process. Complainants should be guided through the response journey and informed at the earliest opportunity when concerns are being addressed—not only once actions have been completed.
71. The Trust apologised and explained it has introduced a new complaints process. It confirmed that a Datix report had been entered and that this fulfilled its duty of candour by logging concerns with the CQC.
72. The Trust has since introduced action plan tables with target dates in its complaint responses, which improve clarity and help track progress.
73. In the later stages of the complaint, response times improved. The second local resolution meeting was arranged within 65 days, and the final response was issued 27 days later. This suggests the Trust’s service improvements are beginning to have a positive effect.
74. While these improvements came too late to address Mr N’s core concerns, they demonstrate that the Trust has taken meaningful steps to improve its complaint handling processes. The introduction of clearer tracking tools, better access to records, and more timely responses reflects a shift toward more effective practice.
75. We acknowledge the delays in communication and resolution had a significant impact on Mr N and his family. The extended timeline, lack of clarity around progress, and missed opportunities to engage with relevant staff contributed to a sense of frustration and mistrust. These concerns are valid and have been taken seriously throughout our review.
76. Taking account of the evidence available to us, we are satisfied the Trust has now responded appropriately. It has recognised the concerns raised, implemented service improvements, and shown a commitment to learning. In line with our Principles for Remedy, we consider the actions taken to be proportionate and sufficient. We do not consider further action is necessary.
77. We thank Mr N for bringing his complaint to us and we understand this was a difficult time for him and his family. We hope our explanations provide some reassurance that where we have seen failings, the Trust has taken appropriate actions and learning to improve its services.