17. 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.
18. Mrs Y complains the Trust did not follow the correct guidance when it transferred Dr Y to the Hospital of St Cross, Rugby on 3 January.
19. After Dr Y was admitted to the Trust in December 2023 he was transferred to a stroke ward. By 3 January the Trust had ruled out a stroke. At around midday on 3 January, a doctor recorded Dr Y could be transferred to ‘any medical bed’ if the bed on the stroke ward was needed. Records written at 6.30pm say Dr Y was to be transferred to the Hospital of St Cross and the bed manager (responsible for coordinating patient flow by managing admissions, discharges, and internal transfers) had requested an ambulance.
20. The guidance we have looked at when considering Mrs Y’s complaint is GMP. This describes what is expected of all doctors registered with the General Medical Council. GMP says doctors should record their work clearly, accurately and legibly and they should make records at the same time as the events they are recording or as soon as possible afterwards. It also says doctors must contribute to the safe transfer of patients between healthcare providers. This means they must share all relevant information with colleagues involved in the patient’s care within and outside the team, including when they refer patients to other health or social care providers.
21. GMP guidance also says doctors have a duty to be considerate to those close to their patient and to be sensitive and responsive in giving them information and support.
22. In January 2024 the Trust’s internal guidance said inter hospital transfers should be recorded on its clinical results reporting system (CRRS). CRRS was replaced by the Electronic Patient Record (EPR) system in June 2024.
23. Dr Y was transferred to Hospital of St Cross at 7.30pm on 3 January.
24. Mrs Y says she the Trust did not contact her to inform her of the transfer. We can see no records that show any attempts were made by staff to let her know of the move.
25. Hospital of St Cross records made at the time Dr Y arrived say he was transferred there as a medical outlier (this means a patient requiring medical care is admitted to a hospital bed that is not in their clinically appropriate ward, often due to lack of space in the correct department).
26. At 8.30pm staff noted Dr Y had been due time critical medication at 8.00pm (this is his Parkinson’s Disease medication) and they informed a site co-ordinator.
27. RPS guidance says a patient’s medication should be obtained in good time to allow medicines to be available when needed for discharge/transfer. It says staff should ensure an adequate supply is available to suit the destination.
28. Records show the site coordinator brought the missing medication at 11.15pm. Dr Y’s medication was usually administered by nasogastric (NG) tube. It could not be given immediately however because staff could not get any aspiration from the NG tube (this is needed to confirm the NG tube is positioned correctly because a misplaced NG tube can lead to serious lung complications).
29. A doctor inserted a new NG tube at 11.30pm and a chest X-ray was taken to confirm it was positioned correctly.
30. Dr Y was being fed by NG tube during his admission to the Trust. His feeds were scheduled to be given overnight. At 11.40pm staff recorded Dr Y’s feeding was on hold because they were waiting for the outcome of the chest X-ray to confirm the tube was positioned correctly. After the X-ray confirmed the NG tube was in the correct position, staff noted feeding could still not start because Dr Y’s feeding regime sent by University Hospital Coventry was confusing.
31. Dr Y’s Parkinsons’s Disease medication was administered at 12.40am on 4 January. This is over four hours later than it should have been.
32. Dr Y’s first NG feed (he was given water in the meantime) after being transferred to Hospital of St Cross was given at 9.00pm on 4 January. This means he missed one night of feeding.
33. We have seen records to explain Dr Y was transferred to the Hospital of St Cross because he no longer needed to be treated on a stroke ward, and the bed was required for another patient. The records also indicate he was transferred to the Hospital of St Cross because an appropriate bed was available for him there. That said, the decision to transfer Dr Y should have been recorded on the Trust’s CRRS and this did not happen. We have also seen Mrs Y was not told Dr Y had been transferred on 3 January and did not find out until the Hospital of St Cross called her on 4 January.
34. Additionally, the Trust did not transfer Dr Y’s Parkinson’s Disease medication with him as it should have, and his feeding regime records were not clear enough for staff at the Hospital of St Cross to be confident they could start NG feeds.
35. We think these indicate failings by the Trust because it did not follow the guidance we have referred to above.
36. Where we have seen an indication of a failing, we look at the impact the complainant says it caused. We must consider whether the impact is likely to have happened as a result of the failings.
37. Mrs Y says the transfer contributed to Dr Y’s health deteriorating and his subsequent death on 14 January.
38. Our adviser says the medication Dr Y was prescribed for Parkinson’s Disease was levodopa. They explain it has a short-term effect in improving a patient’s mobility and is rapid and short acting. Even before Dr Y’s medication was delayed, records show he was having difficulty with his sitting balance and required a hoist for transfers. They say Dr Y’s mobility was already extremely poor and the short-term effect of the medication would have been extremely limited. Once the medication was administered, Dr Y would have been returned to his previous level with an hour. The delay of over four hours in administering the medication would have no impact on Dy Y’s care or outcome.
39. In relation to the NG feed, our adviser explains missing one overnight NG feed would not have a significant negative effect on an individual’s health.
40. This tells us that although the transfer guidance was not followed correctly, Dr Y’s condition was not impacted. We do acknowledge however, that Mrs Y would have been caused distress by the Trust’s failure to document the transfer and notify her of it. We can see the lack of records surrounding the transfer means she has not been given clarity over the reasons for the transfer.
41. Our complaints standards say organisations should give fair and accountable responses. Wherever possible, staff should explain why things went wrong and give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
42. We can see in the Trust’s complaint responses to Mrs Y (on 2 July and 15 November 2024), it acknowledged its failure to properly document Dr Y’s transfer on 3 January and apologised for the distress Mrs Y was caused. The Trust also said all patients transferring to a new medical team should have a clear diagnosis, treatment plan and expected outcome if their treatment was still ongoing from the previous team involved. It said that was not Dr Y’s experience and apologised for the distress this caused. It apologised for the delay in giving Dr Y his medication for Parkinson’s Disease and that he was not fed overnight.
43. This is in line with what we would expect to happen. The Trust has acknowledged the failings, apologised to Mrs Y and taken action to prevent them happening again. These are the outcomes Mrs Y sought to achieve by bringing her complaint to us. We think the Trust has done enough in the circumstances to put things right and for this reason we will take no further action.
Summary
44. We recognise how much Mrs Y’s complaint means to her, and we thank her for bringing it to us. We can see how strongly she feels about what happened and are very sorry to hear how the death of her husband has affected her. While we acknowledge Mrs Y may be disappointed that we will not be considering her complaint further, we hope the information we have provided will go some way towards explaining what happened.