University Hospitals of Liverpool Group

3. Miss X complains about the lack of communication from University Hospitals of Liverpool Group regarding her father, Mr Y’s deteriorating condition. She says she wasted valuable time preparing for his discharge not knowing his condition was deteriorating.

4. Miss X says if she had been told by staff before she left the ward at 7.15pm on 31 January 2023, she would have stayed with her father and been with him before he went into a coma from which he never recovered. Miss X says she lost priceless time she could have spent with her father.

5. Miss X says the failings in communication have caused her deep anxiety and distress which she lives with daily.

6. Miss X is seeking an apology, service improvements and a financial remedy.”

7. Mr Y was admitted to hospital on 18 January 2023 with severe pneumonia, an acute kidney injury, hyperkalaemia (high potassium in the blood) and anaemia.

8. Mr Y’s condition initially showed improvement but there were problems weaning him off oxygen. He deteriorated on 29 January.

9. On 31 January he was given a blood transfusion but this was stopped shortly after it was started due to a drop in his oxygen levels. His family were called in the early hours of 1 February. He died later that day.

Lack of communication

13. Miss X complains about the lack of communication from staff regarding her father’s deteriorating condition.

The relevant guidance that applies here is the General Medical Council’s ‘Good Medical Practice’. This says,

“37 You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information”.

14. On the 30 July 2025 at 11.30am a doctor made the following entry on the ward round, “We found Mr Y generally quite vague during review this morning. He didn't appear to appreciate how unwell he is, nor of his other serious comorbidities (e.g. underlying heart disease). We will need to seek his permission to speak to his NOK as clearly has high O2 (oxygen) requirements with significant underlying comorbidities and has potential to significantly deteriorate.”

15. There is a further entry of the ward round by the same doctor on 31 July at 2.37pm where it is documented that, “This man has significant co-morbidities and with a high O2 requirement and he has the potential for significant deterioration/decline including not surviving this admission. It is important we ensure the family are aware of the situation.” Our physician adviser has confirmed Mr Y was very unwell at this time.

16. The Trust has acknowledged in its response dated 6 March 2024 that there is insufficient evidence of adequate communication with any family members. This was not in line with the above guidance. Our decision is this was a failing on the part of the Trust.

17. We have looked at the impact of this failing on Miss X. She says that she wasted valuable time preparing for his discharge not knowing his condition was deteriorating and that it was likely he may not return home. She has indicated that she would have stayed with him longer and would not have left him if she had known he was so unwell. Miss X says this has caused her deep anxiety and distress which she lives with daily. We do not underestimate how upsetting this must be for her.

18. The Trust has told us that since Mr Y’s death, it has taken action to ensure a patient’s relatives are kept updated regarding a decline in their condition. The Trust has confirmed Mr Y’s family’s experience has been discussed in the ward’s safety and governance meeting and shared with the team.

19. We welcome the improvements made by the Trust. However, the Trust has not fully recognised and addressed the impact on Miss X and apologised for this. Therefore, we uphold this complaint. We have made recommendations below to provide a personal remedy to Miss X.

1. We have found there were failings in communication with Miss X about her father’s deterioration which affected her chances to spend more time with him during his final days. This is a significant source of distress to her which cannot be underestimated.

2. The Trust has not fully apologised or addressed the impact on Miss X and so we have made recommendations to address this as follows.

• The Trust should pay Miss X £750 as a personal remedy in recognition of the significant distress and upset she has suffered because of the failings in communication.

• The Trust should acknowledge and apologise for the impact the failings we have identified have had on Miss X.

20. In considering our recommendations, we have referred to our ‘Principles for Remedy.’ These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

21. Our principles state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

22. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we recommend that:

• Within one month of the date of our final report the Trust should pay Miss X £750 as a personal remedy in recognition of the significant distress and upset she has suffered because of the above failings in communication.

• Within one month of the date of our final report the Trust should acknowledge and apologise for the significant distress the failings in communication caused Miss X.