East Suffolk and North Essex NHS Foundation Trust

3. Mrs R complains about the care and treatment East Suffolk and North Essex NHS Foundation Trust (the Trust) provided to her mother, Mrs L, between 19 December 2023 and 1 January 2024.

4. She complains on 19 December the Trust’s Emergency Department (ED) staff: • failed to administer several consecutive doses of Mrs L’s time critical Parkinson’s medication, despite being informed by Mrs R it was overdue • placed Mrs L on an IV antibiotic drip against her advanced written wishes

5. She also complains the Trust’s inpatient team failed to: • provide adequate nutrition and pain relief between 19 December and 1 January • administer time critical Parkinson’s medication on 30 December and 31 December, despite being informed by Mrs R it was overdue • administer Bunov patches (a pain medication for chronic pain) on 29 December • obtain an urgent CT scan, which was ordered on 19 December and not reported until 24 December • follow Mrs L’s advanced directive • classify Mrs L as end-of-life and initiate palliative care promptly on 20 December

6. Mrs R says the Trust’s actions caused Mrs L to suffer unnecessarily and contributed to her avoidable death.

7. Mrs R also complains despite having power of attorney the Trust failed to discuss Mrs L’s diagnosis or prognosis with her, both in ED and during inpatient care.

8. Additionally, she complains the Trust did not consult or inform her when making decisions about Mrs L’s care and treatment.

9. Mrs R says this caused great distress to Mrs L as it prevented her from being with Mrs L when tests were being carried out. It also meant the Trust subjected Mrs L to medical interventions she would not have wished for.

10. Mrs R says the Trust’s actions also caused her severe distress as she felt she had failed her mother because her pleas for help were ignored.

11. She is seeking an apology, service improvements and financial remedy.

14. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. This ensures the Ombudsman does not interfere with matters which are in the remit of the Courts.

15. We have discussed this with Mrs R to understand her circumstances and the outcomes she wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

16. Mrs R says that the Trust’s failure to give Mrs L her medication, complete a CT scan in a timely manner and provide sufficient nutrients, led to her death. If Mrs R is correct, she would have a legal cause of action.

17. She can pursue a clinical negligence claim against the Trust, as she is claiming Mrs L’s care fell below the expected standard and was ‘negligent’. She is seeking financial remedy of at least £12,500.

18. There is a clear available legal route which Mrs R could use to potentially achieve her desired outcome of financial remedy. It is also possible she could achieve her desired outcomes of service improvements and an apology as a byproduct of legal action.

19. Legal action is therefore something we think Mrs R should explore, given the serious nature of her concerns, what she believes the significant impact of those were on Mrs L and the financial compensation she is seeking.

20. We asked Mrs R if she had any barriers that might prevent her being able to pursue this route. She did not tell us of any barriers. However, she did tell us she would seek legal advice and report back to us.

21. Mrs R also told us she is concerned legal action is not the appropriate route to seek a remedy for her complaint that the Trust failed to follow the law or proper process in carrying out the SJR effectively or recording and reporting their errors to the DATIX system. She is also concerned it is not the correct route for her complaint the Trust did not report itself to the CQC or public health England as she believes it was obliged to do.

22. If Mrs R believes the Trust failed to follow the law, then a legal route may also be appropriate for this part of her complaint. However, should Mrs R succeed in securing legal remedy for some parts of her complaint, but not others, she can return to us with any outstanding complaint components.

23. At that point, we would assess whether we should investigate the outstanding complaint components.

24. It is important to note that our process is not guaranteed to be quick. Mrs R currently has two years remaining of the three-year limitation on legal action.

25. We would not wish to deny Mrs R the opportunity to take legal action by considering her complaint and causing her to be outside of the three-year limitation for legal action.

26. Additionally, as set out above, the law prevents us from investigating a complaint where the complainant could pursue legal action, unless we think it would unreasonable. In this case, Mrs R has a clear legal route, and it appears there are no barriers to her securing representation or pursuing this.

27. A solicitor will be able to advise Mrs R whether she has a case, and a court would be able to carefully consider and assess whether Mrs L’s care was negligent. It would also be able to consider what the impact of that was on her, and determine accountability, including awarding an appropriate amount of compensation if applicable.

28. In summary, we consider it is reasonable for Mrs R to pursue legal remedy. Mrs R can return to our service if she is unable to get legal representation, or if she has outstanding outcomes, we can achieve following legal action.

29. If Mrs R chooses to bring the complaint back to us, we would advise she does so as promptly as possible. This is because we have a one-year time-limit by which to consider complaints (from the day a person became aware of their reason to complain). We have discretion to set this time-limit to one side if there are strong reasons to do so. We will consider the time it has taken us to consider the complaint and any other delays outside of her control.

30. We are sorry to hear of Mrs L’s death and the devastating impact this has had on Mrs R and the rest of Mrs L’s family.

1. We have carefully considered Mrs R’s complaint about East Suffolk and North Essex NHS Foundation Trust (the Trust). We are very sorry to hear about the circumstances of her complaint and sympathise with her for her loss. We appreciate how traumatic Mrs R found Mrs L’s inpatient stay and are sorry for this experience.

2. We have decided to take no further action. This is because we consider Mrs R could take legal action on the matter she has brought to us, and it is reasonable for her to explore this.