Kingston and Richmond NHS Foundation Trust

4. Mr U complains about the care and treatment his father, Mr T, received from Kingston and Richmond NHS Foundation Trust (the Trust). Mr T was a patient at the Trust in June 2024. Mr U specifically complains staff:

• did not give sufficient encouragement or assistance to help his father eat and drink once admitted, despite him being a vulnerable adult with dementia • did not re-refer his father to the specialist dementia team after the initial assessment and when his eating and drinking declined • failed to inspect his mouth or provide oral healthcare when his father’s eating and drinking declined • failed to respond to family concerns about his father’s eating and drinking, and did not tell the family his eating and drinking had declined • did not communicate the risks of his father’s poor nutrition to the step-down provider upon his discharge and • communicated poorly between themselves about his father’s decline in eating and drinking 5. Mr T was discharged from the Trust to step down accommodation in June 2024 and was discharged home the following month. He had contracted Covid-19 and subsequently died of Alzheimer’s disease a week later.

6. Mr U says as a result of the failings, his father's condition deteriorated rapidly during admission. He says his father lost weight, became weaker and returned home unable to eat or drink due to mouth pain and discomfort. Mr U says the family were distressed by the sudden decline compared with his condition before admission and felt their concerns were ignored. Mr U believes the Trust's lack of communication and joined-up working caused unnecessary suffering for his father and he missed out on additional support. He says this caused significant emotional upset for the family.

7. By bringing this complaint to us, Mr U seeks assurances lessons have been learned, and systemic changes are being made to prevent similar events happening to others. He seeks assurances to ensure people with dementia and other vulnerable patients receive effective support to eat and drink, for staff to communicate risks about nutrition and hydration to step down teams, for oral health checks and mouth care to be part of ward routines and carer’s concerns are heard and acted upon.

8. Mr T, who had dementia, was admitted to the Trust in June 2024 with frailty. During his admission, his eating and drinking declined.

9. He moved to step down accommodation later that month and was discharged home in early July.

10. Sadly, Mr T died a few days later.

13. Mr U was unhappy with the care and treatment received by his father during his admission. The Trust acknowledged there were missed opportunities in Mr T’s care. Mr U wanted clear evidence the Trust had made improvements so other families would not have a similar experience.

14. Our ‘NHS Complaints Standards’ explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’ Further, it says we expect organisations to ‘take action to make sure any learning is identified and used to improve services.’ Finally, our standards say organisations should be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’.

15. The Trust accepted responsibility for the shortcomings in Mr T’s care and recognised the impact this had on his family. It told us it is committed to learning from the incident and ensuring these failings are not repeated.

16. When we asked Mr U about the outcome he wanted, he told us he sought reassurance that lessons had been learned, and systemic changes were being made. He specifically wanted a written action plan showing what improvements the Trust had made and evidence these actions had been completed.

17. We then contacted the Trust to see if it would be willing to provide this. The Trust agreed and has now produced a document outlining the improvements it has implemented. The Trust also agreed to send a copy to Mr U.

18. We are satisfied the Trust has now acknowledged its failings, accepted responsibility and taken steps to learn from what went wrong. These actions meet the outcomes Mr U sought by bringing his complaint to us.

19. We are satisfied we have been able to successfully resolve this complaint. We would like to thank both parties for their cooperation and understanding during this process.

1. We have carefully considered Mr U’s complaint about Kingston and Richmond NHS Foundation Trust (the Trust). Mr U complains about the care and treatment his father, Mr T, received during his admission in June 2024.

2. In its response, the Trust confirmed there were missed opportunities in Mr T’s care. It apologised and said it would be making service improvements in response. While welcoming this, we felt the Trust could do more to put things right.

3. The Trust confirmed it would provide an action plan to Mr U, outlining the service improvements implemented since his complaint, to reassure Mr U that real and substantial changes have been made. We are satisfied these proposed actions are appropriate to resolve this complaint. We explain this in more detail below.