University Hospitals of Leicester NHS Trust

3. Miss A complains about the care provided to her father, Mr B, by University Hospitals of Leicester NHS Trust (the Trust) between 6 and 27 March 2021. Miss A also complains about the Trust’s handling of her complaint and issues in relation to Mr B’s inquest. Specifically:

• Confirmation of who was in charge of Mr B’s care and escalating the delayed review by orthopaedics. Who and why they decided to continue to keep Mr B bedbound which made him prone to hospital acquired pneumonia • Whether any escalation by the doctors on ward 34 was made to orthopaedics between 9 and 15 March 2021. And if not, why?

• Why was there a delay in sending a trolley to take Mr B for X-rays after the orthopaedics review on the evening of 17 March 2021? A porter with a wheelchair only came to take Mr B for X-rays on the afternoon of 19 March 2021 and then returned with a trolley at 9.40pm when Mr B was half-asleep and unwilling to go for the X-rays. The X-rays did not take place until Saturday 20 March 2021 and this in turn delayed physiotherapy seeing Mr B until Monday 22 March 2021 • Review of blood tests in March 2021 to compare these to tests from November 2020 and January 2021, to judge whether Mr B had myeloma instead of MGUS in March 2021. Reviewing Mr B’s symptoms during his hospital stay to judge whether he had myeloma, especially as his medical records from March 2021 state that myeloma should be reviewed due to his out-of-range blood results. At Mr B’s inquest, the doctors present could not say for certainty whether Mr B had myeloma, and no haematology specialist was present • Why Mr B’s CRP marker never materially reduced despite antibiotics being administered from the day of admission on 6 March 2021? Which antibiotics were used, their doses and between what dates? If changes were made to the antibiotics, why and what were the conclusions on their effectiveness?

• How was Mr B’s fluid in lungs observation from 6 March 2021 investigated specifically? What diuretic medicine was being used and between what dates, and on which doctors’ recommendation? Did the doctors feel that this symptom was resolved?

• Personal distress to Miss A following bereavement in terms of the protracted complaint and delays in finding out exactly what went wrong and by whom from the Trust to try to ensure that errors are not repeated. The constant delays, typographical mistakes, and lack of response from the Trust meant Miss A could not pursue complaints to the NMC and the GMC. Miss A had to write to the Trust to eventually obtain the names of the nurses, which were provided on 3 May 2023 despite asking for their names since 17 March 2021. Actions were agreed with the Trust at a virtual meeting on 5 January 2022 and then they stopped responding or redirected Miss A towards Access to Health Records for some of her queries, and when Miss A approached Access to Health Records and waited the several months for them to consider her request, they signposted her to the Trust again. Miss A feels that she has been pushed around since Mr B’s admission, and no one wants to respond to her questions. It feels like a stalling tactic to not respond to her concerns when Mr B was alive, and now to give Miss A the run around on agreed actions and the Trust suggested deadlines and failing to deliver with no explanation. Miss A says this suggests maladministration as a minimum on the Trust’s part. She is unable to get closure, and Miss A says her family have been unable to complete the last religious rites for Mr B’s ashes (when this should be done soon after the cremation) • In addition, Miss A says her and her mother have had to leave the home that they shared with Mr B for 45 years as a direct consequence of his untimely death. Miss A says she had to relocate with her mother as they could not face going back to the Trust for her mother’s continued cancer care (she was diagnosed with oral cancer in January 2018 and was in the middle of her 5-years’ follow-up care with the Trust when Mr B died). Continuing to go to the Trust for quarterly check-ups caused Miss A and her mother immense anxiety and upset, and they had to move to be closer to other family, who could provide care for Miss A’s mother who is disabled, when Miss A needed to go into her office for work. Miss A says the legal remedy does not cover for these stresses, costs, and disruption in their lives and her mother’s cancer care, which incidentally was delayed by a year as it took this length of time for records to be passed by the Trust to the new hospital • During the inquest, Miss A says the coroner informed her that the Trust should have referred Mr B’s death in 2021 and her approach to the coroner had prompted an enquiry at the Trust and there were other instances where the Trust had not referred unexplained, and therefore potentially unnatural, deaths to the coroner’s service when it should have. Miss A says an earlier inquest would have helped to give her closure; instead, the Trust’s lack of referral to the coroner has contributed to her distress following bereavement from an avoidable death. Miss A says she felt suicidal since Mr B’s untimely passing and Trust processes, including the complaints process, have exacerbated her mental torture and anguish over several years • The doctors that attended the inquest clarified that Mr B did not have sepsis until the date of his death, yet the hospital medical records refer to sepsis and urosepsis throughout his stay of 3 weeks. Miss A says this has had an impact on the medical negligence claim as misleading records were referred to. Again, the consequence has been to delay resolution and closure which has contributed to Miss A’s distress and anguish. Proving the inaccurate records have also come at a financial cost to Miss A • Miss A says the inquest also brought to light two further safety incidents recorded on Mr B’s care and additional comments to a structured judgement review. These were not shared with Miss A by the Trust despite the formal complaint that she raised with them and corresponded at length on between 2021 and 2023. Miss A says she was only aware of the one death incident and structured judgement review comments up to a point prior to the inquest • Miss A says the doctors at the inquest could not agree whether Mr B had heart failure, however, one said that he had heart failure with preserved ejection fraction (HFpEF). This was the first time that clear reference was made to this despite Miss A asking about heart failure repeated times in her complaints about care since 2021 • Miss A says one doctor at Mr B’s inquest volunteered to keep her informed about the status of IT improvements that were planned at the Trust, at every 3 to 6 months intervals. Miss A contacted him 6 months after the inquest and was informed that nothing had progressed and that she should contact the Chief Executive of the Trust, which Miss A did immediately on 8 August 2024. Miss A says the Chief Executive then passed her concerns to the complaints team. It took until 4 November 2024 to respond and even then, their answers were not detailed and ignored two of Miss A’s questions. The Trust complaints process has not improved with time; in fact, the process has got worse because complaints addressed to the Chief Executive are ignored and without any explanation

4. Overall, Miss A says that Mr B’s death was avoidable, and this has caused her and her family a great deal of distress which is ongoing.

5. As a set of outcomes, Miss A wants further explanation about her outstanding concerns with Mr B’s care and changes in procedure at the Trust to prevent similar failings in the future. Miss A also wants a financial remedy of £2950.

6. Mr B was 74 years old. He was admitted to a hospital which is part of the Trust on 6 March 2021 with a history of and an inability to get up from a collapse onto the floor at home and subsequent difficulty passing urine. He had been complaining of back pain radiating into his legs for the few days before this admission.

7. The Trust queried whether Mr B was suffering from cauda equina, and investigations confirmed that he had severe spinal cord stenosis at L3, L4 and L5 which were likely to be degenerative, and the radiological team advised an urgent orthopaedic review. This review was requested immediately by the ward doctors on the 7 March 2021, and they continued to treat his other medical conditions including a urinary tract infection, heart failure, hyponatraemia, and low albumin all of which were complex and resulted in his condition becoming frailer.

8. Mr B was not reviewed by the orthopaedic team until the 17 March 2021 when it was confirmed by them that he was not suffering from cauda equina but did have a degenerative spinal condition which required no acute treatment and the advice was that he could mobilise immediately.

9. Sadly, by this time, Mr B’s physical condition meant that he was unable to mobilise. This delay led to Mr B being kept on precautionary bedrest although other significant factors were affecting Mr B’s ability to mobilise, as outlined above, even as early as his admission to hospital. Sadly, Mr B succumbed to pneumonia and died in hospital on 27 March 2021.

10. Miss A originally complained to the Trust in March 2021. She got a (first) final response to her complaint in June 2022 and originally brough her concerns to us later that month. We decided in March 2023 that Miss A had a reasonable alternative legal remedy to resolve her complaint about the Trust.

11. Miss A then pursued a successful clinical negligence claim against the Trust on behalf of Mr B’s estate. The judgement in the legal action indicates there was an unacceptable delay in Mr B being seen by an orthopaedic surgeon when he was in hospital. This contributed to Mr B developing hospital acquired pneumonia and probably contributed to his death. The legal action achieved £55,000 in compensation from the Trust.

12. Meanwhile, Miss A had continued to raise concerns with the Trust during 2023 and 2024. She received a (second) final response to her complaint in February 2025. After conclusion of the legal action, Miss A reapproached us in August 2025.

14. We cannot investigate a complaint where there is a reasonable alternative legal remedy. If legal action has resolved a complaint, we would not consider it any further. For all other issues that were not resolved by legal action, we then consider if there are indications of failings that have led to an unremedied injustice.

Mr B’s care issues and impact on him

15. Bullet points 1-6, as outlined in ‘The Complaint’ section above, are directly about the care that Mr B received from the Trust when he was in hospital during March 2021.

16. We consider they form part of the clinical negligence claim that has been resolved by settlement. While it is unfortunate that Miss A feels these issues were omitted from the claim, we consider they have already been adequately remedied by the legal action. If Miss A felt they were outstanding, she could have specifically raised them with her legal representatives at the time. Overall, Miss A had an alternative legal remedy to deal with these issues. Therefore, we do not intend to consider them any further.

Complaint handling and impacts on Miss A and her mother

17. Bullet points 7, 8 and 13 are about how the Trust handled Miss A’s complaint and the related impacts on Miss A and her mother.

18. We are sorry to hear about how protracted the complaints process was with the Trust and the related difficulties that Miss A encountered. We appreciate that this was ongoing (on and off) for approximately four years from 2021 until 2025 which must have been time-consuming, as well as frustrating for Miss A.

19. Our Principles for Remedy state: ‘an appropriate range of remedies will include:

• an apology, explanation, and acknowledgement of responsibility • remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these.

20. In situations like this, we must consider the significance of the impact, and look to see what action, if any, has already been taken. In the Trust’s complaint response dated 5 February 2025, it apologised to Miss A for its management of her complaint. It informed Miss A that since 2022 there had been significant changes and improvements within the complaints structure. It also clarified which policies its complaints team adhere to.

21. Furthermore, the Trust has informed us that since 2022, a new complaints team has been formed to deal with formal complaints which is separate to PALS. This means the formal complaints process is more focussed for complainants. It allows formal complaints to be acknowledged more promptly and responses to be issued in a timely way. A new role of Complaints/PALS Lead has been created to oversee the team. Also, more senior staff have committed to involvement in the more challenging complaints received by the Trust. This ensures greater oversight in dealing with complaints, as well as more depth of knowledge and experience of clinical issues to assist in responding to concerns.

22. We are satisfied these apologies and remedial action constitute sufficient action by the Trust, in line with Our Principles, in response to the impacts caused to Miss A by the complaints process. The Schedule of Loss from the clinical negligence claim that Miss A has provided refers to a sum for the scattering of Mr B’s ashes. Therefore, we consider this fell under the scope of the legal claim.

23. We are also sorry to hear that Miss A and her mother felt the need to relocate from their home of 45 years as they had lost faith in the Trust and did not feel confident that it would provide appropriate cancer care to Miss A’s mother, given what happened to Mr B. We appreciate the relocation would have caused stress, anxiety, upset, financial costs and disruption for Miss A and her mother.

24. We note this was not part of the Schedule of Loss. It seems likely that it would have been highly contested (as part of the legal process) to suggest losses incurred by the Trust’s breach of its duty of care to Mr B, included his wife and daughter (Miss A) needing to relocate to another part of the country.

25. There is a link, but it is not part of Mr B’s care issues. It is specific to Miss A and her mother who say the impact is that they did not want to use the Trust. It does not say that they explored using another Trust nearby. Therefore, we consider the relocation issue forms part of wider decisions made after the death of Mr B for which his estate has already been compensated by the Trust through the legal action. In other words, we respect the family’s decision to relocate, but we could never link any failings by the Trust to this as it was their decision to do this.

26. As for the Trust’s promised IT improvements, this is linked to the assurances about improvements in the Trust’s complaints process as highlighted earlier. The Trust’s complaint response letter dated 5 February 2025 stated that the Trust’s core patient administration system remained on track for March 2025. This will help improve tracking referrals between Trust services. The Trust also confirmed that the introduction of e-Trauma is in progress.

27. Unfortunately, improvements like this can take time and while the delays highlighted by Miss A are regrettable, the Trust has, in line with our Principles, provided assurances that the implementation of IT improvements is now complete. Therefore, we consider a sufficient remedy has been put in place and there is no further action for us to take.

Inquest/coroner issues and impacts on Miss A

28. Bullet points 9, 10, 11 and 12 are about inquest/coroner issues and related impacts on Miss A.

29. We are sorry to hear that the Trust did not refer Mr B’s death to the coroner in 2021 when it should have done. It is understandable that an earlier referral would have helped to give Miss A closure and because this did not happen promptly and complete until 2024, these delays exacerbated Miss A’s overall distress after Mr B’s sad death.

30. The Trust explained in its complaint response letter dated 5 February 2025 that in 2021, many deaths with concerns about the care provided were subject to internal review rather than coroner referral. This has now changed so all deaths where there have been possible problems in care or the death is considered to be of unnatural causes are referred to the coroner.

31. We note that Miss A feels that misleading records were referred to about whether Mr B had sepsis. We have not seen Mr B’s medical records, but if they were considered misleading or inappropriate, we would have expected this to be picked up by medical experts and considered as part of the negligence claim as it goes towards establishing negligence.

32. If Miss A is suggesting this impacted the medical negligence claim, we consider she should have raised this with her solicitor and addressed it as part of the claim. Any delays this caused would usually be considered when the settlement was being agreed as part of negotiations.

33. The issue about the two other safety incidents regarding Mr B that arose through the inquest is linked to the handling of Miss A’s complaint by the Trust. This must have been an unexpected shock for Miss A.

34. The Trust explained in its complaint response letter dated 5 February 2025 that both these incidents were categorised as ‘minor harm incidents’, so Duty of Candour did not apply. It explained why these reports were shared with Miss A and her family at the inquest. It also explained the background to Duty of Candour requirements and its relationship with the complaints process.

35. Miss A says the doctors at the inquest could not agree whether Mr B had heart failure, but one said he did. We appreciate this was another shock for Miss A as it was the first time clear reference was made to Mr B having heart failure despite her asking the Trust about it on several occasions since 2021.

36. The record of the inquest document provided to us by Miss A states that heart failure was one of the conditions that Mr B was being treated for by the Trust when he was in hospital in March 2021. It seems likely this information was taken from Mr B’s medical records (which we have not seen) provided by the Trust. We know there were some problems with the Trust’s complaint responses including typographical mistakes and questions not always being as fully addressed as Miss A would have liked. This could be why Miss A only found out at the inquest, but it is also not unusual for doctors to have different opinions about a patient’s conditions and diagnosis.

37. Separately, it should also be pointed out that this is a clinical question about the care provided to Mr B by the Trust. Therefore, we consider it would fall under the clinical negligence claim alongside other points highlighted above. Overall, we are satisfied that the Trust has addressed Mr B’s inquest/coroner issues appropriately, so no further action from us is necessary.

38. In summary, Mr B died unexpectedly in 2021 after a period in hospital. This was a tragedy for Miss A and her family which they are still coming to terms with over four years later. We do not underestimate the impact of these events on Miss A and her family, but we consider the issues that Miss A feels are still outstanding have already been adequately addressed and remedied by the Trust and through the legal action taken. It is unfortunate that local resolution with the Trust was so convoluted and time-consuming. We acknowledge that this may have exacerbated Miss A’s grief but, eventually, we are satisfied that the Trust has adequately addressed the outstanding issues. We decided in 2023 that Miss A had a reasonable alternative legal remedy to resolve her complaint against the Trust. Miss A was subsequently involved in successful legal action against the Trust on behalf of her father’s estate. A financial settlement of £55,000 was agreed with the Trust which we consider adequately remedies the clinical issues. While we recognise the strength of feeling from Miss A regarding these issues, we do not consider there is any further action for us to take.

1. We have carefully considered Miss A’s complaint about University Hospitals of Leicester NHS Trust.

• We consider that some of the concerns Miss A has brought to us are covered and adequately remedied by the legal action already taken against the Trust • We have decided the Trust has already done enough to put right the impact of some of these events on Miss A.

2. We appreciate that Mr B’s death was unexpected and heartbreaking for Miss A and her family. They are still coming to terms with these tragic events. We also recognise that Miss A still has outstanding concerns after taking successful legal action against the Trust, but we consider that some of these concerns have already been adequately remedied by the legal action. We consider that Miss A’s other outstanding concerns have already been adequately addressed by remedial action taken by the Trust. Therefore, we do not intend to consider Miss A’s outstanding concerns any further.