We have set out the reason for our decision under subheadings below.
Communication
18. Mr D told us the family were not made aware of how serious Mrs D’s condition was during her final admission. He said they felt unprepared for the rapid deterioration on 17 July and believed clearer communication from the Trust would have helped them understand what to expect.
19. The records show the Trust updated the family at 12.25am on 16 July with Mrs D’s care plan at that time. Aside from this update, we found no evidence of further conversations with the family about her prognosis, expected deterioration, or treatment limits.
20. Given Mrs D’s very poor outlook, GMC guidance and ReSPECT framework indicates the Trust should have had clearer and earlier discussions with her family about the seriousness of her condition.
21. GMC guidance on end‑of‑life communication emphasises the importance of honest discussions with families about expected decline, treatment limitations, and likely outcomes. The ReSPECT framework also highlights the need for shared decision‑making and documented escalation plans to help families prepare for deterioration. There is no evidence the Trust held these conversations with the family.
22. Our adviser told us communication with the family should have been clearer earlier in the admission, particularly around Mrs D’s prognosis and the likelihood of deterioration. He explained Mrs D had significant underlying health conditions, and her decline was not unexpected.
23. Our adviser explained a clear discussion about the limits of treatment and what the family should prepare for would have been appropriate. There is no evidence these conversations took place.
24. The absence of clear communication about Mrs D’s prognosis meant the family were not prepared for her deterioration on 17 July. Earlier and clearer conversations may have reduced the shock and distress they experienced.
25. We have considered the impact of the indicated failings in communication, as set out above, and reviewed what the Trust has already done to put things right. The Trust acknowledged communication was not always consistent, apologised for not addressing the family’s concerns and for not sharing information about Mrs D’s investigations and treatment plan, and has shared the learning with relevant staff.
26. The service improvements the Trust has introduced focus on training and clinical documentation in relation to deteriorating patients. These actions may indirectly support clearer communication in future.
27. The NHS Complaints Standards say organisations should identify when things have gone wrong and take responsibility for them. Our Severity of Injustice Scale explains where the impact is short‑lived emotional distress, and there is no ongoing or wider effect that can now be remedied, an apology is usually an appropriate response.
28. In this case, Mrs D’s family suffered emotional distress at the time, and the Trust’s apologies and actions are proportionate to that level of impact. We do not consider a financial remedy to be required.
29. We are very sorry to hear how difficult this was for Mr D and his family. The Trust has acknowledged the indications of failings in communication and taken steps to address them, and we are satisfied that no further action is required on this part of the complaint.
Inappropriate food 30. Mrs D’s family told us they were shocked to find bread on her breakfast tray on 17 July, even though staff already knew she had swallowing difficulties.
31. RCSLT guidance and the BDA/IDDSI framework states patients with swallowing difficulties must receive texture‑modified diets that match their assessed needs. A level four puréed diet means food must be smooth, blended, and free from lumps, and should not require chewing. Fluids prescribed at level zero (thin) are standard liquids that do not require thickening.
32. The records show at 1.50am on 16 July, staff documented Mrs D’s pre‑existing swallowing difficulties due to vocal cord palsy and prescribed a thin fluid and puréed diet in line with this guidance. Despite this, after her overnight transfer, staff placed solid food (bread) on her tray in error.
33. The Trust accepted this was inappropriate and apologised. It explained Mrs D’s dietary requirements were not handed over clearly during the transfer, which led to the wrong meal being provided.
34. We understand the family were concerned about the risks of Mrs D being given bread when she had known swallowing difficulties. We found no evidence Mrs D ate the bread, and the records do not show she consumed any solid food.
35. Our adviser explained her deterioration had already begun before the bread was provided, and her longstanding swallowing difficulties meant she was always at risk of aspiration, even without solid food. Aspiration happens when food, drink, or saliva enters the airway instead of the stomach and can sometimes lead to a chest infection known as aspiration pneumonia.
36. Although aspiration pneumonia was considered during her clinical investigations, CT and chest imaging did not show evidence of this. Mrs D died following a cardiac arrest, with pulmonary fibrosis recorded as the underlying condition.
37. Taking this into account, the provision of the bread to Mrs D caused her family distress and presented an avoidable risk. There is no evidence of clinical harm linked to the incident.
38. We have considered this impact and reviewed what the Trust has done to put things right. The Trust acknowledged the error, apologised, and introduced safeguards such as mealtime coordinators and enhanced monitoring of food and fluid charts to ensure meals match patients’ assessed needs.
39. In this case, the Trust’s apology and service improvements are proportionate to the level of injustice and reduce the risk of recurrence. This is in line with the NHS Complaints Standards. We will take no further action on this part of the complaint.
40. We appreciate how upsetting it must have been for the family to see unsuitable food offered at such a sensitive time. Their willingness to raise this concern has allowed the Trust to reflect on what happened and strengthen its practice.
Delays in investigations 41. Mrs D’s family told us they were worried about delays and confusion in her care plan. They said staff did not share results before her transfer from the Acute Medical Unit to the ward and did not explain whether referrals to speech and language therapy or dietetics had been made.
42. They also told us they repeatedly asked about urine tests, ultrasound, and whether a catheter was needed, but did not receive clear answers. This left them feeling the original plan was not being followed.
43. The records show on 15 July doctors reviewed Mrs D and set out a plan for blood tests, intravenous (IV) fluids, a chest X‑ray, urine osmolarity (a test that measures how concentrated the urine is), and an abdominal ultrasound.
44. Staff carried out several elements of this plan. They took blood tests at 11.01pm, administered IV fluids between 8pm and 2am, and performed a chest X‑ray that night. Staff repeated blood tests on 16 and 17 July, repeated the chest X‑ray on 17 July, and performed a bladder scan on 16 July. Doctors also requested CT imaging on 17 and 18 July.
45. Staff did not repeat the urine osmolarity test or abdominal ultrasound during this admission. Instead, clinicians relied on recent results already available in the record, including an abdominal ultrasound from January 2023 and osmolarity results from June and July 2023.
46. A urine sample was taken, which ruled out infection, but this was not the osmolarity test originally planned. The Trust explained some investigations could not be carried out overnight and that clinicians prioritised urgent imaging based on clinical need.
47. It also confirmed recent speech and language therapy and dietetics assessments were available electronically, so staff did not need to make new referrals. The Trust apologised for not communicating this clearly to the family.
48. Our adviser reviewed the records and noted that although not every step was documented in detail, the investigations carried out were reasonable and clinically appropriate. There is no indication that any delays in investigations altered Mrs D’s clinical outcome.
49. GMC guidance says clinicians should use their judgement to balance risks, avoid unnecessary repeat testing, and prioritise the most urgent investigations. There is no indication that they failed to do this with Mrs D.
50. We recognise the family felt distressed by the uncertainty around what investigations were being carried out and why some were not repeated. The Trust acknowledged its communication about these decisions was unclear and apologised.
51. The clinical investigations themselves were reasonable and appropriately prioritised, so we do not find anything went seriously wrong in terms of delays in investigations. The issue here was the lack of clear explanation, which caused understandable worry for the family.
52. The Trust has apologised for this and reinforced communication processes with staff. Given the nature of the injustice and the steps already taken, we are satisfied the Trust has done enough to put this right in line with the NHS Complaints Standards. We will not take further action on this part of the complaint.
Response to deterioration 53. Mr D told us he was concerned staff did not act quickly enough when Mrs D deteriorated on 17 July. He said her breathing worsened, her oxygen needs increased, and her level of consciousness dropped, but staff did not escalate her care promptly. We understand why this felt alarming for the family.
54. The records show at 6.52am on 17 July, Mrs D had a NEWS score of six, which indicates a high risk of deterioration. The National Early Warning Score (NEWS) is a system used in UK hospitals to identify when a patient may be becoming critically unwell.
55. Staff increased her oxygen from one to three litres per minute when her oxygen levels fell to 89%, and this improved her saturations to 95%.
56. At 10.47am, staff took a venous blood gas which showed severely abnormal results, indicating type 2 respiratory failure. This happens when the lungs cannot remove enough carbon dioxide from the body, meaning the person is not effectively exchanging gases. The records also show a drop in Mrs D’s level of consciousness around this time.
57. The Glasgow Coma Scale (GCS) is used to measure how responsive a person is, and a lower score can indicate deterioration. Our adviser explained results like this, combined with a reduced GCS, would normally prompt immediate escalation to a senior doctor under NICE CG50 and GMC Good Medical Practice. A consultant reviewed Mrs D later that day, requested a repeat blood gas, and the repeat test showed improvement.
58. The records also show staff recorded no routine observations between 10.09am and 5.17pm, leaving a seven‑hour gap. Under RCP NEWS2 guidance, a NEWS score of three requires observations at least every six hours. Staff took them just over seven hours later, which was not in line with guidance.
59. Whilst this delay was not in line with guidance, our adviser told us it did not have clinical consequence, as Mrs D’s NEWS scores had been consistently low (two to three) for more than a day and a half.
60. Our adviser explained the actions staff did take, including increasing Mrs D’s oxygen, repeating blood gases, prescribing antibiotics and arranging a consultant review, were reasonable in the context of Mrs D’s chronic and severe respiratory condition.
61. The Trust’s Deteriorating Patient Policy requires urgent senior assessment within 60 minutes for NEWS scores of five to six. In Mrs D’s case, escalation was slower than this protocol recommends, and documentation of escalation actions was limited. This represents an indication of a failing to follow escalation policy, although it did not change the clinical outcome.
62. Our adviser explained Mrs D’s deterioration and cardiac arrest were expected outcomes of her pulmonary fibrosis and chest infection. Earlier escalation and clearer planning may have reduced uncertainty for the family, but we are not able to say they would have prevented her deterioration or death.
63. We recognise how distressing it was for the family to witness Mrs D’s breathing worsen and to feel her care was not being escalated quickly enough. The Trust acknowledged escalation was slower than expected and apologised.
64. It reflected on this with the nursing team, reminded staff to use clinical judgement alongside NEWS scores, and arranged deteriorating patient training to strengthen staff confidence in recognising and responding to deterioration.
65. The Trust also apologised for the delay in observations and said this had been fed back to the nursing team, with the need for timely monitoring included in the deteriorating patient training. It shared the complaint with the relevant teams for learning. This is in line with the NHS Complaints Standards, which say organisations should identify when things have gone wrong and take responsibility for them. There is no further action we think we need to ask the Trust to take.