The Dudley Group NHS Foundation Trust

The Royal Wolverhampton NHS Trust

4. Mrs X complains about aspects of the care and treatment provided to her husband, Mr X, by the Royal Wolverhampton NHS Trust during his inpatient stay between 22 December 2023 to 30 August 2024. Specifically, Mrs X complains the Trust:

• failed to conduct a timely diagnosis and lack of follow up treatment/assessments • misinterpreted Mr X’s symptoms • failed to discuss Mr X’s pancytopenia diagnosis with him or his wife • failed to provide appropriate care and treatment to Mr X • failed to evaluate Mr X’s condition proportionate to the seriousness of his multifactorial condition • failed to discuss DNR and palliative care with Mrs X • kept trying to treat Mr X when he was actively dying instead of doing more end of life; and • did not enter Mr X’s room to close his eyes or communicate with the family and Mrs W in the room upon his death.

5. Mrs X says the Trust’s actions have amounted to improper care and treatment of Mr X. Mrs X specifically says that the improper care and treatment of the necrosis impacted Mr X’s ability to walk. Mrs X tells that because he could not walk, Mr X became extremely depressed. Mrs X says if not for the Trust’s poor service, Mr X may have been well enough to go through chemotherapy. Mrs X adds the Trust’s actions have amounted to poor service that extended Mr X’s suffering at the time of his death and says his suffering was avoidable. Mrs X tells that Mr X and herself were distressed during Mr X’s hospital admissions. Mrs X believes that Mr X had an extremely undignified death. Mrs X adds she feels the Trust lacked communication and honesty about the severity of Mr X’s condition and how long he had left to live.

6. As an outcome to her complaint, Mrs X is seeking service improvements, and an acknowledgement. Mrs X also seeks a financial remedy of between £1,250 and £12,500 or more to recognise Mr X’s experience.

The Dudley Group NHS Foundation Trust

7. Mrs X complains about aspects of the care and treatment provided to her husband, Mr X, by the Dudley Group NHS Foundation Trust from 29 March 2024 to 3 May 2024. Specifically, Mrs X complains the Trust:

• should have withdrawn the prescribed antibiotics when adverse reactions arose in March 2024, considering they had known Mr X had an allergy to penicillin • neglected to ensure Mr X was not in pain or discomfort when he was in psychosis and having bowel problems • failed to have an appropriate on-call consultant available on a bank holiday • incorrectly assessed Mr X’s vitamin needs and failed to recognise his multifactorial condition required further vitamin B12 injections • failed to inform Mrs X of Mr X’s fall during admission • insufficiently treated the necrosis on Mr X’s heel, letting it get worse • produced an incorrect final report as physiotherapy plans were documented as carried out when, in fact, they were not; and • failed to discuss DNR with Mrs X as Mr X’s wife when appropriate, given his age and condition, when the Trust first thought he was seriously ill or before his operation.

8. Mrs X says the Trust’s actions have amounted to improper care and treatment of Mr X. She believes the improper care and treatment by the Trust led to a life expectancy estimate of only one year that further decreased due to the continuing improper care and treatment. Mr X died in a few months, short of the one-year life expectancy estimate. Mrs X specifically says that the improper care and treatment of the necrosis impacted Mr X’s ability to walk. Mrs W tells that because he could not walk, Mr W became extremely depressed. Mrs X tells Mr X and herself were distressed during Mr X’s operation at this Trust.

9. As an outcome to her complaint, Mrs X is seeking service improvements, and an acknowledgement. Mrs X also seeks a financial remedy of between £1,250 and £12,500 or more to recognise Mr X’s experience

13. We have carefully considered the available information. 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. We have discussed this with Mrs X to understand her circumstances and the outcomes she would like. We do not consider whether legal action would succeed but whether it would be a reasonable option.

14. Mrs X has raised several concerns about aspects of the clinical care and treatment both organisations provided to her husband, Mr X. She believes these failings reduced Mr X’s life expectancy and extended his suffering at the time of his death.

15. Mrs X has described the significant physical and emotional impact this had on Mr X. Mrs X would like a financial remedy in recognition of the impacts of the organisations’ failings. It appears there may be a potential clinical negligence action for Mrs X to consider. This is because she believes the failure in providing appropriate care and treatment resulted in further pain, suffering and loss of amenity, worsened treatment outcomes and reduced life expectancy for Mr X.

16. Clinical negligence occurs when the standard of care provided by a medical professional fall below what is reasonably expected, resulting in injury or loss. Negligence, in law, is an act or failure to act (omission), that does not meet the level of appropriate care expected, which results in injury or loss. If a doctor or health professional is negligent when giving you medical treatment, this is called 'clinical negligence'. As there are time limits for making a legal claim, we do not want to deprive her of this option when it could potentially achieve what she is seeking.

17. As a legal remedy appears to be open to Mrs X, we have gone on to consider whether it is reasonable for her to pursue the matter in that way. In doing this we have considered the outcomes sought, including the amount of financial remedy Mrs X seeks, and whether we are likely to recommend them in relation to the injustices claimed.

18. We considered whether legal action could achieve the outcomes Mrs X is seeking. Mrs X seeks service improvements, explanations and acknowledgement of responsibility. Mrs X would also like the organisations to review their diagnosis and treatment of the necrosis and the pancytopenia.

19. We discussed the figure Mrs X is hoping to achieve and shared our Severity of Injustice (SOI) Scale with her. While Mrs X could not specify an exact amount, she seeks a financial remedy of between £1,250 and £12,500 or more to recognise Mr X’s experience. We understand she is also hoping to receive compensation for the financial losses she suffered from Mr X’s loss of amenity and reduced life expectancy. We understand this to likely be more than what we would normally recommend.

20. Legal action could allow for a financial remedy in line with what Mrs X is seeking. Furthermore, it is more likely to lead to a higher award (covering general and special damages). While explanations, acknowledgement of responsibility, and service improvements would not be directly achievable through that process, it is a likely byproduct of successful legal action. Successful legal action is also likely to lead to the organisations reviewing their diagnosis and treatment of the necrosis and the pancytopenia. It therefore appears legal action could achieve the outcomes she is seeking.

21.

Lastly, we discussed whether there are any barriers in taking legal action. Mrs X has confirmed she has started legal action. That being said, Mrs X expressed concerns about the financial risk of the legal process. We appreciate her concerns in this and made her aware of potential options open to her such as pursuing a ‘no win no fee’ claim as well as signposting her to independent and impartial resources to finding free legal representation.

22. Mrs X can return to us if she finds she is unable to pursue legal action. She can also return to us if she has outstanding outcomes after legal action such as service improvements or if the court was unable to consider parts of her complaint. If she does decide to return to us, she should bring her complaint back to us promptly. Mrs X is aware of our time limits, as we are unable to investigate complaints brought to us 12 months after someone has become aware of the problem. We can put this time limit aside if we think there is a good reason to do so.

23. We thank her for bringing her concerns to us. We were sorry to hear of Mr and Mrs X’s experiences and the way Mr X died. We hope this statement clearly explains why it appears legal action could achieve the outcomes she is seeking.

1. We have carefully considered Mrs X’s complaint about The Royal Wolverhampton NHS Trust and The Dudley Group NHS Foundation Trust on behalf of her late husband, Mr X. We were sorry to hear how Mr and Mrs X had been affected.

2. Having reviewed the available evidence, we consider Mrs X could take legal action on the matters she has brought to us.

3. We will explain our reasons for our decision in this decision statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mrs X for sharing her experience with us.