19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We consider any gaps between the two and whether this amounted to maladministration or service failure. We have done this and have not found any indications that something has gone wrong.
Postmortem and incorrect cause of death
20. Miss X says Miss Y’s death certificate incorrectly states that she died from community acquired pneumonia (pneumonia acquired outside of healthcare facilities such as hospitals or nursing homes) and decompensated liver disease (advanced stage of liver damage where the liver can no longer maintain its normal function, leading to life-threatening complications). Miss X says Miss Y died from a cardiac arrest, and this was not included in Miss Y’s death certificate.
21. Miss X says the Trust did not carry out a postmortem of Miss Y’s death or consider that the death certificate may be wrong.
22. Guidance on the notification of death says medical practitioners are required to notify the coroner of a death if certain circumstances are met. Examples of these include poisoning, exposure to toxic substances, the use of medicinal products, controlled drugs or psychoactive substances, violence, trauma or injury, self-harm and neglect. Based on all the available evidence our adviser says Miss Y did not meet the criteria outlined in the regulations to be referred for a postmortem.
23. The Health and Care Bill 2021 implemented a medical examiner system to provide greater scrutiny of non-coronial deaths. It allowed NHS bodies to appoint medical examiners to scrutinise all deaths that did not require a coroner to be notified. Miss Y’s medical records show her death was reviewed by medical examiner in late May 2025.
24. The medical examiner agreed to the cause of death proposed by the attending practitioner. Community-acquired pneumonia was the cause of death and decompensated alcoholic liver disease contributed to the death.
25. Our adviser explained when a patient dies a cardiac arrest will occur as the heart will stop beating. They explain this would be the mode of death not the cause of death. They also explain that when the cause of death is documented on the death certificate, it would state what underlying health conditions a patient has which contributed to the persons death.
26. We consider the Trust acted in line with policy, guidance and legislation. The Trust correctly identified Miss Y did not meet the criteria for a postmortem. It has also followed legislation by carrying out a medical examination after Miss Y’s death. The attending practitioner and the medical examiner have agreed on a cause of death, and this has been signed on the death certificate.
27. We do not see a gap between what should have happened and what happened in relation to this complaint.
28. For these reasons we will not consider this issue further.
Mrs Y’s cardiac arrest
29. Miss X says the Trust delayed making a request for resuscitation when Miss Y went into cardiac arrest.
30. Our adviser explained that when a patient goes into cardiac arrest the attending nurse or doctor would raise the alarm (request resus) and then begin CPR (cardiopulmonary resuscitation – emergency procedure when heartbeat or breathing stops). They explained a different member of staff would then make the resus call.
31. Guidelines on adult basic life support emphasise the importance of early recognition of cardiac arrest to ensure the best possible outcomes.
32. A written statement from the attending nurse says they were attempting to provide care to Miss Y when they found her unresponsive with clenched teeth. We can see the nurse attempted to give care, but this did not work. The nurse called for help, pulled the emergency buzzer and commenced CPR whilst 2222 (cardiac arrest call) was contacted.
33. The medical notes show cardiac arrest began at 7am. At 7.03am the resus call was started. CPR was in process whilst the resus call was being made and therefore treatment was being given continuously to Miss Y.
34. Miss Y’s heart rhythm was checked eight times and adrenaline was given on four occasions. At 7.22am, after nineteen minutes of CPR, the team discussed and decided to stop Miss Y’s treatment.
35. We consider the Trust met its expectations in providing assistance to Miss Y when she went into cardiac arrest. Cardiac arrest was recognised quickly, and treatment was started. We do not see a delay in making the request for resus. We also see that CPR was began in a timely manner and continued throughout the nineteen minutes.
36. We cannot see a gap between what should have happened and what did happen and therefore do not see any indication of failings. We recognise our decision may be difficult for Miss X to read.
37. We are saddened to learn the circumstances of Miss Y’s death turned Miss X’s world upside down. We thank Miss X for taking the time to bring her complaint to our attention and for sharing details of such a devastating experience with us. We hope our explanation brings some reassurance about the care and treatment provided to Miss Y.