Mid and South Essex NHS Foundation Trust

2. Mr A complains about the care provided to his mother, Mrs C, by Mid and South Essex NHS Foundation Trust (the Trust) from 6 April to 5 May 2024. Specifically:

• Mr A says Healthcare Assistants (HCA’s) were rough and heavy-handed towards Mrs C whenever they were undertaking personal care, turning, and repositioning her. Mr A says this caused fractures to bones in Mrs C’s spine • Mr A says nurses attempted to apply safeguarding measures to the wrong patient because they could not pronounce Mrs C’s first name, and then failed to implement the safeguarding measures all together • on 5 May 2024, Mr A says Nurse B gave him prescribed medication for his mother to take instead of administering the medication to Mrs C herself, contrary to the Trust’s medication policy. The medication administered to Mrs C caused her to choke • Mr A says the Trust’s investigation of his concerns was flawed and undermined by multiple mistakes, deliberate lies, false omissions, and accusations in order to completely absolve nursing and medical staff from blame.

3. Mr A says that as a result of witnessing his mother’s traumatic avoidable death when she was in hospital, he has been signed-off work for over 6 months due to mental health issues including depression. Mr A says the experience will stay with him forever and he has suffered a considerable loss of earnings from being unable to work. Mr A has also moved out of the catchment area so he can avoid the hospital in the future. Moving house has cost him a considerable amount. Mr A’s father who has also since died was left in financial debt after his wife’s funeral.

4. Mr A wants changes in procedure at the Trust to prevent this happening to other patients. He also wants a financial remedy of £3977 to cover the cost of his mother’s funeral.

5. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

6. Mrs C was 92 years old and bed bound. She was frail and vulnerable with kyphotic postures and curvature of the spine, as well as being double incontinent. Mrs C was unable to speak due to her dementia and had difficulty eating and drinking. She went to Basildon Hospital which is part of the Trust on 6 April 2024 due to constipation. During the next 4 weeks, Mrs C was on the ward, but Mr A says there were many problems with the care provided to his mother by nurses and HCA’s.

7. For example, on 19 April 2024 Mr A says he had to ask the nurses to turn Mrs C onto her strongest side as he was worried about them damaging her joints and bones. On 25 April 2024, it was agreed that a specific HCA would no longer care for Mrs C. On 29 April, the same HCA attended to another patient on the ward and there was confusion about whether Mrs C or the other patient was to be moved.

8. On 5 May 2024, Mrs C was given prescribed dissolvable medication which she took. Unfortunately, the liquid foamed in the back of her throat blocking her airway. The Trust said nurses provided assistance on more than one occasion that evening through suctioning, and it was noted that only saliva was suctioned. The Trust said nurses completed clinical observations, and it was noted that Mrs C had no readable observations, and no pulse. Sadly, Mrs C had died.

9. The Trust initially thought Mrs C’s cause of death was pneumonia, advanced dementia, frailty, and colitis, but there was uncertainty about this, so it was referred to the coronary. After two interim Death Certificates had been issued, a Death Certificate dated 5 December 2024 stated that Mrs C had died due to old age, frailty, and dementia. This concurred with the findings of Mrs C’s post mortem.

Personal care

14. Mr A says HCAs were rough and heavy-handed towards Mrs C whenever they were undertaking personal care, turning, and repositioning her. Mr A says this caused fractures to bones in Mrs C’s spine.

15. We understand there would have been some challenges with Mrs C’s personal care, turning, and repositioning whilst she was on the ward given her different health conditions, lack of mobility and general frailty. We recognise that personal care tasks must have been uncomfortable for Mrs C and distressing for Mr A to witness. Our adviser says the relevant NICE guidance for HCA’s (under the supervision of nurses) in this type of situation states at paragraph 1.2.9:

‘Ensure that the patient's personal needs (for example, relating to continence, personal hygiene, and comfort) are regularly reviewed and addressed. Regularly ask patients who are unable to manage their personal needs what help they need. Address their needs at the time of asking and ensure maximum privacy.’

16. On Mrs C’s admission to hospital on 6 April 2024, it is documented in the records within a moving and handling assessment that she was bedbound and required physical assistance with the use of aids for all movement, including the use of a hoist. A patient movement assessment and care plan was also completed on 8 April 2024 and stated that Mrs C required use of a hoist and sling.

17. Our adviser says there is evidence of regular repositioning of Mrs C throughout this episode of care from assessment documents in the records. Within these assessments, it states which position Mrs C is in, which position she has been changed to, if she is compliant with the turns and if she requires analgesia, details which we would expect to see.

18. On 11 April 2024, it is documented that Mr A called the ward requesting that due to two fractures that his mother ‘still had’, she should be positioned regularly on her right side. This is documented in Mrs C’s records on several occasions.

19. In summary, given Mrs C’s health conditions, and general frailty, it must have been a challenging situation for the HCA’s who were involved in her personal care, turning, and repositioning her. We were not present when this was happening and although we do not discount Mr A’s recollections that HCAs were heavy handed towards Mrs C, we have not seen evidence of this. Our nurse adviser says the contemporaneous records indicate that the HCAs acted in accordance with the NICE guidance when providing Mrs C with personal care and undertaking repositioning. We have not seen evidence that care provided to Mrs C by HCAs when she was in hospital from 6 April to 5 May 2024 caused fractures to bones in her spine, as Mr A has suggested.

Safeguarding

20. Mr A says nurses attempted to apply safeguarding measures to the wrong patient because they could not pronounce Mrs C’s first name and then failed to implement the safeguarding measures all together.

21. We are sorry to hear about this incident which must have been concerning for Mr A and Mrs C at the time. The Trust acknowledged in its complaint response that a safeguarding issue was raised regarding Mr A’s concerns about the HCA. It also acknowledged there was some confusion on 29 April 2024 regarding whether Mrs C or another patient was to be transferred.

22. We were not present at the time, so we cannot be sure what happened in terms of applying safeguarding measures to the right patient or whether nurses could pronounce Mrs C’s name. We consider this is an unfortunate one-off incident that can happen on a busy hospital ward. The Trust has apologised and made it clear that verbal instructions should be clear when a patient is to be moved. If there is any confusion, this should be clarified before the transfer takes place.

23. Our adviser has considered Mrs C’s records and which safeguarding measures should have been in place for her. Safeguarding for Mrs C centred on the MCA and DoLS which is part of the MCA legislation.

24. The MCA indicates that care must be delivered according to the principles. The MCA states that a person must be assumed to have capacity unless proven otherwise and that any action on behalf of someone lacking capacity must be in their "best interests".

25. The DoLS indicates that in cases where care and treatment might deprive a patient of their liberty, hospitals must follow the DoLS authorization process. This legal framework ensures restrictions are in the patient's best interest and are proportionate to the risk.

26. Our adviser says that Mrs C had a capacity assessment completed on admission and was deemed not to have capacity. A further capacity assessment was undertaken on 10 April 2024, signed by two healthcare professionals, which again deemed that she did not have capacity.

27. On 14 April 2024, it is noted that a DoLS had been submitted as Mrs C could not consent to treatment and remaining in hospital. The records also indicate that a referral to the safeguarding team was made due to the strained relationship between Mrs C’s husband and his son, as well as him refusing any social care support in caring for his wife. Mr A disputes that his relationship with his father was strained.

28. In relation to planning and communicating Mrs C’s care, our adviser says the records indicate that her husband was constantly with her whilst she was in hospital and her son also visited regularly. It is documented that conversations were had daily about Mrs C’s condition and treatment. Overall, we consider that appropriate safeguarding measures were applied to Mrs C throughout this episode of care in accordance with the MCA and DoLS guidance.

Medication on 5 May 2024

29. On 5 May 2024, Mr A says Nurse B gave him prescribed medication for his mother to take instead of administering the medication to Mrs C herself, contrary to the Trust’s medication policy. Mr A says the medication administered to Mrs C caused her to choke and led to her tragic death.

30. Mrs C’s medication administration chart indicates that Nurse B gave her Sando-K (oral replacement of potassium) at 9.30pm on 5 May 2024. Our adviser says that the usual dosage for oral replacement of potassium is two tablets, three times a day. This concurs with what was administered by the nurse at this time and is in accordance with the NHS guidance for the treatment of Hypokalaemia in Adults.

31. We note that Nurse B has documented in the records at this time that she was trying to give Mrs C sips of the Sando-K, dispersed in water but that she was not tolerating it. According to the records, Mr A asked for the medication to be left with him as Mrs C would take things for him. Nurse B has documented in the records that she refused to do this, and that Mr A was unhappy about this.

32. Unfortunately, shortly after this, Mrs C began to cough and then started choking. The nurses tried to deal with this by using suctioning on Mrs C. The Basic Life Support (BLS) protocol, in accordance with the Resuscitation Council UK, Adult choking algorithm, in place (from 2021) at the time of this episode of care was to assess severity and consciousness of a patient which the nurses did for Mrs C. Then, continue to check for deterioration until obstruction is relieved. Mrs C had a cough and had started to choke, but the suctioning tried to relieve her airway in accordance with the guidance in place at the time. Our adviser says this guidance was updated in 2025 to call the resuscitation team, call for help, and try to dislodge the foreign body.

33. Our adviser says it would have been difficult to try and dislodge what Mrs C was choking on if it was liquid, therefore the nurse followed an appropriate course of action by using suction to try and clear her airway.

34. We appreciate there are conflicting accounts of what happened with Mrs C’s Sando-K medication on 5 May 2024. We were not present at the time, so we cannot fully verify what happened. What we do know is that Mrs C’s condition deteriorated after this incident and she tragically died on 5 May 2024.

35. Nurse B has fully documented her account of events in Mrs C’s records, as outlined above. As there was uncertainty about Mrs C’s cause of death, it was referred to the coroner. We have considered the post mortem report which did not find any airway obstruction or evidence of aspiration in Mrs C. The cause of Mrs C’s death as stated in the post mortem is old age, frailty, and dementia. This concurs with her Death Certificate. These documents do not indicate that Mrs C’s death was caused by the medication she was given on 5 May 2024 or the reported choking that she suffered. On the balance of probabilities, we consider that Nurse B administered an appropriate dose of Sando-K to Mrs C on 5 May 2024, in accordance with relevant guidance. Even if this did cause Mrs C to cough or experience choking symptoms, there is insufficient evidence for us to say that the medication administered caused Mrs C's sad death.

Investigation of complaint

36. Mr A says the Trust’s investigation of his concerns was flawed and undermined by multiple mistakes, deliberate lies, false omissions, and accusations in order to completely absolve nursing and medical staff from blame.

37. We note that Mr A originally made a complaint to the Trust on 20 April 2024. The Trust acknowledged this on 23 April 2024, and it asked for further personal details about Mrs C on 10 May 2024 which were provided by Mr A. The Trust then escalated the complaint to its complaints team. The Trust said on 10 May 2024 that it aimed to complete the investigation within 40 working days, but that it could take up to 60 working days.

38. The Trust provided its written response to Mr A’s complaint on 18 June 2024. Having considered the Trust’s response, we did not see evidence of flaws, mistakes, lies, false omissions or accusations in its investigation of Mr A’s complaint. Therefore, we asked Mr A to provide examples of these.

39. Unfortunately, the original examples provided by Mr A were in relation to Mrs C’s care rather than in relation to how the Trust handled or investigated his complaint.

40. Mr A was unhappy with the Trust’s response, so he wrote back to it on 28 June 2024. The Trust replied on 4 July 2024 stating there was no further information it could provide and that it felt local resolution of Mr A’s complaint was exhausted. Therefore, the Trust suggested that Mr A contact the Ombudsman as a next step.

41. Mr A wrote to the Trust again on 25 July 2024, in response to its letter dated 18 June 2024. The Trust replied on 31 July 2024 reiterating its previous advice and steering Mr A to the Ombudsman. Mr A submitted his complaint to the Ombudsman in October 2024.

42. However, Mr A has highlighted that the timings around his mother’s death in the Trust’s letter of 18 June 2024 are incorrect. Having reviewed this letter, we consider it wrongly implies that Mrs C was still alive up until approximately 11am on the morning of 6 May 2024. In fact, Mrs C had sadly died the previous evening as verified by her Death Certificate. Mr A says his mother died at approximately 9.50pm on 5 May 2024. The Trust’s contemporaneous records state that Mrs C was not breathing and had no pulse at 10.41pm on 5 May 2024. It is recorded that Mrs C had died by 11.42pm on 5 May 2024, but her death was not fully verified until the early hours of 6 May 2024. This may have led to some confusion about the date of Mrs C death, as reflected in some of the records we have seen.

43. In summary, the Trust provided a substantive written response to Mr A’s complaint. Mr A has rightly highlighted an unfortunate error around the timings and date of his mother’s sad death in the Trust’s complaint response. We recognise this is upsetting for Mr A in addition to his bereavement, but we do not consider that it constitutes maladministration by the Trust. We have not seen evidence of flaws, multiple mistakes, lies, false omissions or accusations in this or in the Trust’s wider investigation of Mr A’s complaint, as he suggests. We appreciate that Mr A was unhappy with the response to his complaint by the Trust. He went back to the Trust on more than one occasion seeking further clarification of points that he felt were outstanding, but the Trust did not feel it could provide him with any further clarification. That is the Trust’s prerogative, and it correctly referred Mr A to the Ombudsman as a potential next step.

44. This concludes our investigation of the complaint. Please note there are legal restrictions on disclosing information that we give you. This means that you cannot share or make public any information or documents we gave you during our investigation. The legal restrictions do not apply to this final report.

1. We have not seen any failings in the nurse or healthcare assistant care provided to Mrs C by the Trust from 6 April to 5 May 2024, or in the Trust’s investigation of Mr A’s complaint. Therefore, we will not uphold Mr A’s complaint.