20. 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. For some of Miss M’s complaint, we have not seen indications that things went wrong.
21. If we see indications something has gone wrong, we then look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we consider the Trust has already done enough to put right the impact of these events where there are indications things may have gone wrong.
Discussing a likely cancer diagnosis with Mr M, without his family present.
22. Miss M complains on 30 April, staff discussed a likely cancer diagnosis with Mr M, without his family present to support him.
23. Miss M told us since experiencing a stroke, Mr M had not been retaining information well. She said Mr M had a note on the front of his notebook which said important information should only be given to him when his family were present to support him.
24. Miss M said a doctor reviewed Mr M on the ward, on 30 April, when he was alone. She said the doctor asked him if he knew why he was in hospital and Mr M said it was because of his chronic obstructive pulmonary disease (COPD, a group of lung conditions that cause breathing difficulties) and a stroke. She said the doctor told him he also had cancer. Miss M told us following this, Mr M phoned her to tell her what had happened and was very upset. She told us how distressing this was for her.
25. In its complaint response of 20 January 2025, the Trust clarified Mr M was not given a formal diagnosis of cancer during the discussion in hospital on 30 April. It said the documentation suggests one of the differential diagnoses considered was cancer.
26. It is documented in Mr M’s medical records he was reviewed by the respiratory team on the morning of 30 April. Staff documented Mr M seemed lucid during the review, and a potential underlying cancer was discussed.
27. The GMC’s guidance on Decision Making and Consent says medical professionals must start from the presumption that all adult patients have capacity to make decisions about their treatment and care. Our physician adviser said there is nothing in Mr M’s medical records suggesting he did not have capacity. They said when communicating with an adult who has decision-making capacity, information regarding their care should be discussed directly with them unless they have explicitly requested otherwise.
28. GMC Good Medical Practice says doctors must promptly provide suitable advice when needed. Our physician adviser said it was reasonable for the doctor to have had this conversation with Mr M while he was on his own on 30 April. They said while the presence of family members is preferable, their absence should not delay the provision of essential information.
29. It is also documented in Mr M’s medical records he had a telephone consultation with the respiratory team on 10 April 2024, prior to his inpatient stay. Staff documented his partner was with him during the consultation, and he was made aware of a possible underlying cancer at this time. Our physician adviser noted considering this phone consultation, the discussion on the ward on 30 April was not the first time Mr M had been told of a potential cancer diagnosis, considering his phone consultation on 10 April.
30. Having considered the evidence available for this part of Miss M’s complaint we have not seen the Trust got things wrong. While it would have been preferable for Mr M’s family to have been with him when he was reviewed by the respiratory team on 30 April, staff acted in line with guidance by providing him with an update promptly when they saw him.
31. We acknowledge Mr M was very upset after talking about a possible cancer diagnosis with a doctor when he was on his own. We can also see it would have been distressing for Miss M to receive a phone call from her father upset when he was alone in hospital. We are sorry this is not the outcome Miss M is hoping for.
Communicating Mr M’s cancer diagnosis with Mr M’s family
32. Miss M complains the Trust did not clearly communicate Mr M’s cancer diagnosis with his family in a timely manner. Miss M told us the Trust should have communicated his diagnosis following the lung MDT meeting on 3 May 2024.
33. In its complaint response of 13 November, the Trust said staff had discussed with Mr M he might have an underlying cancer during a telephone appointment with his partner present on 10 April.
34. Our physician adviser said it was not indicated to share the outcomes of the MDT with Mr M’s family as there was no new information to share from this meeting. They said staff had already communicated with Mr M and his partner that Mr M might have an underlying cancer, and the plan was for him to have a PET scan. A PET scan is a type of scan used to diagnose and plan treatment for cancer.
35. Our physician adviser said at the time of the MDT there was no change. The MDT discussed it was likely Mr M had cancer, but further investigation was needed. The MDT commented Mr M was not fit for further investigation, so the plan remained for Mr M to have a PET scan when he was well enough to do so.
36. GMC Good Medical Practice says doctors must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.
37. We understand it must have been very distressing for Miss M and her family to hear mentions of cancer and to see cancer listed as a cause of death on Mr M’s death certificate when they had not been informed of Mr M receiving a formal diagnosis.
38. We cannot see Trust staff acted incorrectly by not sharing Mr M’s cancer diagnosis with his family in a timely manner, or after the lung MDT. Mr M did not have a confirmed diagnosis of cancer. The MDT did not conclude Mr M had cancer and did not change the plan for his care. Mr M’s partner had previously been informed of his possible underlying cancer and there was no further information to share with the family.
39. We hope we have explained why we think the Trust did not do anything wrong in this part of the complaint.
Delayed referral to the palliative care team
40. Miss M complains staff delayed referring Mr M to the palliative care team. She said the MDT concluded Mr M had cancer on 3 May and staff should have referred him for palliative care following this. She said the family would have had time to make different decisions about Mr M’s end of life care if staff had referred him earlier.
41. In its complaint response of 13 November, the Trust said Mr M’s condition deteriorated rapidly within 24 hours. It said doctors met Mr M during ward round on 7 May and noted he was eating lunch and considered him stable. The Trust said staff recognised Mr M’s deterioration on 8 May. They referred Mr M to the palliative care team who saw him promptly. Mr M sadly died that afternoon.
42. Our physician adviser said it would not have been appropriate to refer Mr M to the palliative care team following the MDT meeting, as the MDT did not decide to withdraw Mr M’s care. They said the MDT planned for Mr M to have further investigations when he was fit enough.
43. Our physician adviser also said Mr M’s medical records do not indicate he was at the end of his life on 6 and 7 May. They said on 6 May it is documented he was able to consent to care and on 7 May it is documented he was oriented to time, place and person. They said the ward round documentation from 7 May notes Mr M was alert, orientated and eating lunch with his daughter.
44. Our physician adviser said Mr M’s clinical notes suggest Mr M experienced a sudden and dramatic clinical deterioration on 8 May. It is documented that morning he was more breathless, and nursing staff asked doctors to review him. It is noted Mr M looked hypoxic (when the body does not have enough oxygen) and had been incontinent (loss of bladder or bowel control). Our adviser said staff referred Mr M to the palliative care team that morning.
45. GMC Good Medical Practice says doctors must adequately assess a patient’s condition and promptly provide or arrange suitable advice, investigation or treatment where necessary.
46. Considering Mr M’s MDT records and the plan for Mr M’s ongoing care, we cannot see staff got things wrong by not referring Mr M to the palliative care team following this meeting. At that stage the plan was for a PET scan and consideration of treatment once Mr M was medically stable.
47. Considering Mr M’s medical records and documentation of Mr M’s condition throughout his inpatient stay, it seems Mr M declined quickly on 8 May. In the days before this, doctors were still investigating his symptoms and actively treating him with antibiotics. Staff acted in line with GMC Good Medical Practice and referred Mr M to the palliative care team after he deteriorated on the morning of 8 May.
48. We understand how distressing it was for Mr M’s family to not know he was at the end of his life until the day he died, and to have not had the opportunity to plan for this. Overall, we have not found any indication staff got things wrong by delaying referring Mr M to the palliative care team.
Assistance with personal care
49. Miss M complains staff did not help Mr M with his personal care during his inpatient stay. Miss M said on 3 May, Mr M was unable to get up by himself and needed his son to help him get onto the commode. She said on 6 May, Mr M’s partner needed to help him with his personal care. Miss M said it was very distressing for the family to witness the lack of dignity afforded to Mr M.
50. In its complaint response of 13 November, the Trust said Mr M was able to care for himself until 3 May. It said after this date and until 5 May, Mr M required assisted washes and said staff helped Mr M with bedside washes. The Trust apologised staff did not help Mr M on 6 May and that his partner needed to help him on this day.
51. Our nursing adviser said Mr M’s clinical records show nursing staff assessed Mr M’s personal care needs and mobility every day he was in hospital. They said staff assessed Mr M when he was first admitted to hospital and every day the assessment considered whether Mr M’s needs had changed.
52. Our nursing said for the first days in hospital, staff assessed Mr M as fully mobile and independent with his care needs. They said the evidence indicates the Trust assessed Mr M’s care needs accurately.
53. Our nursing adviser said on 2 May, staff documented Mr M started to become confused. They said it is also documented Mr M started to experience shortness of breath when mobilising. Miss M told us about a separate incident where Mr M had left the ward and was found alone and confused, outside the ward on that day.
54. Our nursing adviser said on 3 May, it is documented in the clinical records Mr M could mobilise independently if supervised and his ability to self-care was confirmed. It is also noted Mr M was wearing his own clothes.
55. Miss M told us on 3 May, Mr M was unable to get up by himself and needed his son to help him get onto the commode. Staff documented that morning Mr M had been sitting in his chair and took a while to get back to his bed.
56. Our nursing adviser said from a nursing perspective, patients are encouraged to do as much as possible for themselves, as being in bed and not doing anything can contribute to deterioration.
57. Staff documented in Mr M’s clinical records on 4 May that he required support to reposition and required assisted washes. Staff documented on 5 May they assisted Mr M with personal hygiene needs and to mobilise to the toilet.
58. Our nursing adviser said it is likely staff documented Mr M’s care needs inaccurately on 6 May. On 6 May, it is documented Mr M was independent with his hygiene needs. This aligns with Miss M’s account Mr M was not assisted on this day and required his partner to wash him. Before this, staff assessed Mr M as requiring assistance. After 6 May, staff assessed Mr M as requiring full assistance again.
59. NICE guidance says staff must ensure the patient’s personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. Staff must also regularly ask patients who are unable to manage their personal needs what help they need.
60. Considering the evidence, we think it is likely the Trust incorrectly assessed Mr M’s personal care needs on 6 May and did not act in line with guidance on this day. As a result, Mr M was not assisted to wash, and his partner had to help him. We understand it must have been very difficult for Mr M’s family to see him not getting the support he required.
61. We have seen the Trust acknowledged Mr M was not assisted to wash on 6 May and it has apologised for this. As this was a one-off incident, we would place this injustice at level one in our guidance for financial remedy. We consider an apology is an appropriate remedy for an injustice of this nature and the Trust does not need to take any further action.
62. Aside from 6 May, we cannot see staff got things wrong in assessing and assisting Mr M with his personal care. His needs were assessed every day, in line with guidance. When Mr M was first admitted to hospital, he was independent. The Trust recognised Mr M required help after 3 May and it is documented he was given assisted washes after this time.
63. Miss M told us the Trust did not help Mr M because his washbag and toiletries were not touched through his hospital stay. We cannot say staff did not assist Mr M on this basis as they may have used their own products. This is something we would not be able to determine, and we therefore cannot reach an evidence-based decision on this point.
64. We hope our decision reassures Miss M apart from on 6 May, staff acted in line with guidance in assessing and meeting Mr M’s personal care needs during his hospital stay.
Mr M was found sitting in a wheelchair, unable to mobilise
65. Miss M complains Mr M was found by family members in a wheelchair, in the corner of his room and unable to mobilise on the morning of 8 May.
66. In its complaint response of 4 February, the Trust said Mr M’s partner alerted staff to him being very confused and unable to move his hand. The Trust said a nurse who was not assigned to care for him immediately attended Mr M. The nurse noted Mr M appeared hypoxic, confused and incontinent. The Trust said the nurse cleaned Mr M and made him comfortable in bed, increased his oxygen, arranged further observations and asked the doctors to review him.
67. The Trust said a different nurse who had been previously caring for Mr M, had not responded appropriately to Mr M’s deterioration. The Trust said as a response they had been restricted from working within the Trust. We appreciate this must have been very distressing for Mr M’s family. We are reassured another member of staff immediately attended Mr M and ensured his care needs were met. It is documented they also promptly requested a medical review for Mr M.
68. It is documented in Mr M’s medical records, on the evening of 7 May staff wanted to perform a bladder scan on Mr M and attach cardiac monitor cables, but Mr M did not want to get into bed. It is documented a doctor reviewed Mr M in the early hours of 8 May and during this review Mr M was sitting in a wheelchair and did not engage with the examination.
69. Our nursing adviser said Mr M was sadly dying on 8 May and the nursing records indicate he was cognitively impaired (experiencing difficulty with memory, attention, language and decision-making).
70. They said staff cannot force a patient up as this could be seen as manhandling a patient and not treating them with dignity. They said staff should instead try to encourage someone to get up and noted Mr M did agree to return to his bed in the end.
71. The NMC Code states staff must treat people as individuals and uphold their dignity. They must treat people with kindness, respect and compassion.
72. We recognise it must have been very sad for Mr M’s family to see him sitting in a wheelchair in the corner of his room while his condition was deteriorating.
73. Overall, we have not seen indications staff did not act in line with guidance. It is documented staff had previously tried to encourage Mr M to get into bed, but he had declined. We hope our explanation reassures Miss M staff acted in line with guidance by not forcing him into bed when he had declined.
Staff left Mr M covered in faeces
74. Miss M complains staff left Mr M covered in faeces when a syringe driver was inserted in his leg, before he died on 8 May. We understand this must have been very upsetting for Mr M’s family to see.
75. In its complaint response of 4 February 2026, the Trust said the palliative care team reviewed Mr M on 8 May. It said staff inserted a syringe driver to provide Mr M constant medications to relieve his symptoms. The Trust said no concerns on the condition of Mr M’s skin were recorded in his notes.
76. NICE guidance says staff must address a patient’s personal needs at the time of asking.
77. It is documented in Mr M’s clinical records a member of staff attended Mr M on the morning of 8 May when approached by his relative who was tearful due to Mr M’s condition. It is documented Mr M had been incontinent with faeces, and the nurse cleaned Mr M and made him comfortable in bed.
78. The Trust has acknowledged Miss M’s account that there were still faeces present on Mr M’s legs after staff inserted a syringe driver. It apologised for this experience and that staff caring for him had not cleaned him thoroughly following an earlier episode of incontinence.
79. The Trust said since this time, the Acute Medical Unit has undergone changes to strengthen the quality of nursing care provided. It said the unit has been split into two wards to allow more focussed nursing oversight. It also said it has introduced additional Quality and Safety rounds where a member of the senior nursing team checks appropriate care is being provided.
80. Miss M told us Mr M was a very proud man. We understand it would have been incredibly difficult for Mr M’s family to see he had not been cleaned thoroughly when he was reaching the end of his life.
81. Having carefully considered this, we would place this injustice at level one on our guidance to financial remedy as it led to distress of short duration. The Trust has acted in line with our Complaints Standards by apologising to Miss M. We can also see the Trust has made improvements to its nursing care since this time.
82. Therefore, we will not be asking the Trust to take any further action. We understand this part of the complaint is extremely important to Miss M. We are sorry this is not the outcome she was hoping for and do not wish in any way to diminish her distress.
Complaint handling
83. Miss M said the Trust provided two complaint responses to her complaint, which stated different findings.
84. Miss M received a final complaint response from the Trust in November 2024. Miss M was unhappy with the response and raised further questions. The Trust responded to her second complaint in January 2025.
85. Miss M complained the two responses state different findings. In particular, she complained the two responses give different accounts of an occasion where Mr M left the ward and was then found confused and alone in the main reception area of the hospital on 2 May 2024.
86. In the response dated November 2024, the Trust apologised for this ‘unacceptable incident’. It said it had not been able to find out what happened on the day but accepted that Mr M should have been more closely supervised. The Trust apologised that he had not been. The Trust said the incident had been shared in the speciality team meeting to highlight this issue and ensure it was not repeated.
87. In the Trust complaint response dated January 2025, the Trust apologised that there is no documentation around Mr M leaving the ward. The Trust also said there was evidence of Mr M having poor memory and this could have contributed to the situation.
88. The responses are worded differently, however, in both responses the Trust accept the incident occurred. In both responses, it is also agreed the incident was not documented in Mr M’s notes.
89. Upon reviewing the two responses, the only discrepancy we found was in relation to a previous test Mr M had undergone for Clostridioides difficile (also known as C. diff, a bacterial infection which can cause diarrhoea). In its response of November 2024, the Trust said Mr M had a positive C. diff test in 2016. In its response of January 2025, the Trust said Mr M had a test on 16 August 2021. We do not know if one is an error, or if these were different tests. We appreciate this part of the responses is unclear, however, we feel this detail is not a significant part of Miss M’s complaint.
90. Our complaint standards say that when handling complaints, staff should give a clear, balanced account of what happened based on established facts. Overall, we feel the Trust has done this in its two complaint responses. The Trust has also acknowledged when it has not been able to establish the facts and provide greater detail. We have not found any indications of failings in the way the Trust responded to Miss M’s complaint.
91. Overall, we understand Miss M and her family are very upset at the care Mr M received during his hospital stay, before he sadly died.
92. We hope we have sufficiently explained why we either feel the Trust acted in line with guidance, or in parts where it did not, why we think the Trust has acted appropriately through apologising and making service improvements. We will not be taking any further action in relation to this complaint. We are sorry this is not the outcome Miss M was hoping for.