Calderdale and Huddersfield NHS Foundation Trust

6. Mrs E tells us she was concerned about the care and treatment her dad received in 2020. We agreed to describe her complaint as follows:

• In May 2020, Mr O went to A&E because he was seeing blood in his urine. The A&E doctors recognised he needed an urgent referral for an investigation for bladder cancer – a cystoscopy - but failed to properly complete the electronic forms. This led to the cystoscopy not being done for over two months, when it should have been done in two weeks. This caused a delay in Mr O’s eventual treatment for the bleeding.

• The Trust failed to act on phone calls the family made in June and July 2020 to speed up an appointment. The Trust also failed to record or act on communication from the family GP to speed up the appointment. Even though Mr O had to attend A&E again with worsening symptoms, the Trust still did not arrange the appointment.

• The doctors decided to do an operation (TURBT – transurethral resection of bladder tumour – where a lesion or tumour is removed from the bladder). Before this operation, Mr O’s blood thinners had to be stopped. The Trust says this put him at risk of having a stroke. Mrs E is concerned appropriate procedures were not followed in stopping and restarting the blood thinners, partly because there was confusion over when the TURBT was going to be done. The operation was then done suddenly - two days earlier than Mrs E thought it would be.

• After Mrs E’s dad died the hospital arranged a meeting for her with a consultant who knew nothing about Mr O and he gave answers which were not factually correct.

• The Trust did not recognise the seriousness of the complaints Mrs O was making, did not take care with the responses it gave and made only superficial attempts to take action, that is the actions were not meaningful nor likely to bring about change.

7. Mrs E describes the impacts on Mr O and her family as follows:

• The failings in A&E caused a delay to Mr O receiving the right care and treatment at the right time, during which he became more poorly and more likely to have a stroke, which he did.

• The Trust’s failings to act on the family’s phone calls contributed to the delay in getting the right care and treatment, and caused frustration and stress at an already very difficult time.

• The issues with Mr O’s blood thinners may have contributed to his stroke.

• The meeting with the consultant caused Mrs E frustration and stress at a difficult time. She tells us it felt as if she had received a pat on the head and been sent away.

• Mrs E had to take time out from her bereavement to write a complaint and then pursue it to get further responses. This was really hard work and not what she wanted to be doing. She says the Trust failed to put the same effort and care into their letters as she did. She is left believing the Trust was trying to cover up failings.

8. Mrs E tells us, as an outcome to her complaint, she has only ever wanted a sincere acceptance from the Trust about the seriousness of her concerns and an understanding of ‘the shambles’ of her dad’s care. She wants the Trust to take more robust actions about the issues she has raised. She wants to see those actions are based on evidence and can be shown to resolve the failings identified.

9. Mr O had blood in his urine. On 17 May 2020, he went to A&E. At A&E, he was referred for an urgent cystoscopy and discharged. The doctor did not complete the electronic forms correctly and the referral for cystoscopy was not made.

10. During June and July 2020, the family contacted the Trust about Mr O’s ongoing and worsening symptoms. The Trust still did not make an appointment for a cystoscopy. The family GP also called the Trust without success. The GP made another referral for cystoscopy on 13 July 2020 under the two-week wait for suspected cancer.

11. Before that appointment, Mr O was admitted again. He had a cystoscopy during his stay in hospital. The cystoscopy found a lesion in his bladder, which was bleeding. He was told he would be sent an appointment for a TURBT operation towards the end of August. On 26 July 2020, Mr O was discharged.

12. After arriving home, Mr O had copious bleeding and had to be re-admitted the next day. The doctors decided to do the TURBT operation sooner. They told Mrs E they wanted to do it on 31 July 2020. They then told her they had not stopped Mr O’s blood thinner – apixaban - in time to do it. The apixaban had to be stopped 48 hours before the operation because of the risk of bleeding during surgery.

13. Mr O was given the last dose of apixaban at around 10am on 30 July 2020. He had his operation on 1 August 2020. He was due to be discharged on 3 August 2020, but sadly suffered a large haemorrhagic stroke (a type of stroke caused by bleeding from a blood vessel - common causes include high blood pressure) and died.

17. We have considered each of Mrs E’s concerns under the headings set out in her complaint. As her complaints are related, and together tell an important story, we answer them together.

The outcome of the Trust’s complaint process in respect of complaints one, two, three and four

18. In its responses to Mrs E’s complaint, the Trust accepted a doctor input wrong information into Mr O’s electronic patient record (EPR) during his first admission to A&E. As a result, the EPR did not produce the appointment request for the cystoscopy. The Trust recognised Mr O should have had a cystoscopy within two weeks. The Trust apologised (after being pressed to do so by Mrs E), said it would speak to the doctor concerned and send a training video to all staff.

19. The Trust also told Mrs E its staff did not understand the calls her family made were to try and get the cystoscopy appointment letter sent out. It said its staff had acted appropriately by getting medical advice. When Mrs E complained again, the Trust said it recognised staff should establish why someone is calling. It said it would address this issue with appointment staff.

20. Mrs E told the Trust she was concerned the delay may have had an impact on her dad’s stroke. The Trust told her it probably did not, but there was an association between stopping and starting apixaban and stroke. It said the stroke may have happened even if the TURBT operation had been done earlier. But, it said, Mr O’s apixaban was stopped correctly before the TURBT operation. It also said there was an association between conditions such atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate) and stroke, suggesting Mr O was someone who was more likely to have a stroke.

21. Mrs E told the Trust she was concerned her dad’s apixaban was stopped and started incorrectly. She provided evidence as to why. She says the doctors told her on 30 July 2020 the TURBT operation would be done the following day. She says the doctors told her on 31 July 2020 the TURBT operation had been moved to a different day because the apixaban had not been stopped. They said it would happen 48 hours after stopping the medication. However, the TURBT operation was done only 24 hours after that conversation. The doctors did not tell Mrs E at the time when the apixaban had been stopped. She did not know at the time whether or not it had been stopped early enough before the TURBT operation. The Trust denied the TURBT operation was scheduled within 48 hours of stopping the medication. It said the doctor had originally thought there only needed to be a 24-hour wait but did not schedule the TURBT operation. It apologised for the confusion the doctors had caused in their conversations with her and said it would share this with the relevant department.

22. The Trust said the meeting after Mr O died was held at the family’s request. After Mrs E complained again, it corrected this. In its second response, it apologised the doctor was not well prepared and said the meeting should have been held somewhere other than the ward on which Mr O died.

Indications of service failings

23. The Trust recognises service failings to a degree in its complaint responses. We have considered the evidence in earlier sections of this statement. We see signs of service failings as described in the paragraphs below.

24. The Trust did not book the urgent cystoscopy appointment for Mr O when it should have done. The doctor’s failure to input the information correctly is a sign of their failure to accurately record their work, quickly arrange suitable investigations or make use of available resources, in accordance with GMC guidelines.

25. In accordance with our Principles of Good Administration, the Trust should have done what it said it was going to do – organise an urgent cystoscopy appointment - and should have provided a service that was easily accessible. Under the NHS Constitution, Mr O was entitled to care at the right time and in accordance with his priority. That did not happen. Mr O and his family were repeatedly left - by a number of different staff (appointment staff, the consultant and the A&E staff when he attended for the second time) - to try and book the urgent appointment he needed, which did not happen until many weeks after it should have done.

26. There are also indications of failings in the Trust’s communications with Mrs E about her dad’s TURBT operation and when his apixaban was stopped. The doctor’s understanding on 30 July 2020 the TURBT operation could go ahead the following day was incorrect. While the doctor did not act on his incorrect understanding, there are indications they were not acting in accordance with relevant guidelines on 30 July 2020, as required by the GMC’s Good Medical Practice guidance.

27. We got clinical advice about Mrs E’s concerns about the stopping and starting of apixaban. This tells us, according to NICE guidance, patients should stop taking apixaban 24 hours before any bladder biopsy (a medical procedure involving taking a small sample of body tissue so it can be examined under a microscope) and 48 hours before more extensive surgery to remove lesions. Our adviser thinks the apixaban should have been stopped 48 hours before the TURBT operation, based on the size of Mr O’s lesion. The apixaban should have been restarted after the operation once Mr O’s urine was clear. Our adviser confirms the medical records show there were 48 hours between stopping the apixaban and the TURBT operation. They also show the apixaban was restarted when Mr O’s urine was clear. As such, there are no signs the NICE guidance was not followed.

28. There are signs of failings during Mrs E’s meeting with the doctor after her dad died. There are signs Mrs E was given incorrect information about her dad’s cancer and the drugs he was given. This is not in line with our Principles of Good Administration, which say organisations should communicate effectively and be sensitive to people’s needs and circumstances.

29. We also see several signs of service failings in the Trust’s complaint responses to Mrs E. The Trust should have responded appropriately to Mrs E’s complaint in line with our Principles of Good Complaint Handling (our Complaint Standards are now in place, but our Principles were the relevant guidance at the time of these events) and our Principles of Good Administration. ‘Getting it right’ would have meant the Trust taking responsibility for the actions of its staff and listening to Mrs E and the outcome she wanted. ‘Being open and accountable’ would have meant the Trust giving clear reasons for its decisions based on evidence. ‘Putting it right’ and ‘seeking continuous improvement’ would have meant the Trust providing Mrs E with an appropriate personal outcome and reviewing its practices in response to her feedback to assist with the improvement of its services.

30. Firstly, the Trust did not accept its full responsibility to make sure Mr O had the appointment he needed or the severity of the situation. In particular, it suggested the family’s attempts to contact the Trust may not have happened as Mrs E describes. It suggested its staff had responded appropriately by giving medical advice. The Trust did not accept it had repeatedly placed the onus on the family to try and book the urgent cystoscopy appointment, when it was not their responsibility to do so.

31. Secondly, there are signs the Trust did not listen to Mrs E and understand the impact of the delay on her dad and her family. Mr O experienced infections and bleeding throughout the Trust’s delay. He had become more poorly and more worried. He experienced the indignity of continuing symptoms and frightening events such as when he started bleeding in bed after being discharged on 26 July 2020. This was an extremely difficult time for the whole family. Sadly, this turned out to be the last weeks Mrs E had with her dad.

32. Thirdly, Mrs E questions whether Mr O would not have had a stroke or would have been more able to recover from a stroke if he had received earlier treatment for his bladder condition. She feels if he had received earlier treatment he would have been in better health. This is a perfectly common-sense point of view. We asked our adviser whether there was any evidence or research that may link the delay specifically to Mr O’s risk of having a stroke. They could not find any specific evidence. As such, there are no failings in the Trust saying the delay probably did not contribute to his stroke. But had the delays been avoided Mrs E would not have been left with doubts that things may have been different, which is a significant injustice to her. These are signs the Trust failed to listen to Mrs E, understand this impact or reflect it in its response.

33. Fourthly, there are signs the Trust did not attempt to understand the outcome Mrs E wanted. Mrs E tells us she was dismayed by the Trust’s actions in response to her complaints. She said the Trust had not tried to discover the reasons for what had gone wrong nor established the root cause. The Trust’s actions did not reflect the seriousness of the issues.

34. Fifthly, there are also signs the Trust’s response failed to give clear reasons, based on evidence, for its decisions about apixaban. The Trust said there were associations between stroke, stopping and starting apixaban, atrial fibrillation and heart surgery. These associations are with ischaemic stroke (a stroke caused by a blockage of a blood vessel) but Mr O had a haemorrhagic stroke.

35. We asked our adviser whether there is a connection between stopping and starting apixaban and having a haemorrhagic stroke. Our adviser tells us there is no evidence stopping and starting Apixaban increases the risk of haemorrhagic stroke. They explain some research shows patients on apixaban are at a small increased risk of 0.33% per year of haemorrhagic stroke. There is no strong evidence that Mr O’s stroke was likely to be closely linked to the apixaban being stopped and started. So, the Trust’s explanation did not relate to Mr O’s situation.

36. Sixthly, in its complaint responses, the Trust made a number of incorrect claims about Mrs E’s meeting with the consultant after her dad died. The Trust also suggested it could not say how the meeting went because no one at the Trust was there, apart from the consultant, and no records were made of the meeting. The Trust did not put right some of the poorly explained things in that meeting such as the nature of Mr O’s cancer and an allergy he had. It failed to accept the issue was not simply one of communication (see an earlier section of this statement). It also failed to understand its proposed outcome – to tell staff to communicate a plan only once it was finalised – would not put things right. The Trust also did not accept the nature of the further distress Mrs E says she suffered as a result. All this is a further sign the Trust did not act in line with our principles set out in an earlier section of this statement.

37. Finally, there are signs of failings in the Trust not acting appropriately to ‘put things right’. It did not apologise appropriately or suggest actions that would help stop the same things happening to someone else. The Trust identified a number of failings in its first response but it only apologised for them, in the limited way described above, after Mrs E complained again. To Mrs E, the Trust’s actions were not based on putting right what had gone wrong and only addressed small aspects of her dad and her family’s overall experience.

Indications of injustice

38. We have set out in the paragraphs above the injustices Mr O and Mrs E experienced as a result of the failings in Mr O’s care and treatment. The Trust did not fully accept or understood these failings.

39. We have had detailed conversations with Mrs E about the injustice arising from the Trust’s complaint handling. Mrs E says the letters she received lacked empathy and understanding, and they felt robotic. She just wanted someone to listen and to understand, and to make sure her experience would not happen to someone else. She says she would then have been able to move on. That did not happen.

40. Mrs E told us the failure of the Trust to fully accept and respond to her complaint has worsened the significant impact of these events on her. She tells us it means she had to take time away from grieving to write letters to the Trust that she did not want and should not have had to write.

41. Mrs E says that the responses the Trust sent her were meaningless. She feels aggrieved the Trust has taken so little care responding to her when she was making such a significant effort to give it feedback. She says she cannot now be completely reassured about whether the outcome for her dad would have been different because she has lived with the sense the Trust have been covering up for so long. She is not yet reassured someone else will not go through what she went through.

42. When we spoke to Mrs E, we discussed how the Trust could put things right. Mrs E tells us she still wants the Trust to accept what went wrong and to give reassurance this would not happen to anyone else. We agreed to approach the Trust to tell it about her experience.

Agreed resolution

43. When we spoke to representatives of the Trust, they told us they are sad to hear about Mrs E’s concerns and the responses it has sent her. The Trust has reassured us it understands things went wrong several times. The Trust understands its complaint responses lacked understanding and empathy. It has offered information about how things have changed in respect of the EPR, culture, patient experience and complaint processes, which will help prevent anyone else having similar experiences. The Trust wants to write to Mrs E directly to explain all this in more detail and to put things right.

44. We told Mrs E about our conversation with the Trust. She feels positive from what has been said the Trust may change because of her complaint. She agrees direct contact from the Trust, alongside this statement, will resolve her complaint.

45. The Trust agrees to write to Mrs E within four weeks of the date of this statement (1 March 2023). It says the letter will include: • a sincere and appropriate acceptance of all the things that went wrong and an understanding of how they joined together to make a poor overall experience • the personal impact on Mrs E, her dad and her family • more detail about its ongoing work in complaint handling, appointments and culture, and • information about how her story may be used in a patient experience forum or senior nurse briefing to help develop staff-culture work which has already started.

46. Through very challenging personal circumstances, Mrs E has been extremely understanding and determined in waiting so long for this resolution. We hope this statement and the resolution will bring some closure for Mrs E and some reassurance that the Trust will make improvements.

1. Mrs E complains about the care and treatment of her dad, Mr O, at Calderdale and Huddersfield NHS Foundation Trust (the Trust) between May and August 2020. She complains about delays to his treatment and the management of one of his medications before surgery. She complains about the Trust’s responses to her complaint and says they have not adequately addressed her concerns or the significant injustices her dad and her family have suffered.

2. The Parliamentary and Health Service Ombudsman has carefully considered Mrs E’s complaint about the Trust. With her agreement, we have spoken to the Trust about her experiences. The Trust agrees to take further steps to accept failings and put things right.

3. There are signs of service failings in all of Mrs E’s complaints about the care and treatment of her dad received. When she complained to the Trust, it accepted these to a degree. But we have seen signs it did not fully accept the extent of its failings, understand the impact on Mr O, Mrs E and her family, or take adequate actions to put things right.

4. We explain in this statement the reasons why we think there are signs the Trust’s care and treatment fell short of the relevant standards. There are signs of further failings by the Trust because, during the complaint procedure, it did not fully accept the severity of its failings or consider the impact on Mr O, Mrs E and her family, or the injustice they suffered. Its action plan did not provide confidence it would prevent similar events happening in future, as far as is possible. Mrs E wants the Trust to address these failings.

5. The Trust has asked if it can write to Mrs E directly to accept and recognise the failings in her case. It also wants to better explain actions it has taken since her complaint, which should prevent similar events happening in future, as far as is possible. Mrs E agrees to this resolution. We hope that, alongside this statement, this will bring Mrs E closure to her long-running complaint and allow her the space to grieve she wanted from the start.