Hull University Teaching Hospitals NHS Trust

3. Mr A complains the Trust missed opportunities to diagnose his mother with gangrene in her foot between August and September 2023. He also complains about how the Trust handled his complaint.

4. He says half of his mother’s foot has now fallen away with gangrene and this has affected her mobility and quality of life. He feels the issues with her foot may have contributed to her falling and breaking her hip. He told us there is a high chance she will now get sepsis (a life-threatening reaction to an infection) and an end-of-life care plan has been put in place. He says he will never know things could have been different with a quicker diagnosis. He told us the Trust’s complaint handling was not good enough and left him with unanswered questions about his mother’s care.

5. Mr A wants service improvements and a financial payment.

6. Mrs I has dementia. She broke her leg in July 2023 and on 17 August, she attended the Trust’s emergency department (ED) because staff at her care home were concerned that the cast on her leg was too tight and causing her toes to go black. The Trust diagnosed the discolouration on her foot as bruising and discharged Mrs I back to the care home.

8. 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.

9. We discussed the complaint with Mr A, how the Trust’s actions affected his mother and what outcomes he is hoping to achieve by bringing the complaint to us.

10. Mr A explained that after the Trust diagnosed the discoloration on her foot as bruising on 17 August, she attended again on 10, 11 and 13 September but the Trust did not diagnose the gangrene until the final visit. He said the Trust told them her toes are now necrotic (body tissues that are dying) and they will fall off.

11. Mr A said the Trust did not do any tests to rule out gangrene when his mother attended on 17 August. He said by the time the gangrene was diagnosed, it was too late for his mother to have any treatment and unfortunately half of her foot had fallen away due to the condition.

12. He told us the gangrene has affected Mrs I’s mobility and she spends most of her day sat in a chair and she is not able to wear a shoe on the affected foot. He said she also fell over and broke her hip in September and he wonders if the gangrene contributed to her falling over. He told us it is highly likely she will get sepsis and she now has an end-of-life care plan so her care home has the right medication for when it is needed.

13. From what he told us, it is clear that Mrs I has been through a very difficult time. We recognise it must be very worrying and frustrating for Mr A to see the effects the gangrene is having on his mother’s quality of life. We also recognise how distressing it must be not knowing if his mother’s condition could have been improved with a quicker diagnosis.

14. During our conversations, Mr A explained he wants service improvements and a financial payment of more than £10,000. He said this is because his mother has lost part of her foot and she will never recover.

15. Mr A’s complaint strongly suggests that there has been some negligence. He could make a clinical negligence claim and these are handled by a legal process.

16. We discussed this with Mr A and he did not tell us about any barriers that would stop him getting legal advice. He explained he would like to find out what happened with his mother’s care before speaking to a solicitor because he believes the Trust is hiding information which has led to concerns about its complaint handling.

17. Mr A wants a large payment so we think it is in his best interests to get some legal advice now.

18. The time limits for taking legal action are strict. We think it is important that he explores this option by getting legal advice while he still has time.

19. We are satisfied that a court is better placed to find out if the Trust was negligent and to get the level of payment he wants for the significant impact on his mother’s life. Legal action could also achieve the service improvements he wants because if the courts find the Trust was negligent it will reflect on this to learn and improve through its serious incident framework. Legal action may also resolve his concerns about complaint handling because he will be able to find out what happened with his mother’s care and query any information he is unsure about.

20. If Mr A explores legal action but a solicitor will not take his case on, he can bring his complaint back to us and we would look at it again. At that point, we would need to carefully consider the outcome of any legal enquiries and the outcomes he wants. We would also need to consider the time that has passed because our time limit would still apply. It is important that Mr A takes legal advice without any avoidable delays.

21. We understand this experience has greatly affected Mrs I’s health and quality of life and we are sorry that Mr A has concerns about how the Trust managed her care. We hope this statement clearly explains our decision.

1. We have carefully considered Mr A’s complaint about Hull University Teaching Hospitals NHS Trust (the Trust). We are sorry to hear about the experience his mother, Mrs I, had and the challenges she now faces due to the gangrene (a condition where a loss of blood supply causes body tissue to die) that has affected her foot.

2. We think Mr A may be able to take legal action on the matter he has brought to us and we have decided to take no further action for this reason. We are sorry for any added distress this may cause but hope our statement below explains why we think this is the best way to achieve the outcomes he wants.