University Hospitals Birmingham NHS Foundation Trust

5. Mrs E complains it took the ENT Team at University Hospitals Birmingham NHS Foundation Trust (the Trust) three years to diagnose her husband, Mr E, with throat cancer. She says that prior to the diagnosis, the Trust diagnosed him with inflammation. Mrs E says she also requested a PET scan (an imaging test which assesses organs and tissue functions) for her husband which the Trust ignored.

6. Mrs E also complains that during an admission to hospital her husband sustained a hypoxic brain injury (an injury which occurs when the brain does not receive enough oxygen) on 4 March 2022. She says whilst suffering a cardiac arrest, Dr N deprived Mr E of oxygen for 10 minutes. She complains Dr N took no action to resuscitate Mr E despite her requests.

7. Mrs E says by the time the Trust diagnosed her husband’s cancer, he was very sick and required major surgery. She feels if the Trust had diagnosed his cancer sooner, he may have stood a better chance of survival. Mrs E says she is now widowed as she believes her husband’s sudden death was avoidable. She said this has greatly affected her mental health.

8. As an outcome to her complaint, she would like an acknowledgement of failings, an apology, service improvements and financial compensation.

9. The Trust admitted Mr E to hospital on 8 February 2022 with aspiration pneumonia.

10. On 4 March, whilst at Mr E’s bedside, ENT doctors noted Mr E had bleeding from his laryngeal stoma (an opening in the neck which allows the patient to breathe). Following this, Mr E suffered a cardiac arrest shortly after 9am. The ENT doctors attempted to suction Mr E’s airway and a nurse commenced CPR before the resus team arrived.

11. The Trust took Mr E to theatre for neck exploration and arrest of bleeding. The clinical team suspected Mr E had suffered a hypoxic brain injury during the arrest. Following theatre, the Trust admitted Mr E to ICU.

12. On 9 March, doctors agreed to withdraw treatment for Mr E. He sadly died the same day. His death certificate stated the immediate cause of his death was a hypoxic brain injury.

Delayed diagnosis by ENT service

16. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

17. Mrs E told us she first began to have concerns about her husband’s care under the ENT service in late 2018. We can see evidence that Mrs E raised a complaint about this in March 2021 and received a response on 30 June.

18. Mrs E submitted her first complaint to us in December 2022, but we closed this as it was not yet ready for us. Mrs E received a further complaint response from the Trust on 21 August 2023 and resubmitted her complaint to us on 13 September. This means her complaint is around four years outside our time limit.

19. We have discussed this with Mrs E to understand the reasons why she did not bring her complaint to us sooner.

20. Mrs E told us the reason for the delay in approaching us is because of how long the Trust took to respond to her complaint. She told us she raised a complaint about the ENT service in 2019 using the hospital’s website enquiry’s form. She told us she received no response.

21. There is no documented evidence that Mrs E sent a complaint to the Trust in 2019. However, if Mrs E sent a complaint and did not receive an acknowledgment of it, it would have been reasonable for her to chase this up with the Trust within a few months. There is no evidence she did this until March 2021 which was at least a year and three months later.

22. Following this, the Trust sent Mrs E a complaint response three months later on 30 June 2021. Mrs E told us she did not receive this response.

23. Again, if Mrs E did not receive this response, it would have been reasonable for her to chase this up within a few months. We can see no evidence she did this until 29 November 2022 when she contacted the Trust again. This is a further one year and eight months where Mrs E took no action to follow up on her complaint.

24. Because of these two delays in Mrs E actively pursuing her complaint, we consider it is not reasonable to put the time limit to one side for her complaint about the ENT service. We do not accept the explanation that it was the Trust that delayed responding to her complaint. We can see that the Trust responded in a timely way on each occasion.

25. We appreciate this will be a disappointing decision that we cannot look at this part of Mrs E’s complaint because of our time limit. We are in no way underestimating how important this complaint is to her.

Cardiac arrest on 4 March 2022

26. 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 have done this and have not found any indications that something has gone wrong.

27. From Mr E’s medical records from this hospital admission, we can see the ENT team were with Mr E when he began to bleed from his stoma on 4 March. Our adviser said it appears this caused him to go into respiratory arrest as the bleeding was blocking his airway. Following this he went into cardiac arrest.

28. We appreciate how distressing this incident must have been to witness for Mrs E who was also present. It is also understandable that she has concerns about the actions taken by the doctors present at the time.

29. The relevant guidance in this situation is the Resuscitation Council UK guidance. This guidance explains the steps clinical staff should take for medical emergencies in hospital.

30. Our adviser said the clinical team acted in line with this guidance. He explained it seems the ENT consultant acted correctly by suctioning the blood to clear Mr E’s airway. Clearing the airway is the first step needed when assessing a patient in a medical emergency and this action alone may have resolved the situation.

31. Because Mr E had a laryngeal stoma our adviser said it would not have been possible to provide oxygen at the same time as suctioning to clear the airway.

32. We can see a nurse entered the room and noted that Mr E was blue in colour which our adviser explained would have been because his airway was blocked, and he was not getting any oxygen. In discussion with the doctors present, the nurse checked his pulse and commenced CPR prior to the resus team arriving.

33. In summary, Mr E was having a respiratory arrest initially and doctors attempted to clear his airway which was the first step needed in line with the national guidance. Once the clinical team realised Mr E was in cardiac arrest, they commenced CPR.

34. We have taken account of the national guidance and clinical advice, and we can see no indications of failings in how the Trust treated Mr E on this occasion.

35. We were extremely sorry to hear that following this Mr E sustained a hypoxic brain injury. We offer our sincere condolences to Mrs E for his death.

1. We were very sorry to hear of the death of Mr E and the impact this had on Mrs E. We can only imagine how difficult the last few years have been for her. We have carefully considered her concerns about the care the Trust provided to Mr E.

2. Regarding her complaint that the Trust delayed in diagnosing Mr E’s cancer, this complaint falls outside of our time limit. We have carefully considered Mrs E’s reasons for the delays in bringing this complaint to us and decided there is no good reason for us to put our time limit aside.

3. Regarding Mrs E’s complaint about the care Dr N provided on 4 March 2022, we have seen no indication that anything went seriously wrong.

4. We recognise this may be a disappointing decision to Mrs E as we know how much this complaint means to her. We have fully explained the reasons for our decisions below.