Royal Free London NHS Foundation Trust

3. Mrs W complains about how clinicians at Chase Farm Hospital and Barnet Hospital (which are both part of the Trust) cared for her husband on 20 November 2023. She believes nurses at Chase Farm Hospital should have arranged for her husband to see a doctor following a transfusion. She says they should then have arranged for an ambulance to take him to Barnet Hospital.

4. Mrs W says staff should have made a wheelchair available for her husband when he arrived at Barnet Hospital. She also says her husband had to wait too long in the emergency department and he became unresponsive before receiving treatment. She says nurses should be better trained to identify critical cases.

5. Mrs W believes failings in care contributed to her husband’s death. She described how it was traumatic for her to witness these events. She wants to ensure there is a comprehensive review into what happened and that the Trust makes changes to procedures.

6. Mr W had cancer of the bile duct that had spread to the peritoneum (the lining of the abdominal cavity). He started chemotherapy in August 2023. He developed anaemia following the treatment and attended Chase Farm Hospital for a blood transfusion. After the transfusion Mrs W asked whether her husband could see a doctor because she was concerned about his health. This led to him attending Barnet Hospital.

7. A nurse in the emergency department assessed Mr W and noted his history. The nurse recorded Mr W’s observations (including his temperature, heart rate and blood pressure). They did not consider Mr W needed immediate care but noted he did require medical attention.

8. A doctor reviewed Mr W in the emergency department later that evening. They noted he had reduced consciousness, a low body temperature and breathing difficulties. The doctor gave him glucose which helped, and Mr W said he was feeling better. The doctor diagnosed sepsis (the body’s overwhelming response to an infection, which can lead to organ damage).

9. Doctors admitted Mr W to the hospital and treated him with intravenous fluids and antibiotics. Sadly, Mr W died on 23 November 2023.

10. Mrs W complained to the Trust two days after her husband died. It replied to her complaint in May 2024. Mrs W remained dissatisfied, so she complained to us.

Actions following the blood transfusion

13. Mrs W says her husband became ill when he attended Chase Farm for a blood transfusion on 20 November 2023. She says she was concerned about his health and after the transfusion asked one of the nurses if she could see a doctor. The nurse told her there was no doctor available and gave her a number to call.

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have not found any indication that these issues had a negative impact on Mr W.

15. The records from the haematology unit show the procedure started at 10.50am and ended at 11.58am. They do not make any reference to Mr W being acutely unwell before, during or after the procedure. The records refer to Mr W being alert and able to consent to the transfusion.

16. The Clinical Adviser told us Mr W’s observations at Barnet Hospital’s emergency department were within the normal range when recorded at 5.24pm. There is nothing to indicate that Mr W needed an urgent medical intervention up to that point. Later records refer to Mr W feeling weaker after the transfusion.

17. Based on the available records, from Chase Farm Hospital and the emergency department at Barnet Hospital, we cannot see there was an urgent need for Mr W to see a doctor. The Trust has explained that the transfusion unit was led by nurses, so doctors would not routinely have been available on site. It seems a nurse provided contact information to Mrs W if she remained concerned about her husband.

18. Our view is that Mr W was not acutely unwell when he arrived at the emergency department. So, even if staff at the haematology unit fell below the relevant standards this could not have had a significant impact on his health.

19. We recognise Mrs W strongly believes her husband was seriously unwell following the transfusion. Clearly, this was a distressing experience for her. On the balance of the available evidence, we do not consider there are indications that Mr W’s health was negatively affected by the actions of nurses at the haematology unit on 20 November 2023. We have decided not to start a detailed investigation about this aspect of Mrs W’s complaint.

No ambulance available

20. Mrs W says staff at Chase Farm recommended a taxi rather than arranging for an ambulance to transfer her husband to Barnet Hospital.

21. 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.

22. There are no national standards that we are aware of relating to arranging transport for non-emergency patients transferring between different hospitals.

23. There are also no clinical records about this, and we would not expect there to be any records. In its complaint responses the Trust explained it does not have a facility to transport people to hospital by ambulance unless this is arranged in advance. It has apologised that staff did not do more to help Mr W attend the emergency department.

24. We would not be able to say what happened in this respect fell below any standards or guidelines. This means it is unlikely we would be critical of the Trust if we were to investigate this part of Mrs W’s complaint further. We consider there are no indications of failings in this respect. As we have explained above, we have seen no evidence Mr W needed an urgent medical intervention at the time he left the haematology unit. We can also see the Trust has apologised and it is unlikely we would be able to achieve anything further by investigating this issue.

25. We recognise this was a frustrating experience for Mrs W. We have decided not to investigate this aspect of her complaint.

No wheelchair available

26. Mrs W complained that she had difficulty finding a wheelchair for her husband on his arrival at the emergency department. She says it took at least 30 minutes to locate a wheelchair.

27. We have decided to focus on the more serious complaints that people bring to us, where they may have faced a big impact. For example, these may be about a potentially avoidable death or where someone has suffered prolonged pain. These types of complaints are where we can often make the biggest difference. This will allow us to provide the right level of service to those people, as quickly as possible. This means we are not looking into complaints where we can see there has been a smaller impact. This applies to Mrs W’s concern about the delay in getting a wheelchair.

28. We appreciate this incident would have been frustrating for Mrs W. We hope she can see why we have decided not to investigate this matter further.

Waiting in the emergency department

29. Mrs W says her husband should not have waited for hours until his health deteriorated to the point of unresponsiveness before receiving treatment. She says nurses should be better trained to spot danger signs in patients and flag up critical cases.

30. The Initial Assessment Guideline explains how clinicians should assess patients when they first arrive in a hospital’s emergency department. It says a clinician should assess patients arriving in the emergency department within fifteen minutes. The assessment should identify patients with life-threatening conditions and ensure they are prioritised.

31. The Trust has already accepted that Mr W’s initial assessment in the emergency department was delayed. The assessment happened more than ninety minutes after Mr W arrived. The Trust explained that this was over the fifteen-minute recommendation, as set out in the Initial Assessment Guideline. We cannot see that this delay had any impact on Mr W’s health, because when the assessment took place it did not suggest his care needed to be prioritised. If the delay had not happened it seems likely Mr W would still have waited several hours to see a doctor.

32. The Trust has also apologised that Mr W waited more than the four-hour target time for waiting in an emergency department. It explained that both these delays happened because of how busy the department was when Mr W arrived. The Clinical Adviser said it is unfortunate that most emergency departments in the country struggle to meet the waiting time targets. It is unlikely we would ever be able to conclude that this waiting time amounted to a significant failing.

33. The Clinical Adviser said the initial assessment appeared to be appropriate. The nurse took a detailed account of Mr W’s history and symptoms. They examined him and recorded observations. They correctly noted Mr W did not need emergency medical attention. In this respect the nurse followed the Initial Assessment Guideline.

34. Mr W was in the waiting area in the emergency department for around five hours. The Clinical Adviser said it is not usual practice to monitor patients who are waiting. This means there are no clinical records during this waiting period, and we would not expect there to be. It seems a doctor saw Mr W as a priority when he temporarily lost consciousness and staff alerted them. Again, there are no indications of failings in this respect.

35. Based on the evidence we have seen we have seen indications of failings relating to the delayed initial assessment. We do not consider that has had any impact on Mr W’s health. There are no indications of failings relating to the wait for Mr W to see a doctor. This is because he did not require emergency treatment and there is no evidence he needed further assistance until his level of consciousness and blood sugar levels fell. The Clinical Adviser said the doctor who responded to these issues seems to have taken appropriate action.

36. Clearly the events in the emergency department were stressful for Mrs W. We hope she is reassured we have seen no indication that clinicians fell below the relevant standards when they were caring for her husband. We have decided not to start a detailed investigation.

1. We have carefully considered Mrs W’s complaint about the Trust. Mrs W complains about events that happened three days before her husband died. We can see how devastating these events have been for Mrs W. We offer our sincere condolences to her for her loss.

2. We can see no indication that anything went seriously wrong relating to the complaints Mrs W has asked us to consider. Where things may have gone wrong we cannot see any indications that these could have led to a decline in her husband’s health or contributed to his death. We have decided not to start a detailed investigation of Mrs W’s complaint. We recognise this is likely to be disappointing for Mrs W.