Kettering General Hospital NHS Foundation Trust

3. Mrs I complains about the care and treatment Kettering General Hospital NHS Foundation Trust provided her sister, Miss A, between 5 October and 7 November 2021. She raises concerns that staff: • did not isolate her sister in a side room until 12 October despite her being on immunosuppressant medication • did not clean blood pressure cuffs or temperature probes between patients • gave her morphine despite her saying she was not in pain • delayed providing antibiotics • delayed providing oxygen • delayed performing an MRI between 9 and 18 October • did not engage with her sister’s MS team in Leicester • delayed sending a transfer request until she was too unwell to move • delayed sending an extracorporeal membrane oxygenation (also known as ECMO, a life support system for patients with severe respiratory failure) referral until she was in intensive care • claimed excessive family contact was preventing them from providing care which caused them distress.

4. Mrs A says during the admission her sister developed vomiting, diarrhoea, a cough and shortness of breath. She considers poor infection control caused this and contributed to her sister’s deterioration. She says receiving morphine negatively affected her sister’s breathing and contributed to her needing continuous positive airway pressure (CPAP).

5. She says her sister did not receive the care she needed during her admission and that delays and inaction may have led to her death. She considers her sister would have lived if she was under the care of her MS team.

6. In bringing the complaint to us, Mrs I would like the Trust to acknowledge what went wrong and apologise, make service improvements to prevent others from having the same experience and make a financial payment.

7. Miss A had multiple sclerosis (a chronic autoimmune condition). On 5 October 2021 she lost consciousness at home and hit her head. Paramedics took her into hospital where she tested positive for COVID-19 on admission.

8. Staff treated her on a ward for patients with COVID-19 until 12 October when they moved her into a side room as blood test resulted showed she had become neutropenic (a condition where the body has too few white blood cells).

9. By 18 October she was on CPAP due to difficulties with breathing. On 31 October she deteriorated to the point of needing to be intubated and ventilated and staff moved her to the intensive care unit (ITU). She continued to receive ITU treatment until she sadly died on 7 November.

12. 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. We discussed this with Mrs I to understand the reasons for the delays. We also considered the time the Trust has taken to respond to Mrs I.

13. Mrs I became aware of the issues in her sister’s care in October 2021. To meet our time limit for this complaint, Mrs I needed to bring her complaint to us by October 2022. Mrs I brought her complaint to us in October 2024, meaning her complaint reached us two years outside our time limit.

14. Mrs I first raised concerns with PALS whilst her sister was still in hospital. It appears PALS dealt with this informally in writing on 29 October 2021. Mrs I did not raise any further concerns about her sister’s care during her admission.

15. Following this, Mrs I raised a formal complaint with the Trust on 10 January 2022, around three months after the Trust’s informal response. The Regulations says complainants should raise concerns within 12 months of becoming aware of any issues and so we have no concerns about this delay.

16. The Trust did not respond to Mrs I’s complaint until 12 September 2022. This was a delay of two months beyond the target response time of six months as set out in the Regulations. We recognise that NHS organisations were still facing the impact of the COVID-19 pandemic at this time which will have contributed to the delay. This was not Mrs I’s fault.

17. Mrs I then raised outstanding concerns in a reasonably timely way around four weeks later. She specifically requested a meeting to address these. It took the Trust around three months to identify a date where all necessary clinicians were available, and a face-to-face meeting was offered for January 2023. The Trust cancelled this due to an outbreak, and it took just over two months to rearrange this via Teams.

18. The meeting took place on 24 March 2023 and culminated in the Trust agreeing to complete the following actions: • review the policy with regards to the status of neutropenic patients or patients that are at risk • determine what learning can Trust undertake to ensure staff have an awareness of MS medication?

• explain what happened to the ECMO referral, was it completed and if not, why?

• why was radiology reporting delayed?

• feedback to staff about communication with family.

19. The Trust said it would need to establish who could implement the above and then could give a realistic deadline for carrying out the actions.

20. On 25 April the Trust’s Complaints Case Handler emailed Mrs I and agreed to update her on 5 May. The Trust did not provide any further update following its email. This was a lack of update on actions from the meeting and not a lack of a further complaints response as Mrs I had not asked for this.

21. Notes from Mrs I’s conversations with PHSO in 2022 show she was aware we would need a written response addressing her outstanding concerns before we could consider her complaint.

22. Following this there was a year period (between May 2023 and May 2024) where Mrs I did not chase the Trust for an update. Nor did she contact us for assistance despite having done this before. This was a considerable delay and so we have asked Mrs I why she did not chase the Trust for any update or contact us for support.

23. When we spoke via telephone, Mrs I told us she was recovering from what had happened and had gone back to work. She said the complaints process had really taken it out of her and time passed quickly. She also mentioned her father’s prostate cancer having come back at some point.

24. Following our call, we asked Mrs I for more information on her father’s cancer and how she considered this impacted her ability to pursue her complaint. In response she provided a detailed chronology of events spanning April 2023 to April 2024.

25. Mrs I said her father was diagnosed with progressing prostate cancer in March 2022 (two months after she raised her formal complaint with the Trust) and he concluded cancer treatment by April 2023. She says this diagnosis ushered in a new challenging period of ongoing treatment and caregiving responsibilities which she considers affected her ability to pursue her complaint.

26. We cannot say her father’s diagnosis or her supporting him with cancer treatment prevented her from chasing the Trust for an update as she was actively engaging with it and attempting to progress her complaint after this.

27. We understand her father continued to need further care and support after completing radiotherapy. She tells us she is one of several sisters and her eldest sister took on more of the day-to-day care at this time. We recognise supporting her father was challenging and left her feeling depleted, we do not consider it prevented her chasing the Trust for an update for an entire year.

28. Mrs I says between May and September 2023 she was accompanying her daughter to university open days which took up many weekends. After which she focused on moving her daughter, who has ADHD and social anxiety into university.

29. We recognise how difficult it can be for a young neurodivergent person to go through this transition. Especially on a back drop of grief and an unwell loved one. We note Mrs I did have the support of family during this period. We would not reasonably expect supporting her daughter in this way to take up months at a time. Therefore, we do not consider this prevented her from chasing the Trust for an update for an entire year.

30. Mrs I also mentions time spent arranging for her father to move into assisted living, helping him secure benefits and undergoing marriage counselling. These are understandably difficult things to go through, we are not persuaded they prevented her from chasing the Trust for an update for an entire year.

31. Having reviewed her full chronology, we recognise she has provided evidence that her capacity to pursue matters was depleted at points, we are not persuaded this was the case for the entire year. Especially given she tells us that in 2023 she was able to go back to work and sit on the board for a memorial project in honour of her late sister where she supported public promotions such as radio appeals and shop front campaigns.

32. We cannot say for certain how much sooner Mrs I could have brought her complaint to us. On balance we consider it likely this could have been as soon as September 2023 had she emailed the Trust for an update in May 2023. This would have meant the complaint came to us less than 12 months out of time instead of two years.

33. We consider Mrs I could have done more to progress her complaint between May 2023 and May 2024. Whether by chasing the Trust for an update or contacting us for support. She did not contact us for support despite having done so in the past and took around a year to chase the Trust.

34. We understand she was having a difficult time in her personal life and made the choice to prioritise her family over chasing the Trust. This meant she brought her complaint to us significantly out of time, and we do not consider there is enough reason to put our time limit aside.

35. We recognise how deeply distressing the events Mrs I complains about were, and the significant impact the loss of her sister has had and continues to have for her family. We do not underestimate the significance of her concerns. We thank Mrs I for bring her complaint to us.

1. We are very sorry to hear of the death of Mrs I’s sister, Miss A. It is clear from what Mrs I tells us that the loss of Miss A has had a profound impact on her and the rest of her family. We can also see Mrs I has serious concerns about the care her sister received.

2. We have carefully considered the concerns Mrs I has about the care the Trust provided. The complaint falls outside of our time limit, and we are not persuaded to put this aside to consider this further. We know this will be disappointing for Mrs I. We have explained our full reasons for this decision below.