Dartford and Gravesham NHS Trust

3. Mr D complains the Trust administered a medication to his mother, Mrs D on 9 September that led to her death.

4. He says this was incredibly distressing for his father who was present at the time. He says he and his father are devastated at the manner of his mother’s sudden death.

5. He is seeking transparency of what happened to his mother.

6. This brief background is only intended to place the key events in context, not provide a full account of everything that happened.

7. Mrs D (aged 88) had a background of diabetes, heart failure, high blood pressure, dementia and chronic kidney disease.

8. She was admitted to the Trust in August 2024 with heart failure, acute kidney injury and high potassium levels.

9. On 5 September, she was deemed medically fit for discharge. On 9 September she became unwell and sadly died.

13. 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.

14. Mr D told us his father visited his mother at 6pm and she was her normal self, and chatty. He reports that shortly after his arrival, a doctor and nurses attended Mrs D and shut the curtains. He says he heard the doctor say ‘make sure you put it right under her tongue’ several times and then told Mr D’s father to say his goodbyes. She died shortly after.

15. We reviewed Mrs D’s medical records. At 4pm on 9 September, a nurse asked a doctor to review Mrs D as her blood pressure was low and her heart rate was high. They performed an ECG (tracing of the heart) which showed atrial fibrillation (AF- a fast irregular heartbeat). The doctor planned to give Mrs D fluids and digoxin (a medication to control the rate and rhythm of the heartbeat).

16. At 6.30pm, the nursing notes show that Mrs D’s observations had worsened. Her breathing rate had increased, and her temperature was low. They did another ECG and called the doctor.

17. At 6.55pm, the doctor noted that Mrs D had deteriorated and a do not attempt cardiopulmonary resuscitation (DNACPR) was in place. They explained to her husband that they would prioritise her comfort. At 7.13pm, Mrs D sadly died.

18. Our adviser explained Mrs D had a reduced ejection fraction (EF). This means her heart did not pump as effectively as it should due to her heart failure. The ESC guidelines say to give a beta blocker (to slow the heart rate) or digoxin to patients with a low EF and AF. Beta blockers can sometime worsen acute heart failure, so the Trust prescribed digoxin in line with this guidance.

19. We reviewed Mrs D’s drug chart for the evening of 9 September. Staff administered 5000 units of heparin at 6.19pm, This is a blood thinner to prevent blood clots and is injected under the skin of patients who are in hospital.

20. She had a digoxin infusion into her vein between 4.25 and 6.25pm to manage her AF, in line with the guidance above.

21. At 6.54 and 7.02pm, staff gave her Glyceryl Trinitrate (GTN) spray. This is used to treat the symptom of chest pain and is sprayed under the tongue.

22. From our review of the records available, we have seen no indication the Trust administered medications outside of the relevant guidance to manage Mrs D’s deterioration on 9 September.

23. We appreciate how distressing it was for Mr D and his father to see Mrs D deteriorate so quickly. We hope they can be reassured we have seen no indication the Trust acted outside of guidance in treating her. We thank him for bringing his complaint to us.

1. We have carefully considered Mr D’s complaint about Dartford and Gravesham NHS Trust (the Trust). We were sorry to hear of the circumstances of his complaint and how distressing this was for him and his father.

2. We have considered all the available evidence, and we have seen no indication the Trust did anything wrong. We recognise his mother’s deterioration was very sudden and upsetting, and we extend our sincere condolences on his loss.