North Bristol NHS Trust

8. Mrs A complains about the lack of care and treatment her husband, Mr A, received at the Trust between 13 and 19 May 2023.

9. She specifically says:

• the Trust failed to communicate appropriately about Mr A’s care during his admission • she was not allowed to be with him when he passed away and was directed into a nearby office despite being the one to alert the staff that he had deteriorated • the nurses coerced him in to having new medication • his leg ulcers were not treated appropriately • on 18 and 19 May, Mr A suffered an unexplained wound on his right forearm and left hand during the night • the Trust did not weigh him during his admission, and his food and liquid intake were not monitored • he was forced to accept DNA CPR and this was not discussed with her • an electric shaver was stolen • it took the Trust four months to respond to her complaint.

10. Mrs A says the lack of communication (which is her main concern) meant she was shocked when he died so suddenly, and this made the grieving process difficult. Mr A sustained wounds to his hand in hospital that he did not go in with. She also says he lost weight during his admission. His shaver was stolen and this cost £60. She says the poor treatment Mr A received hastened his death.

11. Mrs A would like an explanation of why her husband died and a sincere apology.

12. Mr A was in his late 80s. He presented at the Trust’s emergency department (ED) via ambulance on 13 May 2023. This was due to being unable to pass urine, feeling unwell and with a head injury from a fall at home.

13. On 14 May, the Trust admitted Mr A to Ward 27b and treated him for heart failure and infection (likely to be pneumonia). He was being treated for increased shortness of breath by receiving oxygen. He had no significant injury to his head from his fall at home. He was also being treated for urinary retention and constipation.

14. He died on 19 May. The cause of death as per the death certificate is 1a) heart failure, 1b) aortic stenosis atrial fibrillation (abnormal heart rhythm), 2) chronic obstructive airways disease (COPD - progressive lung disease) and metastatic prostate cancer (advanced prostate cancer that has spread to other parts of the body).

Communication

18. Mrs A is upset the Trust did not update her about her husband’s care and treatment throughout his admission. She says if the Trust had communicated with her better and explained he may die, she could have been able to prepare herself mentally for his sudden death.

19. The Trust has said in its final response letter dated 6 February 2023 that the plan was to update the family on 14 May when Mr A was moved to Ward 27b. It explained, unfortunately this did not happen.

20. The Trust said staff updated Mrs A on 16 May where she also informed the doctor she was unhappy with the lack of communication.

21. GMC guidance says:

‘you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.

22. Our adviser explains the medical records are clear evidence of Mr A’s worsening heart failure being severe. There is evidence in the records he had limited capacity to walk before becoming tired and breathless quickly.

23. Mr A’s chest X-ray from 18 May shows signs of heart failure, signs of chronic obstructive pulmonary disease (COPD is a progressive lung disease characterized by obstructed airflow) and co-existing infection. He was prescribed antibiotics. A ‘CURB’ score (a way of assessing the severity of a community acquired pneumonia) of 1 was scored. This is a low score for the severity of community acquired pneumonia.

24. Our adviser explains the cause of Mr A’s death was sudden and the medical observations do not show a deterioration prior to the sudden death, therefore no requirement for escalation before death. Death can be sudden for patient with a combination of active comorbid conditions, age and frailty, like Mr A.

25. In reviewing the medical records and the final response letter there is clear evidence there was a lack of communication with Mrs A about the reason he was in hospital and what he was being treated for. This is because the records indicate the Trust did not update Mrs A until she asked staff for updates. It is understandable why she is so distressed and upset and why this continues to affect her.

26. Even after 16 May, when Mrs A said she was unhappy with the lack of updates, the Trust did not provide adequate updates about Mr A’s care until he died on 19 May. This is not in line with the GMC guidance referred to above.

27. Therefore, this indicates a failing and we have considered the impact of this and the Trust’s actions in response to this below.

Impact

28. We recognise the complexity of the situation and empathise with Mrs A. We are so sorry that she felt unheard and was not told what to expect, especially as she witnessed her husband in hospital.

29. We acknowledge this was a distressing time for her and how this is still impacting her until this day. We know how important this complaint is to her, and she has told us she wants an explanation about what happened.

30. We are so sorry the Trust did not communicate with her appropriately.

31. The Ombudsman’s Principle for remedy say an appropriate range of remedies where maladministration of poor service has led to an injustice will include an apology, explanation, and acknowledgement of responsibility, revising procedures to prevent the same thing happening again and training or supervising of staff. The principles also say organisations should ensure lessons learnt are put into practice. The principles for remedy are reflected in our more recent NHS Complaint Standards.

32. Within its final response, the Trust has apologised for its lack of communication and understands the distress it caused her. It also recognised the uncertainty and anxiety this caused Mrs A.

33. Because of this complaint, it has reminded its staff about the importance of communicating with families and patients. It is also working with the divisional patient experience team who focus on improving communication and has provided them with reflections and learning from this complaint.

34. On this basis, we can see evidence the Trust has acknowledged its communication should have been better and understands the impact this had on Mrs A.

35. We are satisfied the Trust’s actions are a sufficient remedy in line with our principles, so we will not be taking any further action for this part of the complaint.

Medication

36. Mrs A says she thinks her husband was coerced into taking new medication. She does not understand why this was done or how this affected his care.

37. The Trust has said in its final response that it is sorry if Mr A felt coerced. As a result of this complaint, it has reminded all nursing staff to ensure patients fully understand the medications they are given and what they are for.

38. It has also reflected further and recognised it should have discussed this with her at the time to ensure it kept her up to date.

39. GMC guidance for prescribing medication says,

‘Together with the patient, you should assess their condition before deciding to propose, prescribe or provide a medicine, treatment or device. You must have or take an adequate history, which includes:

• any previous adverse reactions to medicines • current and recent use of other medicines, including non-prescription and herbal medicines, illegal drugs and medicines purchased online or face to face • other medical conditions.

40. We recognise Mrs A has concerns about Mr A’s medications, so we have reviewed these in the medical records with the help of our adviser.

41. We hope the information to follow will alleviate Mrs A’s concerns.

42. Mr A was taking the following medication during his admission:

• his normal medication prior to his admission for his existing conditions • he was prescribed tamsulosin (medication to relax muscle in the prostate and bladder neck making it easier to urinate) in the community which he told the Trust he had stopped taking and the hospital pharmacist removed it off the prescription list. He did not take this during his admission • intravenous diuretic medication called furosemide (twice a day to remove extra fluid to improve his heart failure symptoms) • amoxicillin oral antibiotics for his infection.

43. Our adviser explains the only changes were to his heart medication to add an increased dosage of diuretic medication to treat his heart failure by an intravenous route. This is the usual treatment for heart failure.

44. We recognise the above explanation may provide Mrs A with new information about her husband’s health. We are sorry if this adds to her upset and distress.

45. After careful consideration of the records and our advice, we have not seen any evidence Mr A was coerced into having new medication. The medication he was prescribed was existing medication and any new medication was to treat his new symptoms (for which he was in hospital for).

46. The records show evidence of the Trust discussing Mr A’s medication with him as he was the one who made them aware he had stopped taking tamsulosin. His prescription was adjusted to reflect his needs through the conversations that were had. This is in line with the GMC guidance above as the evidence indicates the Trust worked together with Mr A when prescribing. We have not found any evidence to suggest Mr A was coerced into taking new medication.

47. On this basis, we have not found any indications of failing for this part of the complaint and will not consider this further.

Leg ulcers

48. Mrs A complains her husband’s leg ulcers were not treated properly, specifically his dressings were not changed.

49. The Trust has said in its final response letter, when Mr A was admitted on 13 May his legs were reviewed and re-dressed. The nursing staff took photographs to be able to compare wounds during dressing changes. Wound swabs were collected to ensure there was no infection.

50. The Trust has also said it could not locate a wound care plan (involves assessment, treatment and management to promote healing and prevent infection) within Mr A’s medical records.

51. The Trust has also said on 15 May, Mr A was reviewed by a doctor who had requested a Tissue Viability Nurse review for his dressing. This was because Mr A had said he did not like his current bandages. The Tissue Viability Nurse did not review Mr A because he had already been reviewed on 3 May. The Trust reiterated this did not affect him getting the correct treatment for his wounds.

52. The below guidance is relevant to this case. Even though it was recently updated, the section we have referenced has not changed and was relevant at the time of this complaint.

53. NICE guidance for leg ulcers says:

• a nurse should wash the wound with tap water and dry • use a simple non-adherent dressing • frequency of dressing changes depends on the wound. Dressing changes may only be needed weekly • dressings to be used until the wound has healed.

54. We have thoroughly reviewed the medical records and can confirm the following:

• 13 May, dressing checked and changed • 14 May, leg dressing checked and changed • 16 May at 4.45am, Mr A refused leg dressing change • 19 May at 1.00am, leg dressing changed, cleaned and creams applied.

55. After careful consideration of the records, there is evidence to show Mr A’s leg ulcers were treated and dressings were changed in line with the guidance above.

56. As such we do not think there is an indication of failing for this part of Mrs A’s complaint.

57. We think, the Trust should have been clearer about the times it changed Mr A’s dressings throughout the admission within its final response.

58. It is reassuring to see that because of Mrs A’s complaint the Trust has recognised Mr A’s wound care plan was not completed. It has apologised for this and reiterated this did not affect the care Mr A received.

59. The Trust said it has reminded staff to ensure every patient with a wound has a wound care plan to ensure any changes can be documented. We would not be able to achieve anything more if we were to consider this complaint further.

18 and 19 May

60. Mrs A complains her husband sustained a wound on his right forearm on 16 and 17 May (these dates are from her complaint form) and left hand where his skin had peeled back on 18 and 19 May. She says that this was shocking and heartbreaking to see and that a staff member did it deliberately. She says her husband told her this at the time.

61. The Trust has said in its final response Mr A sustained a skin tear to his left hand whilst trying to reach for the call bell during the night of 18 May. It has not commented on the injury to the arm. It said it updated Mrs A and told her Mr A had been confused and distressed that he could not reach the call bell during the night.

62. The Trust also said Mr A’s risk assessment (completed on admission) showed he required hourly observations and that this was done. The Trust has reflected on this complaint and reminded its staff about the importance of always having the call bell within reach.

63. We have carefully considered the medical records and notes on 19 May at 4.20am Mrs A called the Trust and informed staff her husband had called saying he wants her to pick him up and was very upset. The Trust explained Mr A was trying to reach for the call bell and hurt his hand in the process. The Trust confirmed appropriate dressings were applied to his left hand and the call bell was placed within reach. There are no further notes on any other injuries that may have been sustained.

64. Mrs A is adamant a staff member deliberately inflicted these injuries. She wants the individual to be held accountable.

65. Our SMP guidance says, there will be occasions when we decide there are other reasons why we should not investigate a complaint made to us. One of those reasons that is related to this part of the complaint is:

• ‘that an investigation would not be practical, would not reach a satisfactory conclusion and there would be no value in providing that response through an investigation.

• if the outcome sought is not achievable.’

66. We have considered Mrs A’s account carefully and do not discount her version of events. We are limited to a degree in how much we can say about the medical records.

67. From the records we have seen, it would be difficult to determine that Mr A’s injuries were deliberately inflicted on him by another person.

68. From the evidence, we can say, on balance of probabilities, the injury to his left hand was caused by trying to reach for the call bell because that is what is documented in the records. We have no reason to question the validity of the medical records.

69. We have not seen evidence in the Trust’s response, or in the medical records, about an injury to Mr A’s right forearm. Overall, we think it would be difficult to reach a view for this part of the complaint. This means, it is unlikely we could come to a satisfactory conclusion on this part of the complaint. We have decided not to investigate this issue further. This is in line with our SMP guidance.

70. We understand this must have been a difficult time for Mrs A. We recognise how worrying it must be for her to think someone deliberately hurt her husband. We are sorry we cannot give her a more definitive explanation.

Monitoring of weight and nutrition

71. Mrs A complains her husband was not weighed during his admission. She says she expressed concerns about him losing weight, but staff did not take her concerns seriously.

72. She also says there is no record of his food and liquid intake, and this supports that he was losing weight. She believes this surely hastened his death.

73. The Trust has said in its final response letter it should have weighed Mr A and monitored his weight during his short admission. It explained this was important to do because he was receiving medications to remove the excess fluid in his body for his heart failure.

74. The Trust has accepted there are no records of a nutritional assessment which should have been done in accordance with its own policy.

75. NICE guidance for nutrition says healthcare professionals should review the indications, route, risks, benefits and goals of nutrition support at regular intervals.

76. Our adviser confirms a MUST (Malnutrition Universal Screening Tool, a five step assessment tool helps to identify malnourished adults or those at risk of malnutrition) was done on 15 May 2023 which identified a medium risk.

77. There is no evidence this was monitored or done at regular intervals and there are no food and liquid intake records. This is not in line with the NICE guidance above.

78. Therefore, this is an indication of a failing for this part of the complaint. We go on to consider the impact of this.

Impact

79. We understand the lack of monitoring of Mr A’s weight and absence of food and liquid intake caused Mrs A further distress at an already difficult time and she thinks this hastened Mr A’s death.

80. Our adviser explained patients with advanced medical conditions can lose body mass (fat and muscle) but gain fluid (fluid retention) especially during heart failure. It is important to weigh a patient on admission, especially if the assessment and treatment of the condition may benefit from this information.

81. The notes show an intent of the medical staff to weigh Mr A regularly as part of his heart failure management, but we can see no evidence this was done.

82. Our adviser also explains failure to record nutrition is not likely to have hastened his death as Mr A was not in hospital for a lengthy period (six days). Nutritional deficiencies that cause or contribute to death usually take longer to affect the patient.

83. The evidence shows the Trust’s medical examiner who carried out the verification of death for Mr A did not believe nutritional deficiencies caused or contributed to death. Also, the failure to record weights did not have a negative impact on his heart failure treatment.

84. The Ombudsman’s Principle for remedy say an appropriate range of remedies where maladministration of poor service has led to an injustice will include an apology, explanation, and acknowledgement of responsibility, revising procedures to prevent the same thing happening again and training or supervising of staff. The principles also say organisations should ensure lessons learnt are put into practice. The principles for remedy are reflected in our more recent NHS Complaint Standards.

85. Having carefully considered the advice we received, we think nutritional deficiencies were not likely to have hastened the death. We also note this was not a cause of death listed on the death certificate.

86. We understand that learning this will cause Mrs A distress and anxiety and we are so sorry for this.

87. Within its final response, the Trust has apologised this was not done and recognised it is an extremely important part of the patient’s care. It has said because of this complaint, it has reminded its staff about the importance of nutritional assessments and ensured its staff are adequately trained in completing these assessments. We are reassured the Trust has taken Mrs A’s concerns seriously and reflected on what has happened.

88. To conclude, we do not expect the Trust to do anything further to remedy this concern. The service improvements and actions it has already taken are in line with our principles above. Therefore, we will take no further action for this part of the complaint.

DNA CPR

89. Mrs A is concerned her husband was forced to accept DNA CPR. She is specifically concerned she was not consulted in this decision.

90. The Trust has said in its final response due to Mr A’s frailty and co-morbidities (existing illnesses) chest compressions were not felt to be in his best interests as it was very unlikely it would be successful. The Trust also explained if chest compressions were done, it was likely to cause him trauma and distress.

91. BMA guidance says, ‘the decision not to attempt CPR is a clinical decision. If the clinical team has good reason to believe there is no realistic prospect of a successful outcome, CPR should not be attempted.’

92. The guidance also states the importance of informing the patient of the DNACPR decisions with careful consideration.

93. ReSPECT guidance (the process creates a personalised recommendation for clinical care in emergency situations) says the plan is created through conversations between the patient and the clinical team. The plan also supports patients in emergencies where they may not be able to say what’s important to them, clinical decisions will be made by health professionals acting in the patients’ best interests and benefit.

94. We have carefully reviewed the relevant medical records and notes upon Mr A’s admission, with the help of our adviser. These show the Trust screened him for dementia and delirium. The results of this were low and unlikely.

95. On this basis, the Trust presumed Mr A to have capacity to be able to make his own decisions.

96. The Trust completed a ReSPECT form on 13 May, because it was felt to be in Mr A’s best interests given his frailty. It is important to note the ReSPECT form is only for recording decisions about CPR, Mr A still had other acceptable treatment in an emergency scenario.

97. From discussing with our adviser, we understand DNA CPR is a medical decision. It is not necessary to obtain the family input on this decision if the patient has capacity to take part in the conversation themselves.

98. The process of making this decision is best taken as a ‘shared decision-making process’ promoting the active involvement of the patient. Our adviser notes Mr A was an elderly person and described as ‘frail’ in the medical records and there was a chance he may deteriorate given the nature of his cardiac disease.

99. The notes show a doctor had a discussion with Mr A and made the medical decision not to offer resuscitation. Our adviser explained the evidence indicates Mr A had capacity at the time to be able to understand this decision.

100. Our adviser explained whilst there is no requirement to involve any other person where the patient has capacity at the time of the decision, it is good practice to invite relatives to be present if the situation permits. It is not clear from the notes if Mr A wanted his wife to be involved in this decision or not.

101. We understand Mrs A disagrees with the decision to apply a DNACPR. Having considered the evidence and guidance we are satisfied the Trust acted in line with the relevant guidance when making its DNA CPR decision.

102. Mrs A feels clinicians should have discussed the DNACPR order with her before applying it, but the guidance does not stipulate clinicians must involve families in these decisions (especially when the patient has capacity).

103. To conclude, having considered the advice and guidance above, we are satisfied the Trust acted in line with the guidance and involved Mr A in decisions around CPR (because he had capacity), it did not need to do anything further in relation to this. For these reasons, there are no signs of failing in this part of the complaint.

Mrs A not with husband when he died

104. Mrs A’s concern is that she was with her husband before he died, he slumped forward suddenly, and she ran out of the room to alert the doctors. The doctors rushed to attend to Mr A and she says they pushed her into a side room and she did not know what was happening.

105. We are so sorry Mrs A had to go through this traumatic experience, and we recognise the events that unfolded would have been distressing for her.

106. The Trust has apologised for directing Mrs A into a side room and that the priority was attending to Mr A in an emergency.

107. Our adviser has based their advice on their professional judgment. This is because we have not seen specific or general guidance that applies here. They have told us, if staff did not perform resuscitation, they could have invited Mrs A back into the room where information could have been shared about what had happened. We understand this would only be possible if there was time to have the opportunity to do this.

108. Records indicate, doctors attended to Mr A at approximately 9.30am, after the call bell was alerted and Mrs A informed staff her husband needed help. The doctors attended to Mr A for an emergency. CPR did not take place, and he was unresponsive at the time. This is in line with the ReSPECT form.

109. There is an entry in the medical notes (written in retrospect at 3.15pm) that shows a conversation took place after Mr A had died between a doctor and Mrs A, the exact time is unknown. Mrs A was describing what had happened in relation to Mr A. There is no description of being directed to another room or if any support was provided to Mrs A after her husband had died.

110. It is difficult for us to form a clear understanding of exactly what happened or of the timings involved. We understand the doctors’ priority would have been to deal with Mr A in an emergency situation.

111. As we have explained, the Trust has apologised in its response that it did not allow Mrs A into the room. Having considered this carefully, we think on balance, staff were, more likely than not, trying to attend to Mr A as a priority which was appropriate. We do not think there is evidence to show staff missed an opportunity to bring Mrs A back into the room. For this reason, we have decided there are no indications of the Trust failing to act how it should have and we will not consider this further.

Electric shaver

112. Mrs A says her husband’s new electric shaver which cost £60 was stolen during his admission.

113. We understand the distress this caused Mrs A. We also recognise the financial loss of this.

114. Following Mrs A’s complaint, the Trust has investigated the missing shaver, by:

• asking the ward to investigate and look for the shaver • checking the medical records to see if a property form was filled out.

115. The Trust has said in its final response letter the shaver became misplaced during Mr A’s admission and unfortunately it could not locate it. It has apologised for this. The Trust acknowledged it did not complete a property form on admission for Mr A.

116. Therefore, this is an indication of a failing. We go on to consider the impact of this.

Impact

117. It is understandable why Mrs A is so upset about the missing shaver. Mrs A has not said she would like the money back for the shaver. There is no evidence she approached the Trust for a refund of the £60.

118. The Ombudsman’s Principles for remedy say an appropriate range of remedies where maladministration of poor service has led to an injustice will include an apology, explanation, and acknowledgement of responsibility, revising procedures to prevent the same thing happening again and training or supervising of staff. The principles also say organisations should ensure lessons learnt are put into practice. The principles for remedy are reflected in our more recent NHS Complaint Standards.

119. During the Trust’s own investigation into the missing shaver whilst it did not locate the shaver, it recognised property policy was not followed.

120. As a result of this complaint, the Trust has reminded its staff to ensure the form is filled out when a patient arrives on the ward. In addition, it has reminded its staff to label any valuable items to ensure if they are lost or misplaced, they can be located safely.

121. The significance of this is in the future there will be clear evidence of what belongings the patient has during admission.

122. It is reassuring to see the Trust has recognised where it fell short and that it has made service improvements to stop future occurrences of the event. This is in line with our principles and NHS complaints standards. Therefore, we would not ask the Trust to do anything further.

123. We understand this decision may cause Mrs A distress. We are satisfied the Trust has put right what went wrong.

Complaint handling

124. Mrs A is unhappy it took the Trust four months to respond to her original complaint from 27 October 2023.

125. This caused her additional distress at an already difficult time when she was trying to get answers about why her husband had died so suddenly.

126. The Trust provided its final response on 6 February 2024 with an offer to meet in person if needed.

127. The NHS Complaints standards states, ‘staff should respond to complaints at the earliest opportunity and consistently meet expected timescales for acknowledging a complaint. They give clear timeframes for how long it will take to investigate the issues, taking into account the complexity of the matter’.

128. The Trust’s internal complaints policy states once a complaint is received it will usually take 35 working days to resolve and that the NHS Complaints Regulations 2009 apply to the management of the complaint.

The NHS Complaints Regulations 2009 states: ‘14.—(1) A responsible body to which a complaint is made must— (a)investigate the complaint in a manner appropriate to resolve it speedily and efficiently.’

129. The regulations also say the organisation has a period of six months to provide a written response to the complaint.

130. The Trust emailed us on 12 December 2025 and said 35 working days is an initial time scale. The Trust is transparent with the complainant when the complaint is received confirming things may take longer.

131. For Mrs A’s complaint, the Trust contacted her on 19 December 2023 to discuss and agree an extension because the investigation needed more time to be thorough. The Trust says Mr A agreed to this extension.

132. The Trust confirms throughout the complaints cycle, Mrs A was in regular contact with the complaint’s department and kept up to date.

133. After consideration of the final response letter and the guidance above, we think the Trust completed a thorough investigation into Mrs A’s complaint. There is evidence the Trust agreed the extension where necessary and then kept Mrs A up to date throughout the process. This is all within the six-month timescale recommended by the NHS complaints regulations.

134. On this basis, we cannot say there is an indication of a failing. We are satisfied the contents of the final response answers Mrs A’s complaint thoroughly and the time it took to do that was reasonable.

135. We are so sorry for any distress this decision causes. We fully recognise the impact this traumatic event has had on Mrs A. We thank her for bringing her complaint to us and appreciate how distressing it has been to revisit what happened to her husband.

1. We have carefully considered Mrs A’s complaint about North Bristol NHS Trust (the Trust). We are sorry for the circumstances of this complaint and extend our sincere condolences for the loss of her husband.

2. We understand the emotional stress she experienced because of the events she complains about and how that made the grieving process challenging. We know this was an incredibly difficult time for her and understand the ongoing emotional impact she is facing.

3. We have seen indications of failings in relation to the following:

• lack of communication • monitoring of weight and nutrition • loss of electric shaver.

4. We consider, it is unlikely that these indications of failings contributed to or hastened Mr A’s death. We are satisfied the Trust has reflected on the above aspects of the complaint thoroughly and made service improvements to ensure this does not happen again. This is in line with our principles of remedy. We have decided not to investigate these parts of the complaint as we do not think we would achieve anything further.

5. We have not seen any indications of failings in relation to the following:

• Mr A was coerced into taking new medication • management of leg ulcers • DNA CPR (do not attempt cardiopulmonary resuscitation) • Mrs A not being with her husband when he died • complaint handling.

6. In relation to Mrs A’s complaint about the hand and arm injuries that occurred on the night of 18 and 19 May, we have decided not to consider this part of the complaint further. This is because an investigation by us would not reach a satisfactory conclusion, and we would be unlikely to achieve Mrs A’s desired outcome.

7. We understand how important this complaint is to Mrs A and the impact on her. We explain the reasons for our decision in detail below.