University Hospitals of North Midlands NHS Trust

9. Ms T complains about the care her father, Mr T, received from the Trust in January 2025. She complains the Trust did not:

• handle her complaint sensitively and missed the deadline for responding without communication • carry out Mr T’s endoscopy promptly or communicate the results • appropriately manage Mr T’s bedsores or refer him to the tissue viability (TV) team • ensure Mr T took his medication • adequately attend to Mr T’s personal hygiene needs • appropriately manage Mr T’s nutritional needs.

10. Ms T says the poor care her father received meant he chose to discharge himself to be at home in the final days of his life, and the delays he experienced meant he had less time at home with his family before he died. She says the experience also caused herself and her family immense distress and anxiety.

11. Ms T is seeking acknowledgement of failings, an apology, service improvements and financial remedy.

12. Mr T was diagnosed with terminal oesophageal cancer in December 2024. He began palliative chemotherapy and received two doses. At the end of January 2025, he attended the hospital emergency department (ED). He was admitted with symptoms of jaundice (yellowing of the skin and eyes), caused by his cancer metastases (spread of cancer) blocking his bile duct. Bile ducts are small tubes that connect the organs of the digestive system.

13. At the beginning of February 2025, Mr T underwent an unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). This is a procedure used to treat conditions of the bile and pancreatic ducts, such as jaundice, which involves passing a flexible camera tube through the mouth to the small intestine. He had a drain inserted and underwent a further, successful ERCP several days later.

14. Mr T was referred to palliative care two days later and was told he likely had days to short weeks of life remaining. Mr T expressed a wish to die at home and was discharged via the hospital’s fast track palliative pathway. Sadly, he died in mid-February 2025.

The Trust mishandled Ms T’s complaint

18. Ms T complains the Trust did not respond to her complaint sensitively. She also says the Trust missed its deadline for responding without communication.

19. The Trust apologised for not sending its response on the agreed date.

20. Our NHS Complaint Standards says that organisations should respond to complaints with empathy, courtesy and respect.

21. Ms T first complained to the Trust in February 2025, when Mr T was still in hospital. The Trust responded the following day and acknowledged the complaint. It requested that Ms T and her sister provide confirmation of identity and either consent from Mr T to complain on his behalf, or confirmation that they held power of attorney (POA) for health for Mr T. Ms T’s sister confirmed she held POA on the same day.

22. Mr T died in mid-February. Several days later, Ms T emailed the complaints department and enquired why she had not received a follow up to her complaint. In its response, the Trust advised it had not received confirmation of identity, a completed consent form or a copy of the POA. In response, Ms T said these requests for documentation were insensitive, given the recent death of her father.

23. Ms T’s complaint was passed to the Trust’s Head of Patient Experience. The following day, they replied to Ms T and expressed condolences on the death of her father. They explained that the complaints process was governed by legislation which required the confirmation of identity before disclosing sensitive information. They said that, in the circumstances, they would progress the investigation as long as the required documents were provided in due course. They said this was not the usual process, but they wanted to make the complaints process easier for Ms T. Ms T responded the same day and the complaints process progressed thereafter.

24. We consider the Trust engaged with Ms T empathetically and courteously, in line with our complaint standards. We will therefore not be looking at this part of the complaint further.

25. Our NHS Complaint Standards also say that organisations should respond to complaints within expected timescales. These are set out in the relevant legislation, Local Authority Social Services and National Health Service Complaints (England) Regulations (2009). Section 14 explains that an organisation should respond to the complainant within six months of the complaint being received. It also explains that if there is a delay, then the complainant should be notified in writing and the response given as soon as reasonably practicable.

26. Ms T first complained to the Trust in February 2025. At the end of February, the Trust gave a provisional deadline for a final response of the end of April.

27. In mid-April, the Trust advised the complaint response was in the final checking stages and gave a deadline of mid-May.

28. On the first working day after the deadline, Ms T emailed the Trust seeking an update. She asked the Trust to provide a response within two further days. On the day of Ms T’s proposed deadline, the Trust emailed Ms T its final response and sincerely apologised for not sending the response the previous week, on behalf of both the Complaints and Administration teams. It said this was due to an administrative oversight.

29. This period encompasses approximately four months from when Ms T first complained to the Trust to when she received its final response. This is within the timescales for a response laid out in the relevant legislation and in line with our complaint standards.

30. Although the Trust did not send its complaint response to Ms T before its proposed deadline, and did not communicate with her that the deadline would be missed, it issued the response promptly when contacted by Ms T. We do not consider this delay of a few days to be a case of maladministration. We will therefore not be looking at this part of the complaint further.

The Trust did not carry out Mr T’s endoscopy appropriately or communicate the results

31. Ms T complains the Trust did not carry out Mr T’s endoscopy promptly and did not communicate the results to him or his family.

32. The Trust said Mr T’s first endoscopy had been unsuccessful, which caused a delay in his treatment. It said it had followed standard referral processes and apologised to Ms T for the lack of communication.

33. The records show Mr T was admitted to hospital at the end of January 2025. He had a CT scan the following day and was referred for an ERCP that afternoon. The referral was vetted and approved the following day, a Friday, but there was no space in the elective surgical list. Mr T’s ERCP was therefore booked for the following Monday, at the beginning of February, as elective ERCPs are not usually conducted over the weekend.

34. Mr T’s ERCP at the beginning of February was unsuccessful. Mr T and his family were not informed of the reasons for this. He was booked in for a repeat ERCP three days later, which was successful. He was subsequently referred to palliative care and discharged several days later.

35. GMC ‘Good Medical Practice’ sections 6 and 7 say clinicians should provide a good standard of clinical care promptly. British Society of Gastroenterology guidance says ERCP referrals should be vetted for appropriateness before being booked.

36. Our adviser said the Trust decision to treat Mr T with an ERCP was appropriate for his condition of obstructive jaundice, which was secondary to the progression of his cancer. They said the process followed by the Trust prior to the first attempted ERCP was reasonable, carrying out a CT scan first and then making the referral promptly on the same day. The referral was vetted the following day, which is in line with section 3 of British Society of Gastroenterology guidance on ERCPs.

37. Our adviser said there is a facility for urgent ERCPs to be carried out over the weekend, but Mr T’s palliative presentative meant he did not fit into this category. They said he was therefore correctly treated via the elective pathway.

38. Our adviser said an ERCP is a difficult procedure which is not always successful. They said the report of the failed ERCP is clear and the clinician was suitably qualified to carry it out. It was reasonable to wait several days for inflammation to subside before attempting a repeat ERCP, which was successfully completed. They said the ERCP procedures were in line with GMC ‘Good Medical Practice’ sections 6 and 7, which say clinicians should provide a good standard of clinical care promptly.

39. Our adviser said it was normal that Mr T would not have been initially informed about the outcome of his procedure. This is because patients are often heavily sedated and would not be able to process the information. They said it would be expected that staff update the patient and their family, where appropriate, on the procedure and its impact on subsequent care on the next ward round, which did not appear to have happened. They said this was not in line with GMC ‘Good Medical Practice’ section 28, which says clinicians should share information with patients about their condition and treatment.

40. Our adviser said that while the Trust’s communication around Mr T’s ERCPs was not in line with guidance, it did not impact on his clinical progression. Although Mr T and his family were not informed that his first ERCP had been unsuccessful, Mr T would always have needed to remain in hospital for a repeat ERCP. He could not have been discharged any earlier. They said that following the successful ERCP, Mr T remained under observation for a day before he was referred to palliative care. He was discharged two days later. Our adviser said the discharge process was completed very quickly following the successful ERCP, and any delays were not avoidable.

41. In summary, the Trust followed relevant guidance when carrying out Mr T’s ERCP referral and treatment. It did not follow guidance in its communication with Mr T and his family following the treatment.

42. Our NHS Complaint Standards say organisations should give fair and accountable responses to complaints and identify ways to put things right. The records show the Trust acknowledged its communication was poor in its final response. It acknowledged that improvement was required in its communication to patients and families following procedures. It said it would remind staff to ensure patients are fully aware of their procedure outcomes going forward.

43. Our Severity of Injustice scale identifies a level one injustice as annoyance, frustration, worry or inconvenience typically arising from a single (one-off) incidence, where the effect is of short duration and there is no adverse effect or ongoing impact on care. We conclude a single incident of short duration caused the worry to Mr T and Ms T. We acknowledge this would have been distressing to them in the context of Mr T’s ongoing treatment.

44. We believe this complaint component falls at level one on our Severity Of Injustice scale. The worry experienced was the result of a one-off incident of short duration and had no ongoing or adverse effects. The Trust responded to Ms T’s concerns on this point in line with our complaint standards. It acknowledged Ms T’s concern, apologised for the inconvenience caused and outlined the learnings it has implemented since.

45. We consider the action the Trust has taken to put things right, namely an apology, is appropriate for the worry caused to Mr T and Ms T. We will therefore not be looking at this part of the complaint further.

The Trust did not appropriately manage Mr T’s bedsores or refer him to the Tissue Viability (TV) team

46. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.

47. Ms T complains the Trust did not appropriately manage Mr T’s bedsores or refer him to the Tissue Viability (TV) team, which caused Mr T unnecessary discomfort and caused worry to Mr T and Ms T.

48. In its final response, the Trust said it should have documented the cream used in Mr T’s treatment. It said it should have referred Mr T to TV and apologised to Ms T.

49. The records show that on admission, Mr T was risk assessed for pressure ulcers and deemed low risk. The associated care plan documents say positional changes should be undertaken every four hours but states where patients are independent and self-caring, as Mr T was, clinical judgement can be used.

50. The records show Trust staff offered Mr T further skin assessments after his admission, but Mr T declined until early February. The records show staff advised him of the risks and suggested he reposition himself frequently.

51. Three days after Mr T accepted a further skin assessment, he was noted to have pressure damage to his sacrum (bottom of the back). He was then referred to a dietitian for a nutritional assessment. The records do not show there was any referral made to TV.

52. NICE Clinical Guideline CG179, ‘Pressure ulcers: prevention and management,’ says adults should be risk assessed on admission and skin assessed if considered high risk. It says staff should reposition patients and use pressure redistribution devices and barrier creams where appropriate. Section 1.4.4 says adults with a pressure ulcer should be offered a nutritional assessment by a dietitian or other appropriate healthcare professional.

53. Our adviser said the Trust treated Mr T in line with NICE guidance. They said Mr T was risk assessed on admission in line with guidance. They said staff appropriately used their clinical judgement in deciding when to reposition Mr T, as he was deemed to be independent and self-caring. They said Mr T was offered skin assessments and frequently declined them. They said the referral to a dietitian when staff identified sores on Mr T’s sacrum was in line with NICE guidance 1.4.4.

54. Our adviser said that while a referral to TV could have been made if the Trust suspected Mr T’s wound was deteriorating, the Trust’s local policies would determine whether the referral should have been made.

55. In its final response, the Trust said it should have made a referral to TV. It said that where skin damage is identified, a referral to TV is compulsory according to Trust policy. It said it had reminded staff of the correct process at a ward meeting.

56. The records show the Trust identified Mr T’s skin damage on in early February 2025. He was referred to palliative care two days later and discharged via the fast-track pathway four days later.

57. Our Severity of Injustice scale identifies a level one injustice as annoyance, frustration, worry or inconvenience typically arising from a single (one-off) incidence, where the effect is of short duration and there is no adverse effect or ongoing impact on care. We normally consider an apology sufficient to remedy this level of injustice. We have concluded the discomfort and worry caused to Mr T and Ms T was the result of a single incident of short duration. We do not think it had an impact on Mr T’s ongoing care. We acknowledge this would have been concerning to them in the context of Mr T’s ongoing treatment.

58. Having reviewed the evidence, we are satisfied the Trust’s management of Mr T’s skin damage was in generally line with guidance. In its final response, the Trust apologised to Ms T and acknowledged it should have referred Mr T to the TV team following the identification of skin damage, as per its internal policies. We consider this apology sufficient to put right the injustice to Mr T and Ms T. We will therefore not be looking at this part of the complaint further.

The Trust did not ensure Mr T took his medication

59. Ms T complains the Trust did not ensure Mr T took his medication during his admission. She says she witnessed important medication being left on his bedside.

60. In its final response, the Trust acknowledged medication may have been left on the bedside and apologised for this poor practice.

61. Our adviser said the prescription chart and nursing notes show the Trust gave Mr T his medications in a timely manner, as per his prescriptions.

62. NMC guidance (4.14) says nurses should administer medication safely and effectively, in accordance with local and national policies.

63. Our adviser said that if medications were left at the bedside and staff did not observe Mr T taking the medication, this is not in line with guidance.

64. While there is no evidence in the records that medication was left on the bedside, we would not expect this to be documented, given it is not in line with guidance. We do not think there is any reason for Ms T to have been untruthful in her account of what happened, and the Trust has apologised and instituted a learning in its final response. It reminded staff that leaving medication on patient’s bedsides is not acceptable and carried out regular spot checks to prevent any reoccurrence.

65. On the balance of probabilities, we think it is likely the Trust did not always follow guidance when it gave Mr T his medication.

66. We contacted the Trust to discuss this and other elements of Mr T’s care which were not in line with guidance. The Trust agreed to pay Ms T financial remedy and make a further apology. We explain this in more detail below.

67. We consider this sufficient to resolve this part of the complaint. We will therefore not be looking at this part of the complaint further.

The Trust did not adequately attend to Mr T’s personal hygiene needs

68. Ms T complains the Trust did not adequately attend to Mr T’s personal hygiene needs during his admission. She says used urine bottles were left at Mr T’s bedside for several days and Mr T was sometimes left in soiled clothes.

69. In its final response, the Trust apologised for not removing the bottles and for Mr T’s experience. It noted he was deemed to have capacity and there were no records of him asking for assistance.

70. The records show Trust staff assessed Mr T on admission. He was documented to be independent with activities of daily living (ADLs), which personal and hygiene care when using the bathroom. He was documented as being independently mobile and self-caring of hygiene needs. The records also show Mr T was assisted with personal care needs, such as washing, dressing and using the commode, when required.

71. NICE guidance CG138, section 1.2.9, says staff should regularly review and address patient’s personal needs, and regularly ask patients who are unable to manage their personal needs what help they need. Our adviser said because Mr T was assessed and considered to have capacity to carry out his own personal care, the Trust’s care of his personal needs was in line with guidance.

72. The records show Mr T occasionally used urine bottles but there is no evidence of him being incontinent in the records. Ms T says that on occasion, she found Mr T in soiled clothes following an episode of incontinence. The records do not suggest Mr T alerted staff on these occasions and requested assistance. Ms T says she made staff aware on these occasions but staff did not respond to repeated requests for assistance.

73. NICE guidance section 1.2.1 says staff should treat patients with dignity. Section 1.2.9 says staff should attend to patients’ personal needs at the time of asking. Our adviser said if Mr T was left in soiled clothes for a period of time, this would not be in line with guidance.

74. While there is no evidence in the records that urine bottles were left at Mr T’s bedside or that he was left in soiled clothes, we would not expect this to be documented, given it is not in line with guidance. We do not think there is any reason for Ms T to have been untruthful in her account of what happened, and the Trust has apologised and instituted learnings in its final response. It reminded staff to remove urine bottles and encourage patients to ask for assistance when needed and instituted an audit into the use and disposal of urine bottles.

75. On the balance of probabilities, we think it is likely guidance was not always followed when the Trust cared for Mr T’s hygiene needs.

76. We contacted the Trust to discuss this and other elements of Mr T’s care which were not in line with guidance. The Trust agreed to pay Ms T financial remedy and make a further apology. We explain this in more detail below.

77. We consider this sufficient to resolve this part of the complaint. We will therefore not be looking at this part of the complaint further.

The Trust did not appropriately manage Mr T’s nutritional needs

78. Ms T complains the Trust did not ensure Mr T was eating or appropriately manage his nutritional needs during his admission.

79. The Trust said it could not force patients to eat and drink, and that Mr T was encouraged to eat as much as he could tolerate.

80. The records show that Mr T’s appetite varied. At times, he did not manage much oral intake but at others, staff recorded there were no problems with his nutrition.

81. NICE guidance CG32, section 1.2, says patients should be screened and risk assessed for malnutrition on admission. The records do not indicate that a Malnutrition Universal Screening Tool (MUST) was correctly completed to assess Mr T’s nutritional risk.

82. The MUST risk assessment assigns patients a score which describes their risk of malnutrition. Our adviser said Mr T’s advanced cancer diagnosis meant he would likely have been considered high risk, which would have required input from a dietician when he was admitted. They said it appeared Mr T should have been referred to a dietician sooner.

83. Our adviser said if Mr T’s MUST had determined him to be high risk, his food and fluid intake would have been monitored. There are no food charts or fluid intake charts evident in Mr T’s medical records as part of his nutritional bundle.

84. I contacted the Trust to confirm whether a MUST risk assessment and nutritional bundle had been completed. It responded to confirm that they had not been. This means the Trust did not follow NICE guidance when caring for Mr T’s nutritional needs.

85. We consider there were three aspects of Mr T’s care and treatment where the Trust did not follow guidance, which are indicative of failings. We consider the Trust did not always follow guidance when giving Mr T his medication or when caring for his hygiene needs, and did not care for his nutritional needs in line with guidance.

86. We use our Severity of Injustice (SOI) scale to calculate appropriate financial remedy where we see indications of failings. Taken together, we consider the Trust’s failure to follow relevant guidance caused Mr T and Ms T avoidable distress and anxiety at a very difficult time. Although this did not contribute to Mr T’s death, it caused Mr T discomfort during his time in hospital and gave his family the impression that his care and treatment had been poor, which exacerbated the impact of his death on them.

87. Taken together, we believe this caused Mr T moderate distress and added to his family’s distress, during both his stay in hospital and after his death. This places it in level three of our severity of injustice. Based on previous similar cases, we believe an appropriate level of financial remedy would be £600.

88. We contacted the Trust to discuss the complaint. Following our contact, the Trust agreed to pay Ms T £600 in financial remedy and to make a further apology for the distress and discomfort caused to Mr T and Ms T. It also agreed to explain what learnings and improvements will be made to its clinical practice.

89. We consider this sufficient to resolve this part of the complaint. We will therefore not be looking at this part of the complaint further.

90. We thank Ms T for taking the time and effort to bring her complaint to our attention. We recognise this was a very difficult and distressing period for her. We hope our explanation and resolution provides some degree of settlement for her and explains the care and treatment Mr T received. We wish Ms T the best for the future.

1. We have carefully considered Ms T’s complaint about the care her father, Mr T, received from the Trust in early 2025.

2. We were very sorry to hear Ms T’s experience with the Trust had caused her distress and anxiety.

3. Ms T told us the Trust did not ensure her father took his medication and did not promptly remove urine bottles from his bedside, or attend to his personal hygiene needs.

4. Ms T also told us the Trust did not appropriately manage her father’s bedsores or refer him to the Tissue Viability (TV) team. She said the Trust did not carry out an endoscopy promptly or communicate the results. Finally, she said the Trust handled her complaint insensitively and missed its deadline for responding without communication.

5. We have looked at the Trust’s treatment and care of Mr T over this period and the Trust’s response to Ms T’s complaint. We consider the Trust carried out Mr T’s endoscopy in line with guidance. It did not communicate the progress of his endoscopy to him or his family in line with guidance, but this did not affect his clinical progression. We consider the Trust generally managed Mr T’s bedsores in line with guidance, but did not refer him for further care when it should. We consider the Trust has already done enough to remedy this injustice on Mr T and Ms T.

6. On the balance of probabilities, we think it is likely guidance was not always followed when the Trust gave Mr T his medication or cared for his hygiene needs. We saw the Trust did not follow guidance when caring for Mr T’s nutritional needs.

7. We contacted the Trust to discuss the complaint. Following our contact, the Trust agreed to pay Ms T £600 in financial remedy and to make a further apology for the distress and discomfort caused to Mr T and Ms T. It also agreed to explain what learnings and improvements will be made to its clinical practice. We consider this sufficient to resolve this complaint. We explain this in more detail below.

8. We hope our explanation and resolution provides a degree of closure for Ms T and explains the care and treatment Mr T received.