Manchester University NHS Foundation Trust

4. Mrs N complains about the care the Trust provided to her late father, Mr W between 27 and 28 November 2022. She says the Trust failed to pick up on her father’s symptoms prior to his death from aspiration pneumonia.

5. Mrs N feels the Trust missed opportunities to diagnose and treat her father’s condition sooner, which might have affected the outcome for him. She suspects her father may have choked on vomit at the end of his life which would not have happened if he had a proper diagnosis and monitoring.

6. Mrs N says her father suffered pain towards the end of his life. She says losing her father was a shock which had a profound impact on her. She also feels due to the lack of diagnosis the family lost the opportunity to be with her father towards the end of his life.

7. As an outcome to the complaint, Mrs N would like an acknowledgement of failings, financial remedy, and service improvements.

8. Mr W had Whipple surgery (surgery to treat pancreatic cancer) on 21 November 2022. A week prior to this, doctors diagnosed him with pancreatic cancer.

9. Mr W remained in hospital on the High Dependency Unit (HDU) following his surgery and doctors planned to discharge him at the end of the week. On 26 November, HDU transferred Mr W to ward 11 (a surgical ward) at approximately 9pm.

10. Between midnight and 1am on 28 November, Mr W unexpectedly deteriorated. He began vomiting black liquid and had a cardiac arrest. The clinical team commenced CPR, but Mr W sadly died.

11. Mr W’s death certificate and postmortem say his primary cause of death was aspiration pneumonia (a lung infection which occurs when a person inhales food, liquid, saliva, or vomit into the lungs).

Aspiration pneumonia

15. Mrs N is concerned the Trust failed to detect her father’s symptoms and deterioration prior to his death from aspiration pneumonia as recorded on his death certificate and postmortem. We understand why Mrs N is so concerned about this given Mr W’s sudden and unexpected death.

16. The GMC guidance says when diagnosing and treating patients, doctors must:

• adequately assess the patient’s conditions, taking account of their history, their views and values • promptly provide or arrange suitable advice, investigations or treatment.

17. From review of the medical records, our ICU adviser said that during his stay on ward 11, Mr W was not presenting with typical signs of aspiration pneumonia. Although the clinical team documented he had a wet a cough, this alone is not an indication he had aspirated. Our ICU adviser explained he was not showing signs suggestive of an infection.

18. Our surgeon adviser also agreed that there were no signs in the medical records that Mr W had developed aspiration pneumonia. They explained that Mr W’s CRP levels (which are a marker of inflammation and infection) rose initially following his surgery which is consistent with post-operative inflammation. However, following this they began to improve. Our surgeon adviser explained that if Mr W was developing pneumonia, his CRP levels would have increased rather than improved.

19. We can see that on the evening of 27 November at around 11.30pm a doctor reviewed Mr W and noted he had chest pain. However, the medical records showed his saturations at the time were 96 percent which were normal. The doctor listened to his chest and documented this was clear. Our surgeon adviser said there was no obvious signs that Mr W had aspiration pneumonia based on this assessment. The doctor also arranged some blood tests for Mr W in line with the GMC guidance.

20. Our ICU adviser explained that at the end of his life, it appears Mr W suffered a sudden aspiration reflux from his stomach onto his lungs which resulted in a cardiac arrest.

21. Our surgeon adviser also agreed that Mr W suffered an acute aspiration (where substance is inhaled into the lungs leading to immediate symptoms) prior to his death rather than a slow development of aspiration pneumonia over the days leading up to this. Taking this into account, we consider that Mr W’s death was sudden, and the clinical team could not have predicted this.

22. We do not consider the Trust failed to diagnose Mr W with aspiration pneumonia in the days leading up to his death or provide appropriate treatments for this in line with the GMC guidance. We do have some concerns though in how the Trust monitored Mr W from 27 November onwards we have explored further below.

Clinical observations and consultant review

23. The Trust’s Adult Early Warning Score (EWS) policy outlines how staff should record a patient’s clinical observations. This says staff should take a full set of observations including pulse rate, respiratory rate, blood pressure, temperature, neurological status, oxygen saturation, and amount of oxygen received. The observing clinician will then enter these into the Trust’s electronic system (Hive) which generates a score. The score helps identify signs of deterioration in the patient and ensure they receive timely medical intervention.

24. At 11am on 27 November, the Trust recorded Mr W’s clinical observations, and the Trust advised that under its EWS policy, Mr W’s score was a 5. Under the Trust’s EWS policy, a score of 4 or more and/or a score of 3 in one single parameter should prompt repeated observations hourly as a minimum. This should continue until the score reduces to less than 4 or 3 in a single parameter.

25. The policy also says if a patient has a score of 5 or 6, a secondary medical responder should attend to them to start appropriate intervention. The policy says a secondary medical responder is a doctor of grade ST3 (a doctor in third year of speciality training) or above.

26. We have considered if the Trust acted in line with this policy. We can see that following the score of 5 at 11am, the next set of observations recorded for Mr W were at 12.24pm. The Trust say Mr W’s EWS was a 3 at this time. However, the recorded observations from this time were incomplete. We can see no evidence of Mr W’s temperature, pulse, respiratory rate, or blood pressure being recorded at this time. As such, we do not agree that Mr W’s EWS score was a 3.

27. We can also see a nurse practitioner visited Mr W at 12.32pm. The Trust said this visit is evidence staff took appropriate action in response to Mr W’s NEWS score of 5. It said the nurse practitioner completed a thorough review and deemed that Mr W was alert and orientated with no further action required.

28. The nurse documented his confusion reflected the finishing of Mr W’s patient-controlled analgesia and change in environment following his step down from HDU. The Trust also said the nurse practitioner decided Mr W did not require hourly monitoring.

29. However, even though we can see the Trust arranged for a nurse practitioner to review Mr W, we consider the Trust still should have repeated Mr W’s observations at 12pm. Our ICU adviser explained it is not normally up to the individual clinician to determine that a patient requires less frequent monitoring. It is their EWS score that decides this. We also cannot see any evidence the nurse practitioner documented that Mr W required less frequent monitoring.

30. The clinical team took the next set of observations at 1pm (2 hours after the score of a 5). At this time Mr W scored a 3. We consider this to be a failing as we cannot see any evidence the clinical team repeated Mr W’s observations after one hour following his score of 5 at 1pm. We also cannot see that an ST3 doctor (or higher) reviewed him at this time.

31. The Trust say Mr W had further observations taken at 3.30pm. However, it said the observing clinician did not enter Mr W’s oxygen therapy and so an EWS score was not generated. Again, this was not in line with the Trust’s EWS policy which says staff should record a full set of observations, including the amount of oxygen received.

32. Mr W then had observations taken at 5pm. However, the system did not generate a score as the clinician taking the observations did not enter Mr W’s oxygen therapy. However, based on the medical records, the Trust said Mr W would have scored a 5. The Trust acknowledged this should have prompted a repeated observation within one hour which did not occur because the system had not generated a score. In line with the Trust’s EWS policy, a doctor also should have reviewed Mr W. We again consider this to be a failing.

33. We can see further recorded observations at 7.10pm and 11.31pm. From our review of the records, the system did not generate an EWS score following either of these reviews.

34. The NHS Seven Day Services Clinical Standards also says a consultant should review patients in hospital at least once every 24 hours, seven days a week, unless it has been determined this would not affect the patient’s care pathway. It says if the clinical team decide a patient does not need a daily consultant review, they should document this, along with the plan for how they will review the patient each day.

35. We cannot see any evidence of Mr W receiving a consultant review on 27 November. We can see a specialist registrar who was a senior trainee at the time, reviewed Mr W at 9.13am on 27 November. However, we cannot see a plan documented in Mr W’s medical records to state why he would not need a daily review by a consultant.

36. The Trust has explained to us that the decision for Mr W not to require a consultant review would have been made during the hepato-pancreatic biliary (HBD) ward round by the consultant. However, it explained it was not possible to provide any documentation to confirm this. It said this is because its record system ‘Hive’ was newly implemented at the time and clinical teams were still learning where and how to record such decisions.

37. However, in the absence of any documentation to show this, we are unable to accept the Trust’s explanation that the responsibility for this would have been delegated by the consultant. The guidance is clear that any such decision should be documented. We therefore consider this to be a failing as this was not in line with the NHS Seven Day services clinical standards.

38. In summary, there are numerous incidents on 27 November where staff did not take complete observations for Mr W. Subsequently, Mr W did not have observations repeated as frequently as he should have nor did a doctor review him within an hour of him scoring a 5.

39. We can also see no evidence of a consultant reviewing Mr W on this date. Although a specialist registrar did review Mr W, the reasons for this were not documented. We consider these amounts to failings in his care as this was not in line with the Trust’s own EWS policy or the NHS Seven Day Services Standard.

Impact of failings

40. We have considered whether increased monitoring or reviews on 27 November may have altered the sad outcome for Mr W.

41. In its comments on our proposal to investigate this complaint, the Trust said Mr W suffered an acute aspiration from the unexpected and sudden black vomit which staff documented he suffered.

42. Our ICU adviser explained that, on the balance of probabilities, Mr W would not have survived even if the failings had not occurred. They explained Mr W experienced a sudden cardiac arrest in the early hours of 28 November. They explained the medical records show nursing staff were present when Mr W began to vomit.

43. Our ICU adviser said from review of all the evidence, it appears Mr W suffered a sudden reflux from his stomach onto his lungs resulting in a cardiac arrest. Our ICU adviser said this was a very rapid deterioration which, on the balance of probabilities, the clinical team could not have predicted even with closer monitoring or more senior review. Our surgeon adviser also agreed Mr W’s death could not have been prevented.

44. Taking this advice to account, we consider that although we have identified failings in Mr W’s care, it appears unlikely the outcome would have changed, had those failings not occurred. We hope this provides some reassurance to Mrs N that, although the failings should not have happened, they did not cause Mr W’s death.

45. Although we have not found these failings had the impact claimed by Mrs N, we considered what the Trust has already done to address the failings.

46. The Trust explained the issues regarding incomplete EWS recordings in the medical records was likely reflective of a training issue. It said these the events occurred at a time when it had a newly implemented electronic system.

47. It said there are stronger assurances in place today and that ward 11 staff are aware of the need to complete and record patient’s full observations to generate an EWS. It said it has amended training on the electronic record system across the hospital.

48. It also said it requires all registered nursing colleagues to complete an Acute Care Management (Adult) training course to ensure they have the necessary skills and competencies to recognise and response to an acutely unwell adult.

49. The Trust said as of July 2025, 95.7 percent of registered colleagues on Ward 11 are in date of this course (it explained it is not possible to aim for 100% due to long term leave).

50. The Trust said in addition to monitoring of ward-based colleagues, the Out of Hours team have oversight of patient observations and EWS scores entered on Hive. It said since the time of Mr W’s admission, it has implemented trigger thresholds that set out when the out of hours team need to attend and review the patient.

51. We are satisfied the Trust has done enough to improve its service and ensure the clinical team act in line with its EWS policy going forward when responding to deteriorating patients. However, we have made an additional recommendation to the Trust regarding a consultant not reviewing Mr W on 27 November in line with the NHS Seven Day services clinical standards.

1. We were sorry to hear of the death of Mr W and of the impact this has had on Mrs N. We offer our sincere condolences to her. We were also sorry to hear of the serious concerns Mrs N has about her father’s care and treatment.

2. We do not consider the Trust failed to diagnose Mr W with aspiration pneumonia. However, we do have some concerns about how the Trust monitored him for signs of deterioration on 27 November. We do not consider Mr W’s death could have been avoided.

3. We have therefore decided we will partly uphold this complaint. We have made a recommendation to the Trust to help improve its service going forward.