Worcestershire Acute Hospitals NHS Trust

5. Miss G complains Worcestershire Acute Hospitals NHS Trust missed the opportunity to investigate and diagnose her father, Mr A, with a urinary tract infection during his admissions between March and April 2024. She also complains it lost her father’s two gold rings.

6. She says the Trust’s actions led to her father’s sad death and this could have been avoided if the Trust had carried out a urine test. She told us her father never regained his cognitive function which meant she missed the opportunity to have certain conversations with him before he sadly died. She says her father deteriorated and was on palliative care which was significantly difficult to watch.

7. Miss G told us her father’s rings were precious keepsakes and a memory of him which the Trust has taken from her and her family. She says this experience was extremely distressing for her and her family, and it continues to impact them. Miss G wants an apology for what went wrong and service improvements to remedy her complaint.

8. Mr A attended the emergency department (ED) at the Trust by ambulance at the end of March 2024 as he was confused and had incoherent speech. The Trust discharged him to his home six days later.

9. Mr A reattended the Trust’s ED the following day by ambulance as he had been found on the floor at home. He appeared confused. The Trust gave Mr A antibiotics two days after his admission and inserted a catheter approximately 17 days after this.

10. The Trust discharged Mr A to a community hospital towards the end of April. This hospital carried out a urine sample and found Mr A had an infection. Mr A sadly died at the beginning of May.

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so, we cannot link the events complained about with the negative impact Miss G has claimed.

Urinary tract infection (UTI) 14. Miss G complains the Trust missed an opportunity to carry out urine samples and diagnose her father with a UTI during his two admissions at the Trust between the end of March and the end of April 2024. She explained that her father was in a state of confusion during both admissions and the Trust should have explored the possibility of a UTI. She told us these actions contributed to her father’s deterioration and sad death, and this could have been prevented with different action from the Trust.

15. We were sorry to hear Miss G’s concerns about how the Trust managed her father’s care during his admissions and how distressing the experience has been for her and her family. From our conversations with her, it is clear her concerns about the Trust’s actions continue to cause her ongoing worry.

16. NICE guidance on delirium says in people diagnosed with delirium (sudden confusion), identify and manage the possible underlying cause or combination of causes. It goes on to say address infection by looking for and treating infection. Our adviser explained that delirium can be a presenting symptom of a UTI and one of the expected routine tests to explore this possibility is a urine sample sent for culture (to see if any bacteria grows).

17. The Trust admitted Miss G’s father towards the end of March as he was confused and had incoherent speech. The Trust considered if Miss G’s father had an infection after it had ruled out a stroke as a possible cause for his symptoms.

18. The Trust requested a urine sample as part of its investigations for Miss G’s father at the end of March. This request is in line with NICE guidance on delirium which says identify and manage the possible underlying cause. However, it does not appear it carried this out.

19. We cannot see any reasons in the medical records as to why it did not carry out the urine sample and our adviser explained, ideally, this test should have been carried out when the Trust initially admitted Miss G’s father. As it is not documented why the Trust did not carry this test out, we do not know if it missed this or decided it was no longer necessary.

20. It appears there are indications that something went wrong when the Trust did not carry out a urine sample for Miss G’s father to explore the possibility of a UTI causing his confusion in line with NICE guidance on delirium. We will consider the impact of this later in our statement.

21. The Trust carried out other investigations for Miss G’s father such as a chest X-ray and blood tests to explore a possible infection. Our adviser explained the blood tests show Miss G’s father had an elevated CRP. CRP is a protein made by the liver and the level of CRP can be increased when there is inflammation in the body. However, Miss G’s father’s CRP level was falling leading up to his discharge and our adviser explained this may indicate a resolving infection.

22. The Trust discharged Miss G’s father five days after his admission, at the beginning of April, as his speech issues had resolved. It readmitted him again one day later as his carers found him on the floor at home and he appeared confused.

23. The Trust requested a urine sample the same day to explore the possibility of a UTI, but we cannot see it carried out this test in line with NICE guidance on delirium. However, it started Miss G’s father on antibiotics for a UTI the following day. As it appears the Trust missed an opportunity here to follow NICE guidance on delirium and carry out a urine sample for Miss G’s father, we will consider the impact of this later in our statement.

24. The Trust carried out a further chest X-ray and blood tests for Miss G’s father and diagnosed him with pneumonia during his second admission. It gave him various antibiotics to treat this including one to treat infections resistant to other antibiotics. He also had a catheter for the later part of his admission. A catheter is a thin tube used to drain urine from the bladder.

25. Towards the end of April and 23 days after his admission, the Trust discharged Miss G’s father to a community hospital. This community hospital diagnosed him with a UTI the day after it admitted him following a urine sample as part of a routine admission screening. Miss G’s father sadly died at the beginning of May.

26. As we have seen indications that something may have gone wrong when the Trust did not carry out a urine test for Miss G’s father on at least two occasions during his admissions, we have considered how this impacted Miss G’s father and in turn, Miss G.

27. Miss G told us the Trust’s actions contributed to her father’s sad death. She explained this could have been avoided had the Trust carried out a urine sample and diagnosed her father with a UTI. She says if the Trust had treated her father for a UTI, he may have recovered. She told us her father sadly lost his cognitive function before his sad death, and this meant she missed the opportunity to have certain conversations with him.

28. We were sorry to hear how Miss G’s father’s sad death impacted her. From what she told us, it is clear that this was a significantly distressing time for Miss G and her family, and she found her father’s sad death very difficult to witness.

29. Our adviser explained there are reasons why a urine sample can be difficult to get from some patients. For example, if they are incontinent or confused as in Miss G’s father’s case. They explained that based on the medical records, it does not appear the Trust suspected Miss G’s father had a UTI as the cause of his confusion. This is because the Trust documented that he had no apparent urinary symptoms or pain and discomfort when urinating.

30. Our adviser went on to explain that although the Trust did not carry out the requested urine samples during both of Miss G’s father’s admissions, they cannot see any evidence in the medical records to suggest that he did have a UTI during his admissions.

31. They consider a urine sample during Miss G’s father’s first admission may not have led to a diagnosis of a UTI and explained that Miss G’s father had evidence of a different infection (pneumonia) when the Trust admitted him for the second time.

32. This diagnosis of pneumonia explains his presentation of confusion and being unwell. They said that at the time the Trust discharged Miss G’s father at the end of April, he was on complex antibiotics for pneumonia, and his CRP level was falling, which shows evidence his infection was improving.

33. This means we cannot say with any certainty that Miss G’s father had a UTI during his admissions or that a UTI was causing his confusion. Therefore, we cannot say the Trust’s actions when it did not carry out urine samples for Miss G’s father, contributed or led to his sad death or the impact Miss G claims. We recognise this may be disappointing for Miss G.

34. Our adviser explained reasons why Miss G’s father may have been diagnosed with a UTI at the community hospital. The urine sample was taken at the community hospital as part of a routine screening on admission, not because of specific symptoms of a UTI.

35. They explained that Miss G’s father had a catheter as we note above, and bacteria can be present particularly with a catheter, without a clinically significant infection present. We hope this information helps to clarify any information Miss G was unsure about.

36. Based on the evidence we have seen, it appears the Trust did not consistently follow NICE guidance when it did not carry out a urine sample to explore Miss G’s father’s cause of confusion. However, we can see it did carry out other investigations such as X-rays and blood tests to investigate Miss G’s father’s symptoms to reach a diagnosis of pneumonia. It also treated him for this with antibiotics.

37. We cannot see any clinical evidence Miss G’s father had a UTI during either of his admissions based on his symptoms which means we cannot say this action from the Trust led to his sad death as Miss G suspects. Based on this, we will decline to investigate this complaint as we cannot link the events complained about with the negative impact Miss G has claimed.

Lost belongings 38. Miss G complains the Trust lost her father’s two gold rings during his admissions. She told us her father’s rings were precious keepsakes and a memory of him which the Trust has taken from her and her family.

39. We were sorry to hear Miss G’s concerns about the Trust losing her father’s rings and how sentimental they are for her. We imagine this added to her distress at an already stressful time.

40. Miss G said her father’s rings had gone from his possession when the Trust discharged him from his first admission at the beginning of April. The Trust’s complaint response from March 2025 says staff gave the gold rings to Miss G’s brother at the end of March 2024 (during his first admission).

41. The only notes in the medical records about Mr G’s rings are dated at the beginning of April when the Trust admitted him for the second time. The Trust documented he was able to take responsibility to retain his valuables rather than giving them to the Trust for safe keeping. Unfortunately, we cannot see any further evidence in the medical records to say what happened to his rings after this entry.

42. The entry in the medical records is dated after when the Trust said it gave the rings to Miss G’s brother and when she says they went missing. When we asked the Trust for more information about this, it confirmed the staff member who documented Miss G’s father’s valuables during his second admission, saw the rings with him to be able to complete the property list.

43. It appears there are conflicting accounts about what happened to Miss G’s father’s gold rings. Miss G says the rings were missing when the Trust discharged her father from his first admission at the beginning of April, but medical records indicate they were with her father during his second admission, two days later.

44. Based on the evidence from all parties, we cannot reach a conclusion about what happened to the jewellery or say whose versions of accounts is more accurate due to the lack of objective evidence. It is unlikely that we would be able to provide any further information to Miss G about what happened through an investigation.

45. Therefore, we will decline to investigate this aspect of the complaint and take no further action as it is unlikely that we would be able to reach a satisfactory decision about what happened based on the conflicting information available. It is understandable that this will be disappointing for Miss G and we are sorry we cannot reach a conclusion about what happened to her father’s gold rings.

46. From our conversations with Miss G, it is clear that her father’s deterioration and sad death was significantly distressing for her and her family. We hope our report reassures her that it does not appear the Trust’s actions impacted her father’s sad outcome and helps to clarify any information she was unsure about.

1. We have carefully considered Miss G’s complaint about Worcestershire Acute Hospitals NHS Trust (the Trust). We were sorry to hear her concerns about how the Trust managed her father’s care during his admissions between March and April 2024. From what she told us, this has clearly been a significantly distressing time for her and her family and her concerns about whether her father’s outcome may have been different continue to impact her.

2. From the information we have considered, it appears the Trust did not consistently follow guidelines when it did not carry out a urine sample for Miss G’s father during his admissions. Although it appears there are indications that something may have gone wrong, we have decided that we cannot link this to the impact Miss G told us about. We have decided to take no further action on this aspect of the complaint for this reason.

3. We also considered Miss G’s concerns about how the Trust managed her father’s valuable belongings during his admission. Sadly, we are not able to carry out a further, meaningful investigation into this complaint, as there is no evidence available to be able to fully explain what happened that we can take a view on. Therefore, we will not investigate this aspect of Miss G’s complaint any further. It is understandable that this may be disappointing for Miss G.

4. We recognise how important this complaint is to Miss G, and we would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint and provides her with some reassurance that it does not appear the Trust’s actions impacted her father’s sad outcome.