County Durham and Darlington NHS Foundation Trust

7. Mr Z complains about the care and treatment his wife, Mrs Z received at the Trust from 27 May 2023 to 8 June 2023.

8. He specifically says:

• the Trust never told the family she was seriously ill on 7 June • the Trust did not treat her for sepsis despite showing signs of it • she did not receive an MRCP during her admission when her records said she was ‘awaiting MRCP’, and she received an appointment 10 days after she died • the Trust took 18 months to respond to the complaint.

9. Mr Z says as a result his wife died of sepsis that was untreated. He says there were missed opportunities to treat sepsis and this contributed to her death. The lack of communication about his wife’s sudden deterioration added further distress at an already difficult time and make the grieving process extremely hard to come to terms with.

10. Mr Z would like an explanation into the care his wife received so he can gain closure.

11. Mrs Z was in her early eighties and had multiple co-morbidities including previous rectal cancer, ischaemic heart disease (narrowing of blood vessels that provide blood and oxygen to the heart), hypertension (high blood pressure) and a stroke.

12. On 27 May 2023, the Trust admitted Mrs Z with lower back pain and confusion.

13. On the same day, the medical notes say there were no signs of sepsis on admission and the Trust was treating her for hydronephrosis (swollen kidneys due to urine being left inside) as the potential source of infection. The Trust gave Mrs Z antibiotics on 27 May.

14. On 7 June, the Trust transferred her to ITU due to sudden deterioration from sepsis.

15. She died on 8 June. Her cause of death on her death certificate is 1a) multiple organ failure, b) septic shock, c) E-coli septicaemia. Her existing co-morbidities were also listed as secondary causes.

Communication

19. Mr Z says the Trust’s lack of communication about his wife’s sudden deterioration on 7 June meant he had to see her unconscious when he was visiting her in the morning. He was not prepared for this, and it added more distress to an already stressful and upsetting time.

20. The Trust has said in its final response letter dated 5 December 2023, the communication from 7 June should have been better. It acknowledged that when Mrs Z deteriorated overnight, it should have updated Mr Z on her clinical presentation regardless of the time. It explained, unfortunately this did not happen.

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. After careful consideration of the medical records, there is evidence to show Mrs Z had her evening medication and last observations on 6 June at 9.36pm.

23. In the early hours of 7 June, Mrs Z began to deteriorate with a temperature of 41°C. Medical and surgical doctors attended to the emergency.

24. The notes show from 2.40am, the Trust took Mrs Z’s observations hourly.

25. The doctors updated Mr Z and his son at 2.09pm in person. The notes show the doctors explained Mrs Z was now very poorly and that the source of the infection was still unknown. The Trust was treating her with two strong antibiotics and monitoring her closely. The family said they wanted the Trust to do all it could to save her.

26. On the same day at 3.44pm, a consultant reviewed Mrs Z and explained they had switched to stronger antibiotics from Tazocin to Meropenem. There was also a discussion about sepsis, but the source of the ongoing infection was still unclear. The Trust told the family that as Mrs Z had other co-morbidities she could deteriorate rapidly.

27. The records and final response letters show a lack of communication with Mr Z regarding his wife’s sudden deterioration overnight on 7 June, as the family was informed around 12 hours later.

28. This is not in line with the GMC guidance referred to above and is an indication of a failing.

29. It is understandable why Mr Z is so distressed and upset that he visited his wife and was not prepared for this and the effects it had on her.

30. We go on to consider the impact of this and the Trust’s actions in response to this below.

Impact

31. We recognise the complexity of the situation and empathise with Mr Z. We are so sorry he was not told what to expect ahead of his visit to the Trust on 7 June.

32. We are sorry the Trust did not communicate with him appropriately about his wife’s sudden deterioration overnight.

33. 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.

34. Within its final response letters, the Trust has apologised and recognised the distress its lack of communication caused Mr Z. It has recognised the update should have been given to Mr Z overnight regardless of the time.

35. The Trust has also said it has fed this back to the night staff involved in Mrs Z care and reminded them of the importance of updating family when the clinical situation for a patient changes.

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

37. 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.

Sepsis

38. Mr Z’s concern is that he thinks his wife was showing signs of sepsis earlier than 7 June. He is frustrated the Trust did not do anything until it was too late. He says it ignored her symptoms and if it picked them up sooner she would be alive today.

39. The Trust has said in its final response that Mrs Z’s working diagnosis was pyelonephritis (kidney infection) or cholecystitis (inflammation of gall bladder). The Trust were treating Mrs Z with antibiotics for an infection. She deteriorated suddenly overnight on 7 June and was then diagnosed with sepsis and given a stronger antibiotic.

40. Sepsis is a term that describes the body’s response to an infection that is present. It is important to note Mrs Z already had an infection on admission, the source of this was unknown. Our adviser told us the infection was not causing sepsis at that point.

41. Our adviser helped us understand how sepsis attacks the body. The body’s immune system is reacting to the presence of an infection which can lead to tissue damage, organ failure, and death.

42. The development of sepsis is detected by a change in the NEWS (National Early Warning Score – detecting early signs of patient deterioration by scoring vital signs and level of consciousness).

43. NICE guidance for sepsis, NEWS systems that alert to deteriorating adult patients in hospital, 18 February 2020 says the NEWS2 scoring systems measures six physiological parameters:

• respiration rate • oxygen saturation • systolic blood pressure • pulse rate • level of consciousness or new-onset confusion • temperature.

44. A score of 0, 1, 2 or 3 is assigned to each parameter, with higher scores indicating greater deviation from the normal range. Clinical responses are provided for the threshold levels below:

• Low risk (1 to 4) – Ward nurse promptly assesses need for changes to monitoring frequency or clinical care escalation • Low to medium risk (3 in a single parameter) – Ward doctor urgently reviews to identify cause, adjust monitoring or escalate care • Medium risk (5 to 6) – Ward doctor or acute team nurse urgently reviews and considers escalation to critical care team • High risk (7 or above) – Critical care team conducts emergency assessment, typically leading to transfer to higher-dependency care.

45. The recommendation for a NEWS2 aggregate score of 0 (that is, no change to any parameter) is a minimum 12-hourly review and to continue routine monitoring. We refer to this as Early Warning Score (EWS) hereafter.

46. Our adviser has thoroughly reviewed the records and notes the following:

• 6 June, Mrs Z’s EWS was 0 at 9.36pm • 7 June at 2.40am EWS was 8.

47. A doctor saw Mrs Z immediately because the Trust recognised she was becoming unwell. The Trust restarted intravenous broad-spectrum antibiotics. Her condition was stable, but the original infection source was still unclear.

48. Our adviser told us Mrs Z’s NEWS scores prior to 7 June fluctuated between 0 and 1. On this basis it is reasonable to say there is no evidence which suggests she had sepsis earlier than 7 June. This is because she would have had to have a NEWS score of 5 and above to trigger a clinical response to sepsis.

49. NICE guidance for sepsis says investigations of the sources of infection must be tailored to the patient’s clinical history. It also says:

‘1.11.2 Consider urine analysis and chest X-ray to identify the source of infection in all people with suspected sepsis’

‘1.11.3 Consider imaging of the abdomen and pelvis if no likely source of infection is identified after clinical examination and initial tests.’

50. In relation to the investigations and treatment Mrs Z was having for an infection when she was admitted through the Trust’s ED (emergency department), the notes show she had regular EWS monitoring, her blood cultures were negative, and CT scan results did not show any stones in the bile ducts or that they were blocked. The blood tests did not show any signs of a blockage in the biliary duct (tubes between the gall bladder and small bowel) either. The Trust were treating her with broad spectrum antibiotics throughout her admission.

51. Our adviser helped us understand that if Mrs Z had sepsis earlier than 7 June (on admission) the main treatment for this is antibiotics and fluids. The notes show she was having this treatment for her infection, and we can be assured she did not have sepsis before 7 June.

52. After careful consideration of the records and our advice, we have not seen any evidence Mrs Z had sepsis prior to 7 June. We are satisfied the treatment and monitoring Mrs Z was receiving for her infection was appropriate and in line with the NICE guidance.

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

MRCP

54. Mr Z is concerned that when he reviewed the medical records, he can see 41 references to ‘awaiting MRCP’. He thinks that the delay in completing this may have contributed to his wife contracting sepsis. He also says the Trust made an outpatient appointment for 18 June but this was after Mrs Z had died. Mrs Z never had an MRCP.

55. The Trust has said in its final response letter, the purpose of the MRCP was to evaluate the bile ducts. It has confirmed the MRCP was arranged as an outpatient appointment following an earlier admission in May (not part of this complaint). We go on to consider the details of this to provide context in paragraph 57.

56. NICE guidance for MRCP says:

‘1.1.1 Offer liver function tests and ultrasound to people with suspected gallstone disease, and to people with abdominal or gastrointestinal symptoms that have been unresponsive to previous management

1.1.2 Consider magnetic resonance cholangiopancreatography (MRCP) if ultrasound has not detected common bile duct stones but the:

• bile duct is dilated and/or • liver function test results are abnormal’.

57. The Trust admitted Mrs Z on 5 May with a fever. The Trust treated her with antibiotics for an infection and performed an ultrasound scan. The scan showed stones in her gall bladder but a normal bile duct with no blockages.

58. She also had liver function tests which were deranged (raised liver enzymes) but she was never jaundiced. This is important because jaundice would have indicated a complete blockage in the bile duct.

59. A consultant reviewed her on 10 May who noted it was likely Mrs Z had passed a stone from the gall bladder to the duodenum (first part of the small intestine). It was noted that her infection markers had improved. On this basis, he recommended an MRCP on an outpatient basis to ensure there were no further stones in the bile duct. The Trust discharged her on 12 May.

60. On this basis, our adviser explains it is likely this was arranged as a precautionary measure. This is in line with the NICE guidance for MRCP above.

61. Our adviser has reviewed the medical notes and reassured us the delay in having the MRCP had no bearing on the clinical cause of death of Mrs Z during her second admission. It also did not affect her diagnosis of sepsis.

62. We acknowledge the Trust should have been more mindful when sending out the appointment for the MRCP after Mrs Z’s death. We know this would have been frustrating and upsetting for Mr Z, especially since he had been advocating for his wife throughout her admission.

63. To conclude, there is no indication of failing for this part of the complaint.

Complaint handling

64. Mrs A is unhappy it took the Trust 18 months to respond to his original complaint from July 2023. He says the local resolution meeting took too long to arrange and the Trust delayed sending him the medical records.

65. He says that this process caused him additional stress at an already difficult time.

66. The Trust provided a final response on 5 December 2023 with an offer to discuss further. Within this letter it apologised for the delay in responding to Mr Z. It explained there were operational difficulties, but also the complex nature of the complaint meant the investigation took longer than expected. Overall, the Trust took five months to respond.

67. Mr Z was not happy with the final response and asked for clarification and raised more questions as part of his complaint. The Trust responded again on 23 March 2024 and referred him to us. This is a further three months to respond to Mr Z’s additional concerns.

68. 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, considering the complexity of the matter’.

69. 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.’

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

71. After consideration of the final response letters and the guidance above, we think the Trust competed a thorough investigation in Mr Z’s complaint. It issued the first final response within five months and therefore within the six-month timescale recommended by the NHS complaints regulations.

72. Mr Z then responded and asked for clarification and had further concerns about the care and treatment his wife received. The Trust then responded to this on 23 March 2024 and mentioned us in the letter.

73. We think it is reasonable to allow the Trust more time to respond to Mr Z’s additional concerns. This is due to the complex nature and volume of his concerns.

74. The Trust and Mr Z met on 13 September 2024 for a local resolution meeting. Within this meeting it apologised for the time it took to respond and mentioned it has changed its complaints policy and almost halved the time it takes to respond to complainants.

75. The Trust and Mr Z met on 20 January 2025 for another local resolution meeting.

76. We appreciate it can take time to arrange a complaint meeting with all the relevant clinical and non-clinical staff due to busy schedules. The first local resolution meeting was scheduled after both final response letters were issued. This means, Mr Z had all of his complaint responded to by March 2024 at the latest.

77. We acknowledge Mr Z told us there was a delay in the Trust sending him the medical records. We do not think Mr Z needed the medical records to be able to raise the complaint with us. This is because Mr Z made the complaint without the records in the first instance and there are not necessarily needed for the complaints process.

78. Mr Z then referred the complaint to us on 7 March 2025.

79. On this basis, we have not seen an indication of a failing. We are satisfied the contents of the final responses’ answers Mr Z’s complaint and the time it took to do that was reasonable. We have made this decision taking into account the guidance above and the content and length of Mr Z’s complaint.

1. We have carefully considered Mr Z’s complaint about County Durham and Darlington NHS Foundation Trust (the Trust). We are sorry for the circumstances of this complaint and extend our sincere condolences for the loss of his wife.

2. We understand the emotional stress he experienced because of the events complained about and how that made the grieving process challenging. We know this was an incredibly difficult time for him.

3. We have seen indications of failings in how the Trust communicated with Mr Z about his wife’s sudden deterioration. We are satisfied the Trust has reflected on this 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 this part of the complaint as we do not think we would achieve anything further.

4. We have seen no indications of failings in relation to the following:

• the care and treatment Mrs Z received for her infection and sepsis • the delay in receiving the MRCP (Magnetic resonance cholangiopancreatography) scan.

5. We have also not seen indications of failings in how long the Trust took to respond to Mr Z’s complaint.

6. We understand how important this complaint is to Mr Z and the impact on him. We explain the reasons for our decision in detail below.