Calderdale and Huddersfield NHS Foundation Trust

3. Mrs M complains that Calderdale and Huddersfield NHS Foundation Trust (the Trust) failed to recognise the severity of her daughter, Miss H’s medical condition in the emergency department (ED) before she died in January 2023.

4. She says the Trust did not triage Miss H quickly enough, and when it did, it gave her a P2 instead of a P1 priority. This led to a delay in an ED doctor assessing her. Mrs M also says there was delay in a senior doctor assessing Miss H. She says if there had not been delays and a mistake in the triage process, Miss H may not have died.

5. Mrs M also says there were unnecessary delays in the complaints process, and the Trust was reluctant to provide her with the names of the staff involved in Miss H’s care.

6. Mrs M says she is haunted by what happened to her daughter. She says she is traumatised, and the complaints process compounded her grief.

7. She would like the Trust to acknowledge its mistakes and pay her financial compensation to recognise the devastating impact on her. She also wants it make improvements in its service and how it deals with investigations into unexpected deaths, so no other family has the same experience.

8. Miss H had a rare genetic condition that causes muscle weakness that gets worse over time. On 30 December 2022, following a chest infection and flu, Miss H began to deteriorate. Mrs M made several calls to the 111 service and then took Miss H to the ED department of the Trust on the afternoon of 1 January. She died that evening.

Triage

12. Miss H arrived at the ED at 3.41pm. At 4.20pm the Trust assessed her and triaged her as priority two (P2). A triage priority score of 2 indicates a patient should be seen within ten minutes of arrival. The Trust transferred her to a resuscitation room at 4.39pm and a junior doctor assessed her at 5pm. During the assessment, Miss H became unresponsive. The doctor made a call for help and the medical registrar and the ICU teams attended.

13. The surgical registrar reviewed Miss H and said she had likely suffered a perforation of her bowel or stomach. The ICU team started treating her with supportive medication. However, her condition deteriorated. The Trust had a discussion with Mrs M and withdrew active treatment. Miss H died at 10.25pm from intestinal perforation.

14. Mrs M says she told the receptionist on arrival that Miss H needed to see a doctor urgently and they told her to wait for the triage nurse. She says she told the receptionist several times that Miss H was seriously unwell. Mrs M says throughout the Trust’s assessment of Miss H, she was asking for help and telling the staff how unwell she was.

15. In its complaint response, the Trust acknowledged the ED team failed to recognise the severity of Miss H’s condition both before and after triage. It said it should have assessed and completed Miss H’s assessment and observations within 15 minutes of her arrival at the ED. The Trust said Miss H had a pulse of 190, an unrecordable BP and was described as pale and clammy. This is the description of cardiovascular shock. It explained it should have triaged her on admission as priority 1 (P1) and transferred her to a resuscitation room to be assessed by a senior doctor.

16. The Trust said it was evident Miss H was critically unwell when she arrived at the ED. It acknowledged she should not have waited one hour and 19 minutes to be seen by an ED doctor.

17. The NMC’s ‘Code’ says nurses should accurately identify, observe and assess signs of normal or worsening physical health in patients and make a timely referral to another practitioner when any action, care or treatment is needed. The GMC’s ‘Good medical practice’ says doctors should take all possible steps to alleviate pain and distress whether or not a cure may be possible.

18. It is clear from the Trust’s response that it did not act in line with these standards and made significant mistakes in how it triaged Miss H. It should have triaged her as the highest priority immediately on arrival at ED and a doctor should have seen her very quickly after that. So we have not done any further analysis on this. There were failings in the Trust’s actions when Miss H arrived at the ED. We have focused on what the impact of these was.

19. Mrs M thinks Miss H may not have died if the Trust had recognised the severity of her condition when she arrived at the ED and had triaged her correctly. Although the Trust has accepted the failings, it does not think they led to Miss H’s death.

20. Our adviser looked at Miss H’s medical records. They said the treatment the Trust gave Miss H after it assessed her was appropriate. It did a chest X-ray, which confirmed the presence of free air within the peritoneal cavity (the space between the membranes of the abdominal wall). It identified she needed stabilising and transferring to another Trust hospital where she could have an emergency procedure to investigate what was happening. Our adviser said this would have been the same plan if the Trust had triaged her sooner because the clinical situation was the same then.

21. The difference would have been that treatment to stabilise her for transfer would have started earlier, and before she became unresponsive during the assessment at 5pm. But our adviser said, on the balance of probabilities, this would not have changed the outcome. Miss H had gastrointestinal perforation and septic shock. Our adviser said it is more likely than not that she already had sepsis and multiple organ failure by the time she arrived at the ED.

22. Our adviser said based on Miss H’s admission observations and blood tests, her mortality rate was 93%, which is extremely high risk. This is very unlikely to have changed in the time of the delay. She was very poorly, and our adviser says, based on her mortality rate and from their experience, earlier treatment would not have prevented her death.

23. But we can see that Miss H was waiting, in significant pain and distress, for an hour and 20 minutes to see a doctor when this should have happened as soon as she arrived. And Mrs M had to witness her daughter in this traumatic state, and then becoming unresponsive when the doctor was assessing her. She says she was begging for staff to help Miss H. We can clearly see Mrs M did everything she could to advocate for her daughter.

24. Mrs M says she is traumatised and haunted by what happened to her daughter. These were her last hours with her and the last memories she has of her. Sadly the evidence we have seen indicates that would always have been the case. But if the Trust had done what it should have, Mrs M would have known it was doing everything it could for her daughter and she would not have been left thinking things might have been different. The Trust’s mistakes have made Mrs M’s bereavement much worse. We are very sorry she had to go through this experience.

Complaints process

25. Mrs M says there were unnecessary delays in the complaints process and the Trust was reluctant to share the names of the staff members involved in her daughter’s care. She complained to the Trust on 5 June 2023 and it sent a response on 29 September. On 18 October Mrs M’s advocate sent an email to the Trust asking for the names of specific staff members and Mrs M followed this up with an email asking further questions on 18 December. The Trust addressed the further concerns and confirmed the names of the professionals on 11 March 2024. Mrs M sent further concerns on 15 May and the Trust sent its final response on 10 July. In this response the Trust acknowledged the process was lengthier than it would have hoped and apologised for this.

26. The NHS Complaint Regulations says organisations should provide responses to complaints within six months. Our ‘Principles of Good Administration’ say public bodies should communicate effectively and give people information and advice that is clear, accurate and complete. The ‘NHS Complaint Standards’ set out what organisations should do to thoroughly address complaints. They say the organisation should clarify the issues, understand the impact and outcome sought, investigate carefully and provide an appropriate remedy to put things right.

27. The evidence shows the Trust fully investigated Mrs M’s complaint. The clinical director and consultant of emergency medicine, and the head nurse in urgent and emergency care investigated her concerns. And the consultant in emergency medicine reviewed Miss H’s care while she was in the ED. It provided a timeline of Miss H’s care and responses to Mrs M’s specific complaint points. It acknowledged it should have seen Miss H when she arrived at the ED and it triaged her incorrectly. The Trust also explained the service improvements it had made as a direct result of Mrs M’s complaint.

28. When we look at the complaints process objectively, we do not think it took the Trust too long to prepare its responses. We think this was an extremely important complaint and the Trust needed time to gather information and complete an investigation. We can understand how distraught Mrs M is, and how she desperately wanted answers about her daughter’s care. We think the Trust tried to provide these answers and we do not think we can say there was a failing here.

29. We also do not think we can say the Trust was reluctant to provide the names of the staff involved in Miss H’s care. Mrs M’s advocate asked for the names in October 2023 and Mrs M asked further questions in December. When the Trust gave the names, it also answered Mrs M’s questions. We think the Trust’s aim was to answer all of the concerns together, and it did this. We can see the Trust offered to have a meeting with Mrs M, which she declined, as is her right. When we look at the complaint as a whole, we think the Trust acted in line with the NHS Complaint Standards and our Principles. We have not found failings in the complaint process.

What the Trust has already done to put things right

30. The ‘NHS Complaint Standards’ say organisations should identify suitable ways to put things right for people. They say organisations should learn from complaints.

31. In the complaint responses, the Trust offered sincere apologies that it got things wrong in Miss H’s care. It set out the actions it has taken as a result of the complaint to avoid making the same mistakes again. This included reflective discussion with the nurse who triaged Miss H, and the ED senior management team reviewing the department escalation process and capacity management. Mrs M thinks it should have done a serious incident investigation. It did not do this, but the evidence we have seen so far shows us the Trust took the matter very seriously, investigated it thoroughly, identified what it got wrong and took action to prevent this happening again. These actions are in line with the ‘NHS Complaint Standards’.

32. However, given the significant impact on Mrs M, we think there is more the Trust should do to put things right for her.

We partly uphold the complaint about the Trust. We have found it did not treat Miss H quickly enough in the ED department. We have not found that this contributed to her death, but we do think it caused Mrs M extreme distress and added to her bereavement. We think the Trust dealt with Mrs M’s complaint in line with the NHS Complaint Standards.

1. We recommend the Trust to pay Mrs M a financial remedy to recognise the emotional impact its mistake had on her.

2. It is clear from Mrs M’s account how traumatic it was to see her daughter suffering at the end of her life. We hope our decision offers her some reassurance that she did not miss out on treatment that could have prolonged her life.