Northampton General Hospital NHS Trust

8. Miss C complains about aspects of care and treatment provided to her father, Mr C, by Northampton General Hospital NHS Trust. Miss C specifically complains that: • the Trust did not appropriately respond to, investigate or explain Mr C’s sudden deterioration in June 2023 • the Trust did not provide appropriate medical care for Mr C following his deterioration up until his discharge in July 2023 • the Trust did not communicate with or provide the appropriate information to Miss C (who held Power of Attorney) to help her act on behalf of Mr C when he did not have capacity • the Trust prematurely and inappropriately discharged Mr C in July 2023 • the Trust provided complaint responses with an insufficient explanation and caused significant delay to the complaint process.

9. Miss C says she believes the poor care and treatment contributed to Mr C’s decline in health and ultimately may have led to his death in October 2023. Miss C tells us before the end of June, Mr C was well and following the sudden deterioration he never recovered. Miss C also tells us the lack of explanation from the Trust has caused her distress.

10. Miss C would like a financial remedy, answers to her concerns about Mr C’s care, and service changes to address the issues she has raised.

11. Near the end of June 2023, Mr C attended the Trust’s emergency department with severe back pain. The Trust admitted Mr C for further review and investigation. Miss C told us at this point Mr C was in pain but lucid and able to function.

12. Two days later Miss C visited Mr C in hospital and noted he looked very unwell and requested the Trust conduct an urgent review to find the cause. The next day the Trust sent Mr C for a CT scan and ruled out a stroke as the cause of the deterioration.

13. Mr C remained in hospital until late July 2023, when he was discharged to a rehabilitation facility. Three days later Mr C was readmitted to the Trust’s emergency department.

14. Mr C remained in hospital after this and sadly died in October 2023.

18. We have considered the events complained about in the order outlined in the complaint summary and will address these below in turn. For each component we have compared what guidance and policy says should have happened with what did happen to determine whether there is a gap which we would consider a service failing.

Deterioration in hospital

19. Miss C complains the Trust failed to properly care for her father, Mr C, or recognise when he suddenly deteriorated and failed to act on it until she raised concerns.

20. In the Trust’s own complaint response it stated Mr C had previously declined in general functioning from May 2023 before he was admitted to hospital. The Trust stated it believed Mr C’s sudden deterioration in hospital was most likely delirium (sudden onset confusion) and an acute decline in function made worse by Mr C being in an unfamiliar environment and not moving.

21. We can see on day 1 Mr C was admitted in severe pain in his lower back and had a blood test indicating a slight infection. On day 2 Mr C was reported to be eating and drinking normally and independently and was noted to be alert and orientated in the morning. At the end of day 2 nurses documented a discussion with Miss C about Mr C’s care and about signs of confusion they had seen with Mr C during the day.

22. In the afternoon of day 3 nursing and occupational therapy notes show Mr C was needing help with eating and drinking and appeared very sleepy and unable to keep his eyes open. The Trust also received test results on the afternoon of day 3 showing bacteria present in Mr C’s urine, suggesting an infection somewhere within the urinary system (including the bladder and kidneys).

23. In the evening of day 3, around the time Miss C tells us she visited Mr C, the Trust documented Mr C was complaining of chest pain and requested reviews to investigate this (including a review from Urology).

24. In the early hours of day 4 the Trust documented Mr C’s blood test results came back showing very high levels of infection and he was very drowsy. The Trust started Mr C on antibiotics on the morning of day 4. Urology reviewed Mr C at 10am on day 4 and concluded he was ready for discharge for the Urology point of view. We note this does not mean Urology believed Mr C was ready to be discharged from hospital, but he was likely ready to be discharged from Urology’s care.

25. In the afternoon of day 4 the nursing staff raised concerns with Urology stating Mr C was very sleepy, not eating, and had a high temperature. Urology concluded they had no concerns and requested blood tests and a chest X-ray.

26. On day 5 Urology reviewed Mr C and documented there was no obvious urological cause to his symptoms however his mobility was being affected by the infection.

27. On day 7 the Trust documented a discussion with Miss C about the kidney obstruction and managing this conservatively, it also notes Miss C raised concerns about a stroke. The Trust told Miss C there was no further input needed into Mr C’s care from Urology. Following this we can see the Trust sent Mr C for a CT scan to investigate a stroke.

28. From the evidence we have reviewed, Mr C’s condition began to deteriorate on day 3, the same day Miss C visited Mr C in hospital and saw the deterioration for herself.

29. The staff mostly responsible for Mr C during this period will have been nursing staff on the ward. The NMC Code outlines nursing staff must document and identify any problems which arise and take the steps to deal with this. We can see evidence the nursing staff were regularly documenting Mr C’s health status, repeatedly noted he was drowsy and contacted Urology for review when they had concerns. This would be in line with the NMC code.

30. We therefore conclude the Trust’s nursing staff were aware Mr C’s presentation was changing and were documenting and responding to this appropriately.

31. We appreciate it does not appear the Trust began any investigations or antibiotic treatment for the deterioration until around the time Miss C visited Mr C in hospital on day 3.

32. We can see the earliest signs of infection and deterioration began around 2pm. We can also see the ward staff were waiting on a review from Urology who did not attend to review Mr C that day. The next documented symptom was Mr C’s chest pain in the evening. When Urology did review Mr C the next day, day 4, they did not have any significant concerns and ordered some more investigative tests.

33. Before Mr C was in hospital, an anaesthesiologist assessed him in May 2023 and noted there were possible issues with urine drainage from the kidney, and a potential kidney stone blockage. It was decided at this time Mr C would not recover well from surgical interventions to remove the stone or drain the kidney due to his age and poor health.

34. After Mr C was admitted to hospital in late-June 2023, he had an urgent abdominal scan which revealed ‘gross right-sided hydronephrosis’ (significant urine retention in the right kidney) and bone changes to his spine (osteoporosis - this is likely the ‘bone fractures’ Miss C said the Trust told her Mr C had).

35. Our urology adviser explained these findings are consistent with a pelvi-ureteric junction obstruction (a blockage or narrowing of the junction between Mr C’s kidneys and his ureter, stopping the flow of urine). The CT scan showed a kidney stone but this did not appear to be causing the urine obstruction. In response, the Trust catheterised Mr C and drained urine from his bladder.

36. We note Mr C was placed on antibiotics for a suspected urinary tract infection (UTI) after a positive urine culture result and blood tests suggesting infection. The medical notes suggest Mr C’s infection markers were falling with the use of antibiotics, but an infection was still present. Miss C has also reported to us she did not see much improvement in Mr C’s function or capacity as a result of the treatment or antibiotics use.

37. The British Association of Urological Surgeons leaflet explains significant urine retention in the kidneys usually requires urgent drainage, either by a ureteric stent (a thin tube place in the ureter to facilitate urine flow) or a nephrostomy tube (a catheter inserted directly into the kidney to drain urine), especially due to the risk of infection.

38. We can see the Trust did drain some urine from Mr C’s bladder but cannot see whether they reviewed Mr C to see if his kidneys were still retaining urine.

39. Our urology adviser explained that when Mr C’s blood tests started showing signs of infection, an infection of the obstructed kidney would be the most likely cause. We cannot see the Trust considered this as a possible cause and instead diagnosed Mr C with a UTI. We conclude the Trust should have considered the clinical importance of an obstructed kidney when considering the cause of Mr C’s deterioration.

40. We can see a Urologist from the Trust discussed Mr C’s care with Miss C in early July 2023. The records show the Urologist did discuss the obstruction in the kidney and agreed surgical management to deal with the obstruction was not a suitable option. There is no further consideration to whether this obstruction could be infected and contributing to Mr C’s poor health and deterioration.

41. Our adviser explained based on the history of kidney blockage and the consistent infection markers, they would expect the Trust to have recognised and informed Miss C of the possibility an infection in the kidney which could explain Mr C’s clinical deterioration. We have not seen any evidence this was considered any further than a possible UTI.

42. We consider there was a lost opportunity to explore the cause of Mr C’s infection and deterioration further.

43. Our urology adviser explained the treatment options if Mr C had an infected kidney would have either been surgical drainage, stent insertion, or antibiotics alone. Our adviser explained without draining the kidney of urine and potential infection, it would be difficult to fully treat Mr C’s possible kidney infection with antibiotics alone.

44. In mid-July 2023 Mr C had a scan to check whether he had a suspected pulmonary embolism (blood clot in the lung) which noted Mr C still had evidence of an obstructed kidney. Following this scan, Mr C’s general condition was unstable, and there are notes in the medical records relating to ‘urosepsis’ (untreated urinary tract infection) and raised inflammation markers in his blood tests.

45. This information did not trigger any further consideration or investigation into the possibility of a kidney infection. The Trust also did not relay this information to Miss C.

46. To summarise, we have seen clear evidence from the various tests that Mr C’s urine retention and kidney obstruction was likely the source of his infection. We consider the Trust missed an opportunity to recognise that this was the likely explanation for his deterioration, and to inform the family. This is a failing and we will further unpack the impact of this failure later in the impact section of this report.

Care following deterioration

47. After Mr C deteriorated at the end of June 2023, Miss C is concerned the Trust did not care for him properly. She has raised specific concerns about a period where Mr C swelled up and about how Mr C developed pneumonia whilst in the Trust’s care.

48. In the Trust’s own complaint response, it reassured Miss C the staff provided appropriate care and treatment to Mr C to try and discover the cause of his deterioration, and to treat this. The Trust stated it found no evidence of poor care.

49. Our geriatrician (older persons medicine) adviser explained, from reviewing the records, it appears that overall Mr C received appropriate medical care after he deteriorated. This means the medication and general care he received did not raise any concerns of poor or inappropriate care outside of the kidney concerns raised above.

50. Following Mr C’s deterioration, the Trust suspected Mr C was experiencing heart failure as they found fluid around the bottom of his lungs. The Trust treated this with diuretics (water pills) and scanned his heart. Staff concluded Mr C was not going through heart failure. This happened around the time Miss C observed Mr C swollen up with fluid.

51. GMC Good Medical Practice guidelines outline how clinicians should promptly provide or arrange suitable investigations where necessary. We cannot see the Trust tried to further investigate the cause of the fluid around the lungs at this point after staff concluded there was no heart failure.

52. Our geriatrician adviser explained Mr C had very low blood albumin (a protein in the blood) levels which were likely the cause of the excess fluid in his body. Low albumin levels mean the blood was less able to hold fluid, making fluid leak into nearby tissues. Mr C’s low albumin was likely a consequence of his ongoing infection, the cause of which had not been identified. Our geriatrician adviser explained the best way to treat this would have been to find the source of the infection.

53. As outlined in the section above, we believe the most likely source of the infection was Mr C’s obstructed kidney. Our geriatrician adviser explained it would be hard to be critical of the general medical staff for not connecting the low albumin to the issues with fluid retention and the kidneys, as the information they will have received from the Urology team was that Mr C had no ongoing issues other than a UTI for which he was being treated with antibiotics.

54. It is possible if the Urology team had given more consideration to the kidney being the likely source of ongoing infection, then this would have better advised the general medical treatment.

55. Our geriatrician adviser explained they could see Mr C had been diagnosed with two infections (pneumonia in the lungs and a UTI), however neither of these appeared to be severe enough to account for the ongoing signs of infections and persistently high signs of infection in his blood tests.

56. Our geriatrician adviser also explained pneumonia is not an unexpected infection to acquire in hospital. They explained Mr C was dealing with an underlying infection and after his deterioration he was being nursed lying down in a bed. They explained the Mr C’s underlying infection and lack of movement in hospital would put him at a higher risk of developing pneumonia.

57. We do not necessarily consider Mr C acquiring pneumonia to be a sign of failings in care as this unfortunately often happens in hospital when people are very unwell.

58. Overall, we have not identified any failings in the general medical care the Trust provided for Mr C (outside of the issues outlined in the previous section) during this period. We do however understand that this will have been a particularly distressing time for Miss C and Mr C as he was clearly very unwell.

Discharge and communication

59. Miss C raised concerns Mr C was not well enough to be discharged to a rehabilitation centre in late July 2023, and this early failed discharge contributed to his already poor health getting worse.

60. In response to the complaint, the Trust maintained Mr C was medically fit for discharge from Urology, and his infection markers on his blood tests were lower than when he was admitted in June 2023. The Trust explained this meant it was appropriate to try and move Mr C to a rehabilitation hospital so he could continue to recover supervised by hospital staff.

61. Our geriatrician adviser explained Mr C’s infection markers in his blood were consistently high throughout his stay in hospital, which should have indicated to the Trust he had a severe ongoing underlying infection which was not getting better. They explained discharging Mr C to a rehabilitation centre would have been appropriate if his health had reached a stable point, however the blood test results did not support this.

62. The Department of Health and Social Care guidance around hospital discharge outlines people should be supported to be discharged to the right place, at the right time, and with the right support that maximises their independence and leads to the best possible sustainable outcomes.

63. Over the course of July, Mr C’s white blood cell count (one indicator of infection) had decreased, however his C-Reactive Protein (CRP – another indicator of infection) results had been fluctuating and had slightly increased the day before his discharge.

64. Our adviser explained this slight rise in CRP levels should have indicated to staff Mr C’s infections were potentially getting worse and should have triggered further investigation (for example more blood tests) to see if further antibiotic treatment was needed before deciding to discharge him.

65. Mr C was readmitted to the Trust’s hospital three days after discharge to the rehabilitation hospital with suspected sepsis due to Mr C’s unresponsiveness and shortness of breath.

66. We have seen indications the Trust should not have discharged Mr C to the rehabilitation hospital when it did. We find this is a failing and will consider the impact of this later in the report.

67. Miss C also complains when Mr C was discharged she was not contacted, and the Trust failed to provide her access to Mr C’s medical information to act as his Power of Attorney (decision maker when Mr C lacked capacity to make decisions himself) when she requested access to it on the ward. Miss C had also already discussed with the Trust her concerns Mr C was not well enough to be discharged from the hospital.

68. The GMC’s Good Medical Practice guidance outlines the importance of proper communication and documentation, and in responsiveness in providing family members information and support.

69. In addition to being a concerned family member, Miss C also held Power of Attorney for Mr C which allowed her to make medical decisions for him. Guidance from the Office of the Public Guardian for Medical disclosure outlines that attorneys should be able to access medical records to help them make informed decisions about care.

70. The Trust explained it has a process internally for sharing information with family members with Power of Attorney, which involves supervised access to medical records on the ward.

71. The Trust acknowledged it had not properly communicated with Miss C on the day Mr C was discharged to the rehabilitation hospital, and acknowledged staff should have given Miss C access to Mr C’s medical records as his Power of Attorney when she requested. The Trust apologised for this and planned to confirm with staff the importance of communication and understanding the role of Power of Attorney.

72. We agree the Trust failed to provide Miss C with information to support her role as a Power of Attorney. This was not in line with the relevant guidance and so we find this was a failing. We will consider the overall impact and the actions the Trust has already taken later in this statement.

Complaint Handling

73. Miss C told us the Trust originally failed to take on her complaint about Mr C’s care because Mr C had been discharged. Miss C then told us the Trust further delayed responding to her complaint, attempted and then abandoned a local resolution meeting, and provided a final response over a year after she first raised concerns.

74. We can see Miss C first raised her concerns about Mr C’s care to the Trust’s Patient Advice and Liaison Service (PALS) in July 2023, and the Trust confirmed it had opened an enquiry into her concerns. Miss C states that at the end of July 2023 PALS told her it could not look into her concerns further at this time because Mr C had been discharged to another hospital.

75. The NHS England information about feedback and complaints outlines PALS’ role is to initially try and help resolve issues informally with the hospital without the need to make a formal complaint. PALS also provide information and help if someone is considering making a formal complaint about services.

76. We do not consider the Trust’s initial decision to handle this complaint informally to be against the guidance. When this informal handling was no longer available after Mr C was discharged, we would expect the PALS department to provide information about the complaints procedure when it was clear Miss C was still unhappy, in line with its role.

77. We have not seen any evidence to suggest Miss C was given this information about making a formal complaint and can only see she states she was told the Trust could no longer help. We consider PALS did not provide Miss C with the information it should have done about the complaint procedure.

78. From reviewing the complaint file and communications, there are indications the Trust’s communication with Miss C was also lacking throughout the complaint procedure itself. The Model Complaint Handling Procedure outlines the Trust should share realistic timescales for the investigation, agree how it will keep the complainant regularly informed, and notify the complainant immediately of any delays or if it is likely it will not be able to provide a response within six months.

79. We can see the Trust originally aimed to have a first response by mid-January 2024 after commencing the investigation in September 2023. This was not shared with Miss C until March 2024, six months since the start of the investigation and seven months since the Trust logged Miss C’s formal complaint.

80. We would consider six months a regular time frame for a complaint response, based on the Model Complaint Handling Procedure, however we cannot see the Trust was proactive in informing Miss C of the delays before its own set deadlines passed.

81. We can see the Trust offered Miss C a local resolution meeting in April 2024, after she raised concerns about the first complaint response in March 2024. We can see from the emails Miss C was unsure whether this would address her concerns, and the Trust tried to reassure her it would be a good way to have medical staff discuss and explain the medical documentation in person.

82. We can see the Trust was trying to arrange this meeting internally and confirmed a date for the meeting in June 2024. We understand these meetings can take some time to arrange, with multiple staff schedules to consider, so would not consider the delay between proposing and confirming a meeting date to be an unacceptable delay.

83. Six days before the meeting date the Trust had to cancel the meeting due to upcoming staff strikes. After notifying Miss C of the cancellation, we can see the Trust did not respond to Miss C’s emails or questions about what would happen next until July 2024 when it confirmed it was gathering responses to provide a final written response.

84. While we understand the Trust is not responsible for the reasons why it had to cancel the meeting, we consider the lack of communication about the next steps and lack of response to Miss C’s chasing emails between June and July 2024 do not meet the communication standards we would expect of good complaint handling.

85. Miss C then sent further emails after July 2024 asking for updates and timescales on the written response with no reply from the Trust until August 2024. The Trust sent Miss C the final response in October 2024.

86. We can see again the Trust did not appear to be proactive in discussing time frames or delays with Miss C and provided the final response seven months after Miss C’s complaint was escalated. While we can see this is outside of the six months, we consider the cancelled local resolution contributed to this delay which was outside of the Trust’s control. We therefore do not consider this delay to be so outside of standards to be a failing.

87. We find the Trust did fall below standards in how it communicated with Miss C about her complaint and about any delays. We will consider the impact of this below.

88. Miss C is also concerned the Trust failed to fully explain the reasons for Mr C’s deterioration when she questioned this. She tells us this has contributed to her feeling like the Trust is not being truthful or transparent about what went wrong.

89. The first response detailed how the notes said Mr C had a change in state at the end of June 2023. Mr C reported chest pain and the Trust took blood and urine samples and performed an ECG to monitor his heart. Mr C had raised infection markers so the Trust started him on antibiotics. The Trust explained inactivity in hospital can compromise functional capacity which it believed contributed to the decline in Mr C’s ability to speak and swallow.

90. The second response explained it appeared Mr C had developed delirium (sudden onset confusion) and functional decline and explained illnesses can have a significant impact on a frail person’s body. The Trust noted there are no scans or tests which can confirm delirium and it is based on clinical opinion.

91. The Trust provided Miss C with a list of observations and tests which had been done during Mr C’s period of decline and attempted to reassure Miss C the staff had noticed the deterioration and had actioned investigations informed by a therapist’s earlier assessment before she raised her concerns about his state.

92. We consider the Trust did provide information and explanations for Mr C’s deterioration, based on the expert advice it had available. We can see the information about Mr C’s kidney obstruction and increased infection markers was included in the response. A different consultant Urologist was asked to review and contribute to the Trust’s responses as the original consultant no longer worked for the Trust. We cannot see the consultant contributing to the final response considered the possibility of kidney infection as the main reason for Mr C’s decline, based on the evidence available about Mr C’s kidney obstruction.

93. We therefore conclude the Trust did provide an explanation based on its current understanding of Mr C’s condition, however there was another missed opportunity from the Urology team to identify the presence of Mr C’s obstructed kidney as the likely cause of his deterioration.

94. To summarise, we find the Trust failed to meet our complaint standards in how it communicated with Miss C, and there was a missed opportunity to identify a failing. We consider this to be maladministration and will assess the impact below.

Impact

95. If we identify failings we then consider the negative impact these failings had on the patient and assess whether the organisation has already done enough to put this right.

96. To summarise, we find the Trust should have identified an obstructed kidney as the cause of Mr C’s ongoing infection and discussed this with Miss C as his Power of Attorney, that it should not have discharged him to rehabilitation care when it did and that it should have done more to involve her in his care at this point, including allowing her access to his medical information. We also find failings in how the Trust managed Miss C’s complaint.

97. Miss C tells us she feels the Trust’s actions contributed to her father’s eventual death and has wondered if Mr C could have survived with better care. Miss C explains she did not feel the care provided was sufficient and the Trust let Mr C get worse before discharging him inappropriately. Miss C is also clearly frustrated by the way the Trust communicated with her as Mr C’s daughter and his Power of Attorney, which she says was exacerbated by the poor complaints process.

98. Before Mr C was admitted to hospital, a specialist had already considered whether he was suitable for surgery to drain and treat any obstruction in his kidney. It was decided Mr C’s health would prevent him from being eligible for surgical intervention. It is reasonable at this stage to assume the best available treatment Mr C could have received, had the Trust identified the likelihood of an infected kidney obstruction, would have been antibiotics alone.

99. This would therefore suggest the treatment Mr C received from the Trust likely would not have changed had staff identified the obstruction as the most likely cause.

100. Our Urology adviser explained unfortunately Mr C was very unwell, and with antibiotics alone it is very unlikely he would have survived this complex infection. Our Urology adviser explained even if surgical drainage was an option, it is possible Mr C would still not have fully recovered. We cannot see any record of a conversation where Miss C or Mr C were made aware of the chance Mr C would not recover.

101. We understand this news is likely to be very upsetting for Miss C, learning no matter the course of action her father was likely to pass away when he did. We are sorry to have to provide her with this information.

102. Although the treatment options would likely have been the same, we do consider the Trust could have provided Miss C with better information and discussed the likelihood of survival with her and Mr C, had it fully considered the importance of the kidney obstruction.

103. Our adviser explained if the Trust had done this, it could have put in place a Best Interests meeting in line with NICE quality standards which could have helped to better inform and prepare Miss C. Without this, we can see how much harder Mr C’s eventual death will have hit Miss C.

104. We also consider the poor communication with Miss C about Mr C’s health and discharge, alongside refused access to Mr C’s medical information on the ward undermined Miss C’s ability to properly act as a Power of Attorney and make informed decisions for Mr C when he was unable. It also will have meant she was less able to raise concerns about Mr C’s discharge as she was not able to access the relevant information.

105. Our geriatric adviser explained Mr C’s discharge would not have significantly affected his overall health. Mr C’s CRP levels continued to rise, however his condition did not deteriorate until he was transferred back to the Trust’s hospital. Our adviser explained it is reasonable to say even if Mr C had stayed at the Trust, the increasing CRP levels and suspected sepsis may not have been recognised until Mr C deteriorated further.

106. Our geriatric adviser explained Mr C’s discharge to a rehabilitation hospital may have slightly delayed his access to antibiotic treatment, as these are less readily available in a rehabilitation hospital than at the Trust’s hospital. The records show that the infection took several weeks to control and multiple different antibiotics, meaning there was no straightforward solution to treat Mr C’s infection. In our adviser’s view, a slight delay in starting antibiotics would not have had any effect on the outcome.

107. Essentially, although Mr C should not have been discharged when he was, this discharge did not make his health or potential to recover from the infection worse. We can understand the period of movement and readmission when Mr C was unwell will have been distressing for Mr C and Miss C.

108. We can see Miss C was raising her concerns with the Trust’s patient liaison service whilst Mr C was still in hospital. It is clear Miss C was distressed with what she had seen and this was increased by the lack of what she felt was a proper investigation or explanation for what happened to Mr C during the complaints procedure.

109. We consider these issues occurring at a time when Miss C’s father was seriously unwell and then unfortunately died will have added to her grief and bereavement.

110. We appreciate the Trust has already taken actions to remedy the impact of some these failings, however we consider there is outstanding impact which needs to be further addressed.

1. We have carefully considered Miss C’s complaint about the care her father, Mr C, received from Northampton General Hospital NHS Trust (the Trust) between June and July 2023. Mr C sadly died in October 2023. We extend our sincere condolences to Miss C and we are mindful these events continue to cause her significant distress.

2. We found the Trust failed to identify an obstructed kidney as the most likely cause of Mr C’s severe ongoing infections. The Trust was aware of the obstruction and aware of Mr C’s high infection markers in his blood tests and did not consider this evidence further. After careful consideration we do not consider Mr C would have received any different treatment had the Trust identified this most likely cause, as the only treatment option available to Mr C was antibiotics, which he received. We therefore do not conclude these failings led to Mr C’s death.

3. We recognise there was a lost opportunity for the Trust to identity the cause and propose a best interests meeting to discuss with Miss C about Mr C’s care and the likelihood Mr C would not recover from this infection, to better prepare her for the outcome.

4. We also found failings in how the Trust communicated and shared vital information with Miss C about Mr C’s care, obstructing her ability to fully act as Mr C’s Power of Attorney (where Miss C was legally allowed to make healthcare decisions on behalf of Mr C if he lost the ability to make those decisions himself). We acknowledge the Trust has accepted this and put training in place to ensure staff are aware of the proper processes.

5. We also found failings in Mr C’s discharge to a rehabilitation hospital in July 2023 as his infection markers suggested he should not have been discharged and instead should have undergone further investigations and treatment. After careful consideration we do not consider this discharge had any impact on Mr C’s health. We acknowledge Mr C’s discharge will have been distressing for him and for Miss C who had already disagreed with the plan to discharge Mr C.

6. We also found failings in how the Trust communicated with Miss C about her complaint. We consider this added to the distress and grief Miss C was already experiencing.

7. Our decision overall is to partly uphold this complaint. As a result, we have asked the Trust to: • apologise for and acknowledge the impact of the identified failings • pay Miss C £700 for the distress and frustration the Trust’s actions caused her on top of her bereavement • create an action plan to address the identified failings.