Sheffield Teaching Hospitals NHS Foundation Trust

3. Mrs I complains about the care and treatment given to her husband, Mr I, following heart bypass surgery in November 2024. Specifically, she complains the Trust:

• stitched a drain into her husband which then needed to be surgically removed • failed to keep her husband’s surgical stockings on for the recommended 23 hours a day.

• failed to monitor her husband on the ward which meant he went missing for over an hour before he was found unresponsive in a bathroom.

4. Mr I sadly died on 17 November 2024. Mrs I said the additional stress of the surgery to remove the stitched drain, the lack of care regarding the surgical stockings and staff failing to adequately monitor Mr I while in their care may have contributed to Mr I’s poor recovery.

5. Mrs I is looking to achieve financial remedy of at least £12,500 and service improvements to prevent this happening to others.

9. Mr I was admitted to the Trust for a triple heart bypass, which was completed on 13 November 2024.

10. During the procedure two pleural drains and one mediastinal drain were fitted into Mr I’s chest cavity to drain fluid.

11. On 14 November Mr I had a procedure to remove the drains after the mediastinal drain was accidentally stitched to one of the pleural drains.

12. On 17 November, Mr I went for a shower shortly after 6.45am and was found unresponsive in the bathroom at 7.55am. He was pronounced dead at 8.18am.

13. Mrs I raised a complaint to the Trust on 18 December about the care and treatment afforded to Mr I during his admission.

14. The Trust issued its response on 19 June 2025.

15. As Mrs I was dissatisfied with the Trusts response, she referred the matter to us in August.

16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs of service failings or maladministration which the organisation has not put right. Having done so we have found the Trust followed its policies correctly.

Stitched a drain into her husband which then needed to be removed surgically on 14 November 2024.

17. The records show Mr I’s bypass surgery was successful. As part of the procedure, two pleural drains and one mediastinal drain were inserted to remove post-operative fluid.

18. Mrs I says, on 15 November 2024, staff attempted to remove the drains. Whilst not documented in the medical records, Mrs I recalls forceful attempts to remove the drains, to the point Mr I asked staff to stop. Later that day, Mr I underwent a procedure under local anaesthetic to remove the drains. Mrs I is concerned this caused Mr I unnecessary trauma.

19. The medical notes from 2.50pm on 15 November confirm the drains were removed successfully using endoscopic vision. No complications were recorded, and Mr I was described as clinically well following the procedure.

20. The medical records show initially Mr I’s recovery progressed as expected, and he was transferred from the Progressive Care Unit to the Surgical Ward later the same day.

21. The Trust’s complaint response explains it placed two larger drains for early bleeding and a smaller drain for later pericardial fluid collection. It explained this is in line with normal practice. The Trust state it accidentally stitched Mr I’s drains together. The Trust acknowledged the procedure may have been distressing but described it as minor and minimally invasive.

22. Our surgical adviser explained there are no mandatory national guidelines specifying the technique for inserting drains of this type nor are there any for the subsequent removal.

23. Our surgical adviser confirmed surgeons must use their professional judgement on how to approach surgeries. This means the choice of technique is guided by training, experience and the clinical situation. RCS guidance states surgeons should ‘use their professional judgement to apply these principles in practice’.

24. Our surgical adviser confirmed it is common practice to insert drains following an operation such as this. They said drains becoming stuck is an uncommon but recognised complication in surgical practice. They explained drains are often stitched to the patient to ensure they are fixed in place so, as in Mr I’s case, it is not always clear if the drains become stitched internally.

25. Our adviser confirmed the endoscopic method used to remove the drains under local anaesthetic was appropriate and within normal practice. He noted the minor nature of the procedure meant it did not significantly affect Mr I’s condition or recovery.

26. Considering the clinical records, the Trust’s explanations, surgical advice, and the RCS guidance on professional judgement, there is no indication of failings in how the Trust managed the removal of Mr I’s drains. The actions taken were consistent with RCS guidance.

27. We appreciate how distressing this must have been for Mrs I. We hope she is reassured we did not find any indications of failings in how the Trust treated her husband.

Failed to keep her husband’s surgical stockings on for the recommended 23 hours a day

28. Mrs I raised concerns staff did not follow the post operative guidance that Mr I should wear surgical stockings for 23 hours a day. She recalls one occasion on 16 November when he was without the stockings for 3 hours and 45 minutes. She feels this shows a lack of appropriate care and is concerned about the potential impact this may have had on Mr I’s recovery.

29. Mr I was prescribed and administered Dalteparin, a medication used to prevent venous thromboembolism (VTE or blood clots).

30. Mr I’s was prescribed surgical stockings to be applied “once a day” to help prevent VTE. Our adviser told us this does not indicate a requirement for near continuous wear. The expected practice is that staff assist the patient to remove the stockings for washing, checking the skin, and then reapply them once the patient is dry and dressed.

31. The records show daily skin checks were carried out and there are multiple entries confirming Mr I’s surgical stockings were in place

32. NICE guidance states:

• People should be encouraged to wear antiembolism stockings day and night until their mobility has returned to normal.

• Stockings should be removed daily for washing and to allow staff to check the condition of the skin.

• Use of stockings should be monitored at least once a day, and assistance offered if they are not being worn correctly.

• Mechanical venous thromboembolism (VTE) prophylaxis should continue until the person no longer has significantly reduced mobility.

33. Our nursing adviser explained surgical stockings should be worn except for when washing and checking the skin. They noted there is no national guidance for the duration.

34. The records show daily skin checks were carried out and there are multiple entries confirming Mr I’s surgical stockings were in place which is in line with NICE guidance.

35. National guidance does not require stockings to be worn for a fixed number of hours per day, and the prescription in Mr I’s records does not indicate a requirement for near continuous wear. The temporary period without stockings is consistent with the accepted practice of removing them for washing and skin checks. We have not seen any indications of failings.

36. Mr I also received Dalteparin which is in line with NICE guidance which recommends the use of an anticoagulation drug such as Dalteparin.

37. Mrs I may be reassured to know our adviser explained, Dalteparin can be used on its own in patients who cannot wear TED stockings, or in combination with them. Because Mr I was receiving daily Dalteparin, any temporary period without stockings would not have had any clinical impact on his risk of developing a VTE.

38. The postmortem confirmed Mr I did not develop a VTE, the complication that surgical stockings and Dalteparin are designed to prevent.

39. We note the Senior Sister on the ward has reminded all members of the team of the importance of applying surgical stockings, redistributed product information, and completed teaching sessions to reinforce this.

40. We hope Mrs I is reassured by our findings and is pleased that, as a result of her complaint, the Trust has reminded staff of the role of surgical stockings.

Failed to monitor her husband on the ward which meant he went missing for over an hour before he was found unresponsive in a bathroom

41. Mrs I’s main concern relates to the monitoring of her husband on the morning he died. She is concerned Mr I, a patient recovering from major heart surgery, was able to be away from his bed and unmonitored for more than an hour, and she believes this may have contributed to his death.

42. NEWS2 is a system used nationally to assess patients and to recognise deterioration in their condition by allocating the patient a ‘score’ based on six simple physiological parameters to form the basis of the NEWS2 scoring system.

43. A score is allocated to each as they are measured, with the score reflecting how the parameter varies from the normal range. This score is then aggregated.

44. The medical records show that at 1.54am on 17 November 2024 Mr I received a NEWS2 score of 1.

45. The medical notes show Mr I was observed at 3.25am. This was an interim check, often referred to as a ‘comfort check’. It doesn’t impact on NEWS2 timings, unless the patient is found to be unwell. If so, a repeat NEWS2 assessment would be undertaken regardless of the previous score.

46. The medical records indicate Mr I went for a shower at approximately 6.30am. They also show that further observations were undertaken in Mr I’s bay at approximately 6.40am. The records show that the nurse did not recall seeing Mr I at this time.

47. At approximately 7.20am a handover took place as the nurses caring for Mr I changed shift. It noted Mr I was in the shower.

48. Mr I was found unresponsive in the bathroom at 7.55am. Following several attempts at resuscitation, he was pronounced dead at 8.18am.

49. In its complaint response, the Trust explained a nurse spoke to Mr I at around 6.20am where no concerns were voiced. Mr I explained that he was going to shower prior to the bathrooms getting busy and he confirmed he felt well enough to walk unaided.

50. The response says that further discussions were held at approximately 6.30am where Mr I asked for help in his removing surgical stockings prior to his shower. As the nurse was busy at this point, she asked Mr I whether he could wait until she had finished supporting another patient.

51. The complaint response explains further observations were undertaken in Mr I’s bay at approximately 6.45am, but the nurse did not recall seeing Mr I at that time.

52. Consistent with the medical records, the response states Mr I was found unresponsive in the bathroom at 7.55am and after resuscitation attempts, he was pronounced dead at 8.18am

53. We asked our nursing adviser about the NEWS2 score of 1 reached at 1.54am on 17 November. They confirmed based on Mr I’s oxygen saturation level of 95%, the Trust correctly scored Mr I with a NEWS2 score of 1.

54. NEWS guidance states, for a patient with a low score 0, the minimum frequency of observation should be 12 hourly. In a patient with a score of 1-4, frequency of observation should be increased to 4-6 hourly unless more frequent monitoring is considered appropriate by a competent clinical decision maker.

55. Our adviser said, given Mr I’s NEWS2 score was 1 at 1.54am, he should have been next assessed between four to six hours later. Mr I’s next NEWS2 observation would therefore have been due between 5.54am and 7.54am at the latest.

56. Sadly, Mr I was found unresponsive in the bathroom at 7.55am.

57. Our nursing adviser explained NEWS2 timings for repeat assessments are not rigid, it is guidance. Dependent on the patient’s needs, they can be delayed.

58. Our nursing adviser felt it was reasonable for the Trust to leave Mr I to sleep and shower before conducting the NEWS2 observations. They said the records, as well as the NEWS2 score of 1, demonstrated Mr I was stable and there was no indication he needed more frequent monitoring.

59. The Trust were unable to complete the NEWS2 observations after Mr I’s shower as he was unresponsive. There was no indication before his shower he would later unfortunately suffer a cardiac arrest.

60. After careful consideration of the above, we find the care the Trust provided was in line with national guidance. We have found no evidence of service failings in how the NEWS2 scores were reached nor any indication there was a significant risk to Mr I’s health when the Trust left to shower unattended.

61. We appreciate the difficulties Mrs I has faced in dealing with the loss of her husband. We recognise how devastating this has been for Mrs I and her family, and we are sorry for the pain endured while seeking answers about his care.

1. We have carefully considered Mrs I’s complaint about Sheffield Teaching Hospitals NHS Foundation Trust (the Trust). We have considered the evidence regarding Mrs I’s complaint and having done so we have not seen any indications of failings.

2. We are sorry to hear about the circumstances of Mrs I’s complaint. We understand the challenges she has faced and her continued struggle to receive answers about her husband’s care. We recognise the strength of feeling and how important this complaint is to her.