Manchester University NHS Foundation Trust

12. Ms B complains about aspects of the care treatment Manchester University Hospitals NHS Trust (the Trust) provided her mother, Mrs C, between October and December 2023. Specifically, that:

• on 8 October 2023 it did not X-ray Mrs C’s fractured arm in a reasonable time frame • on 8, 11 and 19 October, and 7 December 2023 it did not give Mrs C’s adequate pain relief • on 11 October it gave Mrs C laxatives when there was no clinical need • it did not provide sufficient nutritional support for Mrs C • on 1 December 2023 it delayed administering antibiotics • did not adhere to Mrs C’s Jewish faith death burial requirements after she died.

13. Ms B says her mother was left in pain when the Trust delayed her X-ray and did not give adequate pain relief. She says this also caused her and her family distress.

14. She says the laxatives caused her mother to suffer severe stomach cramps. She says the failure to ensure Mrs C had the right food or help her eat increased her frailness, and the Trust delay giving her antibiotics meant she contracted a chest infection and never recovered.

15. Ms B says a faith burial was very important to her mother and the Trust’s failure to ensure her requirements were followed have devastated her family. Mrs C’s family are angry and upset by the lack of care, respect and dignity their mother was given.

16. Ms B wants the Trust to put measures in place to prevent this happening to another patient. She also wants a financial remedy.

17. Mrs C was admitted to the Trust on 7 October 2023 after a fall at home.

18. The Trust treated her for a broken right arm. Whilst she was an inpatient, she contracted COVID and influenza in late November 2023.

19. Covid and influenza are respiratory infection that affect a person’s breathing.

20. Mrs C sadly deteriorated and died on 8 December 2023. We are sorry for Mrs C’s family’s loss.

X-ray of Mrs C’s fractured arm

26. The GMC guidance says doctors:

‘Must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: (a) adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient (b) promptly provide or arrange suitable advice, investigations or treatment where necessary’.

27. There is no specific guidance on when an X-ray should be performed.

28. Mrs C arrived at the Trust early morning on 8 October 2023 after a fall at home. This must have been a very painful and distressing experience for her.

29. Mrs C’s records show the Trust triaged and assessed her injuries. The Trust booked Mrs C for an X-ray of her shoulder and wrist at 3.52am. This was marked urgent. The Trust conducted the shoulder X-ray at 4.38am and the wrist X-ray at 1.06pm the same day.

30. Our emergency medicine adviser said a prompt investigation would have meant performing both X-rays at the same time. That did not happen. The wrist X-ray was delayed and there is no explanation for this. We find the Trust did not act in line with GMC guidance here.

31. We considered what impact this had on Mrs C. Our emergency medicine adviser said the wrist X-ray showed Mrs C had suffered a minor fracture in her wrist. But the significant injury was to her shoulder and upper arm.

32. We can see from Mrs C’s records that a specialist orthopaedic opinion given later that day advised no further procedural intervention was needed to address Mrs C’s wrist injury. We do not consider therefore that the delay in the wrist X-ray had any impact on the healing of Mrs C’s wrist injury.

33. It would have been inconvenient for Mrs C to go back for a wrist X-ray. She may also have had some pain in her wrist until it was fully stabilised. We can see from her records Mrs C was receiving pain relief. We can see no evidence of specific complaints made by Mrs C about her wrist while she was waiting for it to be X-rayed.

34. The Trust has apologised for the delay.

35. To better understand the impact of these events and Trust’s actions we referred to ‘Our severity of injustice scale’ (our scale).

36. Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of remedy we would usually recommend in those circumstances.

37. Our scale describes a level one injustice as one where there is, ‘Short term minor pain (no more than 1-2 days), which can be managed by use of non-prescription medication and where the person affected can still function normally’. We would generally consider an apology to be an appropriate remedy for level 1 injustice.

38. This was a one-off incident. Any pain, inconvenience or frustration was for short duration. We can see no other adverse or wider impact. For this reason, we are satisfied the Trust apology is in line with what we would expect for the level of injustice described above.

The Trust did not give Mrs C’s adequate pain relief on 8, 11 and 19 October, and 7 December 2023

39. Mrs C had broken her upper right arm bone. This was no doubt very painful and we can see her arm was severely swollen and bruised. We are sorry to learn of the pain she was in during her admission.

40. We looked at what the Trust prescribed Mrs C on each of the dates given above. This was made more difficult because the Trust has, thus far, been unable to provide us with drug administration charts. However, we have enough other evidence from the records to reach a decision.

41. The RCEM guidance says, ‘Opiate medication is first choice for analgesia when patients rate their pain as moderate or severe’.

42. NICE CKS on ‘Analgesia mild to moderate pain’ says:

• ‘The analgesics used to relieve mild-to-moderate pain are: • Paracetamol.

• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen.

• Aspirin (a salicylate NSAID).

• Certain opioids, such as codeine, dihydrocodeine, and tramadol.

43. On 8 October 2023 the Trust emergency department inpatient team assessed Mrs C including a pain assessment. Mrs C had been receiving paracetamol. The Trust put her arm in a sling to immobilise and placed a splint for her wrist. Our emergency medicine adviser said both types of splinting support the healing of fractures, but also by immobilising them provide pain relief in themselves.

44. At 2.02pm on 8 October 2023 the Trust documented Mrs C reporting significant arm pain and prescribing co-dydramol and paracetamol four times a day. This shows Mrs C was receiving pain relief whilst in A&E. When she reported being in severe pain her pain relief was escalated and prescribed for regular administration. At 11.22pm the records show Mrs C gave no indications of pain.

45. Co-dydramol is an opiate-based pain killer used to treat moderate pain. Prescribing it here was in line with the RCEM and NICE CKS guidance above. Mrs C reported no pain later the same day which our emergency medicine adviser said indicates pain relief was effective.

46. We are satisfied on 8 October 2023 the Trust prescribed pain relief in line with relevant standards. Mrs C not complaining of pain later would indicate pain relief was effective on 8 October 2023.

47. NICE CG138 on the patient experience in adult NHS services is relevant next. It says:

‘1.2.8 If a patient is unable to manage their own pain relief: • do not assume that pain relief is adequate • ask them regularly about pain • assess pain using a pain scale if necessary (for example, on a scale of 1 to 10) • provide pain relief and adjust as needed.’

48. Nice CG140 says on pain relief for adults is also relevant next. It says:

‘1.1.16 If pain remains inadequately controlled despite optimising treatment, consider seeking specialist advice.’

49. The Trust had given Mrs C Oramorph (a liquid morphine) on the evening of 10 October 2023. At 9.20am on 11 October 2023, after Mrs C complained of pain, the Trust referred her to its Pain Team for advice. The Pain Team advised discontinuing co-dydramol and oral morphine and prescribed Mrs C oxycodone hydrochloride. This medication is a strong opioid and in line with NICE CKS prescribing for mild to moderate pain. The Trust’s actions in seeking specialist pain advice here was in line with NICE CG140.

50. The Trust documented it was unable to do a full pain assessment and Mrs C was unable to describe her pain on a scale of 0-10. The note goes on to record a discussion about conducting four-hourly pain assessments utilising the PAINAD pain assessment flow sheet (a tool designed to assess pain in patients who cannot verbalise their pain levels) and offer her pain relief if scores were 5/10 or over. The Trust notes Mrs C being given one dose overnight.

51. On the morning of 12 October 2023 the Trust documented no concerns regarding pain and that Mrs C denied pain. This was reassuring and indicates the Trust’s actions on 11 October 2023 had some success in controlling her pain.

52. On 19 October 2023 the Trust documented Mrs C as having no pain and refusing analgesia. This was in contrast to the two previous days when the Trust had given opioid pain relief in response to her complaining of pain.

53. We are sorry to learn from Ms B of Mrs C’s pain on 19 October 2023. Mrs C’s medical record shows Mrs C not complaining of pain on 19 October 2023. We are unable to reconcile Ms B’s account with what the Trust documented. We are unable to reconcile this difference in opinion.

54. On 7 December 2023 the Trust documented Mrs C as being unresponsive. Mrs C could not communicate her levels of pain. Ms B told us Mrs C was in distress and agitated.

55. The Trust documents prescribing Mrs C morphine which it commenced at 1.38pm. At this stage Mrs C was also on anticipatory medications including glycopyrronium and the Trust started midazolam. These medications are given to reduce distress at end of life.

56. The PANG Guideline is relevant here, specifically around terminal agitation. It says the following drugs may be useful in reducing anxiety. It lists Midazolam as first line drug for patients in distress. This is what the Trust prescribed Mrs C on 7 December 2023 when told of her increased agitation. This was in addition to the morphine for any pain.

57. Though we cannot tell what Mrs C level of pain was, the Trust did prescribe stronger pain relief (morphine) in line with NICE CG140 on strong opioids for pain relief and other anticipatory medication when her family indicated her as being in distress.

58. In summary, though incomplete, the evidence we have seen shows the Trust paying attention and responding when Mrs C expressed being in pain in line with standards on the dates we looked at.

59. The Trust provided regular assessment of Mrs C’s pain at clinical rounds, conducting analgesia reviews and adjusting it when it needed to. The Trust gave Mrs C strong opioid pain relief in line with NICE CKS and NICE CG140 guidance on pain relief, obtained specialist pain team advice in line with NICE CG140 and escalated pain relief when clinically indicated in line with what we would expect. We do not uphold this section.

The Trust gave Mrs C laxatives when there was no clinical need on 11 October 2023

60. NICE CG140 ‘Palliative care for adults: strong opioids for pain relief’ says:

• ‘1.1.17 Inform patients that constipation affects nearly all patients receiving strong opioid treatment.

• 1.1.18 Prescribe laxatives treatment (to be taken regularly at an effective dose) for all patients starting strong opioids.

• 1.1.19 Inform patients that treatment for constipation takes time to work and adherence is important.

• 1.1.20 Optimise laxative treatment for managing constipation before switching opioids.’

61. Mrs C’s family complain she was given laxatives despite having poor food intake. As a result, Mrs C suffered with abdominal cramps and pain.

62. The Trust prescribed Mrs C laxatives on 10 October 2023 as she was on opioids (strong pain killers). Mrs C had not opened her bowels since admission on 8 October 2023. The rationale for prescribing laxatives was documented, and the nurses knew the reasons for administration and administered it in line with the prescription. This is in line with the guidance at the start of this section.

63. Our decision is the Trust prescribed laxatives in line with relevant guidance, and we do not uphold this concern. We are sorry to hear Mrs C suffered stomach cramps, these are a known side effect of laxatives and not an indication they were given in error.

The Trust did not provide sufficient nutritional support for Mrs C

64. NICE CG32 says Trusts should assess the risk of malnutrition in patients. It says:

• ‘1.2.1 Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.

• 1.2.2 All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients’

65. The Malnutrition Universal Screening Tool (MUST) is a five-step evidence-based screening tool used by the NHS to identify adults who are malnourished or at risk of malnutrition. The Trust uses this tool.

66. The NICE CG32 guidance above says screening should be completed on admission. We have seen no evidence of the Trust assessing Mrs C’s risk of malnutrition on admission as per the NICE guidance. This is not in line with the standard above. The Trust should have completed a MUST for Mrs C on admission and then weekly.

67. The Trust first used the MUST on 1 November 2023 (more than three weeks after her admission) and then on 4 and 9 November 2023.

68. Despite this, the food charts we have seen show Mrs C having a varied diet and reasonable intake at most mealtimes during the early part of her admission. This indicates there were no early risk of malnutrition in Mrs C’s admission.

69. On 1 November 2023 the Trust documented Mrs C’s MUST score as 0 and said dietician and SALT input was not required. Her BMI (height and weight ratio) was recorded as 25.64. A healthy BMI for adult women is between 18.5 and 24.9. On 4 November 2023 the Trust documented Mrs C’s MUST score as 0 with no dietician input required. On 9 November 2023 the Trust documented Mrs C’s MUST score as 0 with no dietician input required.

70. A MUST score of 0 indicates a low risk of malnutrition. It signifies that the individual has a stable BMI, no significant recent unplanned weight loss, and no acute illness affecting nutrition. The action required is routine, care-based monitoring rather than additional steps. This is what the Trust did here.

71. The next time the Trust used MUST was on 22 November 2023. This is 13 days after the last MUST and is not in line with the NICE CG32 guidance that says it should be done weekly.

72. On 22 November 2023 the Trust documented Mrs C’s MUST score as 1 with no dietician input required. The Trust provided food charts documenting Mrs C’s mealtimes from 20 October 2023 to 4 December 2023. From 17 November 2023, the charts document more often Mrs C as not hungry. The charts also record Mrs C having less food going forward in her admission.

73. At this stage we know Mrs C’s health had begun deteriorating and she was being treated for COVID-19. This is likely the cause for her reduced food intake and increased MUST score, although the records lack information on what prompted this increased score.

74. A MUST score of 1 indicates a patient who is at a medium risk of malnutrition. Our nurse adviser said this means the person is at risk of undernutrition and requires "Food First" dietary advice, including high calorie/protein food, increased snacks, and monitoring, with a review in four to twelve weeks. This also means the Trust should document dietary intake for three days.

75. The Trust food charts from 22 to 25 November 2023 show the Trust did document Mrs C’s intake in line with MUST when she showed an increased risk of malnutrition.

76. We have seen no evidence of the Trust then continuing to utilise MUST weekly as NICE CG32 says it should do. We are therefore unable to say what Mrs C’s MUST risk was after 22 November 2023, whether it should have necessitated further Trust action.

77. Regular daily nursing and doctor ward round notes documented Mrs C needed encouraging to eat and drink on most days. There are clear increasing concerns around her intake as her admission progresses. On 30 November 2023 a Trust nurse documented the need to complete food charts. This is eight days after clinical indication from MUST said it should have been started. The Trust has been unable to provide us with any food charts.

78. The Trust did record Mrs C’s weight throughout her admission as follows:

12 October – 64kg 25 October – 70.8kg 29 October – 71.1kg 31 October – 71.5kg 3 November – 67.8kg 15 November – 67.9kg 17 November – 64.3kg 20 November – 64.1kg 23 November – 63.1kg 3 December – 64.3kg

79. Our nurse adviser said weight alone is not a clear indicator of nutritional status as factors such as fluid retention or overload would increase a patient’s weight. Though the Trust documents Mrs C’s weight to be almost the same at death as it was on admission, we have two periods where Mrs C gained weight (6.8kg in 12 days after admission) and then lost weight (around 9kg in one month).

80. Our nurse adviser said it is not necessary to complete a food chart for every patient unless there are clinical indications of problems with nutritional intake. This is the case here. The Trust assessed Mrs C with a MUST of 1 on 22 November 2023 and regularly documents Mrs C having problems with her intake and needing prompting or assistance and Trust nurses had asked for food charts to be completed. This is what the Trust did.

81. The food charts are inconsistent but where the Trust documents Mrs C’s food and nutrition and what it gave her – we can see it on occasion offered Mrs C choices and alternatives, giving her supplements (such as ENSURE). We also see notes documenting staff being asked to encourage Mrs C to eat and drink more.

82. Though we know the Trust gave Mrs C IV fluids, we also have evidence where the Trust documents Mrs C developing a sore throat and having problems swallowing from 30 November 2023.

83. Our nurse adviser said the expectation for a patient having these difficulties would be for the Trust to escalate its assessment and review of her intake – to complete food charts, to escalate to Speech and Language Therapy (SALT for swallowing assessment) and a Dietician. We have seen evidence of food charts being utilised but no referrals or Trust escalation.

84. We have evidence of good practice. Our nurse adviser was satisfied the Trust acted in line with some of the guidance above. On Mrs C’s admission the Trust assessed her dietary needs, likes and dislikes, weights were regularly documented, and additional nutritional support (supplements) was provided as prescribed. The Trust did use the MUST screening tool when there were concerns about her intake though not from admission. We have evidence of Trust staff encouraging Mrs C to eat and drink more throughout her admission.

85. We have further problems with the Trust recording here. Nursing notes show nutritional intake was considered daily, however, MUST score is rarely referred to within the shift reviews and entries into Mrs C’s medical records are inconsistent in the approach to identifying intake and frequently lack any detail. On many occasions oral fluid is recorded but nutrition not mentioned or poor nutritional intake is recorded. Despite this the section on dietician referral is not completed.

86. In summary, the Trust did not provide Mrs C with the nutritional support we would expect in line with all the guidelines at the start of this section after risk were identified (MUST ‘1 on 22 November 2023). We can see no evidence of the Trust providing a co-ordinated approach to her care (escalating to SALT or Dieticians - although not recommended for a MUST score of 1). Or continuing to use MUST as it should have after it recorded this score of ‘1’.

87. Mrs C’s weight is roughly the same at the start and end of her admission. This would suggest a limited physiological impact from her reduced intake. We know Mrs C was in general deterioration and suffered with a chest infection from late November 2023.

88. We acknowledge eating and drinking well is essential to allow for a patient the best opportunity to recover. it was no doubt frustrating and upsetting for Mrs C’s family to witness her not eating or drinking well enough during the admission.

89. We looked at what the Trust says it has done to improve its service here.

90. The Trust said at an organisational level, it holds monthly nutrition and hydration meetings where key performance data, including MUST compliance and fluid input/output monitoring, are reviewed and discussed to support assurance and continuous improvement. Each clinical area has designated nutrition and hydration champions who receive regular training and act as local leaders to promote best practice. In addition, mealtime standards audits are routinely undertaken in collaboration with the Quality Team to ensure patients receive appropriate support at mealtimes. Patient experience is further prioritised through engagement activities, including catering staff attending wards alongside the senior leadership team to sample food and actively seek patient feedback.

91. Though we uphold this concern, we are satisfied the Trust has provided the service improvement Ms B sought here to prevent the same happening to another patient who presents in similar circumstances. We therefore make no further recommendations here.

The Trust delayed administering antibiotics on 1 December 2023

92. The NMC code says nurses should ‘make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay’.

93. There is no guidance for how quickly medicines should be administered after prescribing. Ideally it would be done as soon as possible.

94. Mrs C contracted influenza and COVID-19 during her admission. On 26 November 2023 due to these acute changes in her condition the Trust prescribed and administered ciprofloxacin and levofloxacin. These are both broad range antibiotics used to treat bacterial infections. Up to 30 November 2023 the Trust continued to give Mrs C oral and IV antibiotics.

95. A Trust microbiology consultant noted on 1 December 2023 it was appropriate to prescribe teicoplanin and aztreonam. These are also broad range antibiotics used to treat bacterial infections.

96. The Trust prescribed aztreonam at 11.42am on 1 December 2023. As the ward did not hold that medication as standard ward stock, it required a specific order from the pharmacy. Our nurse adviser said this is what should have happen if a drug is not in stock. There is no guidance to say this specific antibiotic should be held in reserve at an on-site pharmacy or on the ward. The drug was subsequently administered at 6.39pm once it had been supplied by pharmacy at 5.50pm.

97. There was a gap between prescribing and administration. This is not a failing. The drug was not in stock, the Trust ordered it promptly and then administered after it arrived on the ward. This was a matter of hours. The Nurses acted in line with the NMC guidance at the start of this section and we do not uphold this concern.

The Trust did not adhere to Mrs C’s Jewish faith death burial requirements after she died on 8 December 2023

98. Ms B complains the Trust did not ensure quick release of Mrs C’s body to allow a funeral as soon as possible in line with Mrs C’s Jewish faith.

99. The Trust ‘Care of the Deceased Policy’ says:

‘When performing care after death every effort must be made to accommodate the prior wishes of the patient and/or the wishes of the family, with consideration being given to the ethnic, cultural and religious rituals that accompany a person’s death…’

100. The Trust also has a policy for when the body of the deceased needs to be released outside of usual hours. This policy is to ensure timely release in a number of situations including for faith reasons.

101. The NMC Code says nurses should treat people as individuals. They should avoid making assumptions and recognise diversity and individual choice.

102. Clearly the loss of a loved one is a very distressing experience and Mrs C’s family have our condolences.

103. On 6 December 2023 the Trust documented discussing mortuary plans with Mrs C’s family. Mrs C’s family asked if they could come in and dress Mrs C in her pyjamas before transfer to the mortuary. The note says Mrs C’s family declined rabbi support at that time and it asked Mrs C’s husband (Mr C) to discuss any care after death or religious concerns with the ward team.

104. On 7 December 2023 the Trust again advised Ms B to ask Mr C to discuss any care after death or religious concerns with the ward team.

105. Mrs C sadly died at 8.06pm on 8 December 2023 (Friday night). Her family were able to come in and dress her in her pyjamas and the Trust gave them a bereavement booklet before transferring Mrs C to the mortuary.

106. The Trust documented a further discussion with Mr C had with a nurse at 9.07pm on 8 December 2023. The Trust explained what would happen next. It said it would provide a death certificate and the bereavement office would be in touch with him about the support it could offer.

107. A nurse completed a notification of death form and emailed it to its bereavement team and at 1.04am on 9 December 2023 the Trust transferred Mrs C’s body to the mortuary.

108. Our understanding is that the Jewish faith says burials should happen as soon as possible, ideally within 24 hours of death. But as per the NMC Code, Trust’s should not make assumptions about patients’ choices, even where they indicate they follow a particular faith.

109. A Trust incident report after the events said that even though her medical records noted Mrs C as being Jewish, she had told staff she was not practising her faith so needed no support from that perspective. This is not what Mrs C’s family told us.

110. The report says Ms B was present at the time of death and staff discussed any specific requests and the only request was Mrs C be sent to the mortuary in her own pyjamas. This is reflected in Mrs C’s clinical record.

111. The Trust acted in accordance with the guidance at the start of this section. It spoke with Mrs C and her family about their wishes in advance and fulfilled these. The Trust offered to involve a spiritual care leader (Rabbi). This is documented in Mrs C’s clinical record. It also explained what it would do next and when the relevant paperwork would be completed to allow for Mrs C’s funeral.

112. We are unable to reconcile the differing accounts provided in the notes and provided by Ms B. Discussion did take place both before and after Mrs C’s death about any requirements and this is clearly noted. But we cannot say, even on the balance of probabilities, that the family told the Trust of their expectations for a speedy release of Mrs C to enable a quick funeral in adherence for faith requirements. It follows that we do not find the Trust should have engaged its policy on ensuring a quick release of the body.

113. Our decision is the Trust acted in line with the NMC guidance and in line with its own policies and we do not uphold this section. In coming to that view, we accept that the time taken to release the body was distressing for Ms B and her family.

1. We have carefully considered Ms B’s complaint. We find the Trust did delay Mrs C’s wrist X-ray and did not provide the nutritional support we expected. We find the Trust provided pain relief and prescribed laxatives in line with standards and administered antibiotics as soon as they were sourced. We also find the Trust completed the necessary paperwork for the bereavement team to issue a death certificate in line with relevant standards.

2. We find the Trust should have performed an X-ray on Mrs C’s injured wrist at the same time as it did on her injured shoulder on 8 October 2023. There was a delay here. We are unable to determine why. We partly uphold this section. We find the impact of these failings had on Mrs C was of a short-term nature and the Trust has put this right by apologising for what happened.

3. We find the Trust acted in line with guidelines in responding to Mrs C’s levels of pain or distress on 8 and 11 October 2023, and 7 December 2023. The Trust monitored and documented Mrs C’s levels of pain and listened to her family when they expressed concerns about this. The Trust referred Mrs C to its specialist pain management team who reviewed this and prescribed pain relief in line with guidance.

4. We do not have enough evidence to say what happened with regards to Mrs C’s pain on 19 October 2023. We cannot reconcile the difference between what Ms B tells us and what is documented in Mrs C’s record. Despite this we do not uphold this section. The Trust did give Mrs C strong pain relief when she needed it in line with standards. We were reassured to see Mrs C’s pain levels being brought under control by this.

5. We find the Trust prescribed and administered laxatives in line with guidelines, which say they should be prescribed for any patient starting strong opioid treatment in anticipation of constipation (which strong opioids cause). This was the case here for Mrs C. We do not uphold this section.

6. We find the Trust did not provide Mrs C with the nutritional support we would expect in line with guidelines. The Trust documents regularly Mrs C needing encouragement to eat and drink. This demonstrates clear indication of food intake concerns. We can see the Trust taking some measures to remedy this such as providing nutritional supplements and intravenous (IV) fluids.

7. The Trust completed food charts in line with what we expect, however, we have seen no evidence of a dietician or speech and language therapy (SALT) referral being made, despite Mrs C being assessed at medium risk of malnutrition on 22 November 2023. We have no further evidence of the Trust using MUST to continue monitoring Mrs A’s risk of malnutrition after this.

8. The Trust explained what it has done in response here. Please see this section in the report for details. We are reassured and satisfied here this provides Ms B with the service improvement she seeks.

9. We find the Trust administered antibiotics in line with standards. We acknowledge Mrs C’s family’s frustration at the delay between prescribing and administering of the antibiotic. This was a matter of hours. The drug was not in stock (this is not a failing), it was ordered and then promptly administered when it arrived. Mrs C was at the time on a broad range of other antibiotics treating her infection and we are unable to link any other impact of this delay. We do not uphold this section.

10. We find the Trust acted in line with standards regarding Mrs C’s burial. We do not have enough evidence to say the Trust were made aware it needed to escalate Mrs C’s burial for faith reasons. The Trust completed the necessary death certification paperwork and sent it to its bereavement team promptly post death. We recognise the difference in what the Trust documents and what Ms B tells us, on what the Trust discussed with Mrs C and her family around her death requirements.

11. We are grateful to Ms B for bringing her complaint to us. We know Ms B and her family has been through a very distressing experience which must have been very difficult for them.