University Hospitals of North Midlands NHS Trust

5. Mrs Y complains about the care and treatment provided to her father, Mr Q, by the Trust, between 29 and 31 December 2022 when he was admitted to hospital as an emergency.

6. Mr Q waited 8 hours for an ambulance, 12 hours in the ambulance waiting to be admitted to hospital, and then 16 hours in a hospital corridor due to emergency measures in place at that time. While acknowledging the necessity for these due to extremely high demand for emergency services at that time, Mrs Y says the Trust failed to recognise the urgency of her father’s need and prioritise him correctly.

7. Specifically, Mrs Y says: • the Trust staff who initially examined her father in the ambulance failed to ensure their treatment plan was put into action in reasonable timeframe • there was a shortage of working drip equipment and significant delays addressing the problem, leading to excessive waits for treatment • staff on the overflow corridor failed to recognise her father’s deteriorating condition and act when he became unresponsive, especially in light of his history and how long he had been waiting for some treatment • her father’s leg ulcer dressings were left unchanged for a significant length of time • the Trust failed to provide the antibiotics and fluids set out in her father’s initial triage plan for an excessive length of time • the Trust’s responses to her complaint lacked compassion.

8. Mrs Y says that, because of the long delays these failings caused before receiving active care, her father’s infection took a firmer grip. She says her father’s risk of cellulitis and sepsis complications increased, and he deteriorated to a state where he developed dysphagia. She says this could have been avoided with earlier intervention and this significantly contributed to a worse outcome for him. Mr Q died within three weeks, which she says would have been much less likely if not for how weakened he had become before active treatment started.

9. Mrs Y seeks service improvements and a financial remedy.

10. On 29 December 2022 Mr Q was visited by district nurses to change his leg dressings. He had a history of chronic leg ulcers and prior cellulitis infection. The nurses noted his temperature was very low, he was passing dark urine, and he was unwell and lethargic. His dressings were left in place, and he was advised to call an ambulance. This was done at 11.55am.

11. At the time of Mr Q’s initial care, local NHS services were experiencing extremely high demand for emergency care in the community. The available staff and resources were under strain despite drawing upon all possible extra resources. The Trust had declared a Critical Incident, meaning a level of disruption resulting in the organisation temporarily or permanently losing its ability to deliver critical services as the hospital and its emergency department (ED) was full.

12. This resulted in significant waiting times before Mr Q could receive treatment. We found the timing of events to be slightly different to those set out in the scope, but broadly these covered the same time span. His wait for an ambulance was almost 7 hours. When this arrived and took him to hospital, he needed to be cared for in the ambulance for another 13 hours due to there being no room in the hospital. He was, however, triaged and assessed on board the ambulance shortly after arrival. He was identified as being at risk of sepsis due to an unknown infection, and a plan was made to give him IV antibiotics and fluids.

13. Mr Q was moved to a hospital corridor to await a space in the ED at 8.40am on 30 December 2022, 21 hours after the initial call for an ambulance. Mr Q was cared for on the corridor for a significant length of time. During this period of care Mr Q’s clinical observations were completed periodically and documented as relatively stable, despite the delays in him receiving the planned care. He was also documented as being alert during this time, which is disputed by Mrs Y.

14. However, at 11pm his blood oxygen saturations were noted to have dropped significantly, and increased confusion was noted (Mrs Y says this was present much sooner). His care was escalated, as his clinical observations had now worsened, and he was moved to a cubicle in the main ED area and placed on oxygen to help improve his saturations. Here his leg dressings were changed, and he was reassessed during the night. A CT head scan was ordered to investigate his confusion, and his antibiotics were changed following a chest X-ray result and new symptoms indicating emerging pneumonia.

15. Mr Q was then moved to an inpatient ward at 8.33am on 31 December 2022 where his care continued. Despite his condition initially improving, his difficulty swallowing continued. This was diagnosed as dysphagia (loss of ability to swallow) due to sepsis, following a neurology assessment. He was started on tube feeding due to his risk of aspirating (inhaling into the lungs) food and fluids.

16. Sadly, Mr Q’s condition then started to worsen after 10 days, despite continuous treatment, and he died on 24 January 2023. His cause of death was recorded as sepsis secondary to aspiration pneumonia (respiratory infection caused by accidental fluids or solid entry into the airways) and dysphagia, with ischaemic heart disease and frailty of old age as contributing factors.

20. To better understand the conditions the Trust was operating under at the time, we sought advice from our A&E adviser, who has expertise in contingency planning for crisis management. They reviewed the Trust’s operating procedures at the time of Mr Q’s care, of which we provide a lay overview below.

21. NHS England’s OPEL Framework sets out guidance on how Trusts should respond in times of high service pressures. OPEL sets out a four-tier escalation process for contingency planning at times of high demand on services. The Trust was at OPEL level 4, indicating the Trust was at the highest possible OPEL state of readiness, and had activated all of its contingencies to manage demand on 29 December 2022. This included diverting staff and resources from other departments and bringing in agency staff to cope with demand.

22. Despite these precautions, demand was so high in the ED at that time that the Trust declared a ‘Critical Incident’. We obtained details of all the Trust’s contingency plans and evidence of the measures in place from 29 December. Following careful review of these, our A&E adviser explained that the Trust had exhausted its resources and options beyond OPEL4 and had no further ability to increase capacity to cope with the number of emergency patients arriving at the hospital. We therefore recognise that factors beyond the Trust’s control were significantly challenging its ability to provide its normal standard of service, despite it doing everything it reasonably could be expected to do to manage.

23. NHS England’s Emergency Preparedness, Resilience and Response Framework defines critical incidents as: ‘any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions.’

24. We have taken into account the Trust was in this situation when Mr Q arrived and that its ability to deliver care was significantly compromised. We recognise that resorting to corridor care was not desirable, but the Trust made a decision to minimise the pressures on ambulances, who would otherwise have had to hold patients for even longer periods.

25. Mrs Y raises several specific points in her complaint to us, but her key concern is that her father was in a worse condition than was recognised at the time he was awaiting care. While Mrs Y acknowledges the pressures on services at the time, she says he should have been made a higher priority to receive care as soon as possible, and that the consequences of the long delays he experienced have not been fully recognised by the Trust.

26. Fundamentally, her concern is that if her father had got his treatment sooner, he would not have developed dysphagia and not been weakened by sepsis. Her concern is that these two factors significantly decreased his chances of survival. In considering this it is useful to set out some established facts from the evidence we have available.

27. In looking at Mr Q’s condition over the period in question we have considered his New Early Warning Score 2 (NEWS2) records. NEWS2 is a scoring system based on a series of physiological clinical observations scoring 0 to 3, depending on how far from normal range they are, and then added together.

28. NEWS2 was developed by RCP as a system to standardise the assessment and response to acute illness. It is used as standard practise across the NHS. The total aggregate score indicates a patient’s clinical risk of deterioration at a particular time, and how urgent their need is for intervention.

29. Actions in response to NEWS2 score are graded as follows: • 0 to 4 - low risk (patient can be safely managed by normal ward nursing and medical team without needing urgent escalation) • 5 to 6 - medium risk (increased need for intervention and frequency of observations) • over 7 (or any individual observation scoring a full 3) - high risk (urgent need for clinical intervention as soon as possible).

30. Mr Q’s NEWS2 score when attended at home by the ambulance was 5 and he was taken to hospital. By the time he arrived at hospital his NEWS2 had reduced to 3, and then 2, as his temperature and blood pressure (which had contributed to his high score) improved. This indicates his condition had stabilised significantly by the time he arrived. We have taken this into account in considering our provisional views, as set out below.

Failing to ensure their treatment plan was put into action in reasonable timeframe; and failing to provide the antibiotics and fluids set out in her father’s initial triage plan for an excessive length of time 31. We have considered these two parts of the complaint together, as delays did occur, partly as a consequence of an initial failure to prescribe medication once Mr Q was assessed as needing treatment. Partly this was also not identified sooner due to nursing staff being overwhelmed and unable to check and pick up the error sooner.

32. The Trust has accepted it failed to provide antibiotics and fluids in a timely manner. We recognise there were mitigating circumstances around the Trust’s ability to deliver care at the time, and some question over the severity of the impact from that failure to deliver treatment in line with sepsis guidance.

33. Upon arrival at hospital Mr Q was initially triaged in the ambulance and screened for sepsis prior to being seen by a doctor. It was not possible to move him off the ambulance into the hospital for a significant time, due to the capacity pressures described previously. His screen identified no red flags for sepsis but did identify two risk factors. This means that, at that point, there were no flags to indicate clinical evidence of sepsis, but the signs placed him at moderate risk of developing sepsis later.

34. The Surviving Sepsis Campaign guidelines indicate this should have prompted a ‘rapid assessment of infectious vs non-infectious causes of acute illness, and… to administer antimicrobials within 3 hours if concern for infection persists.’ To meet this guidance Mr Q should have received initial treatment by 10.44pm, at which time he was still on the ambulance.

35. Mr Q was then assessed in the ambulance by a doctor within half an hour of his arrival, at 7.44pm. His risk of sepsis was recognised and a plan for IV fluids and antimicrobials made. The notes also record further work was needed to identify the source of infection to optimise treatment.

36. Mr Q’s chest was clear, and he had no problem breathing or with his O2 saturations, which was reassuring concerning his chest. The initial suspicion for the source of infection was cellulitis from his leg ulcers, or a urinary tract infection as the smell of his urine had been noted to be concerning. He therefore did receive a rapid assessment, in line with the Sepsis guidance.

37. However, our A&E adviser said the attending doctor did not also prescribe the medications to put the plan into action, in line with GMC Good Medical Practice guidance on Good Medical Practice, sections 15 and 16. They said, generally, the clinician who attends the patient and sets their treatment plan should prescribe the medication. This would be necessary to allow nursing or ambulance staff to administer treatment, as neither can prescribe.

38. This was not done in this instance, and so we found the doctor failed to act in line with Good Medical Practice. We recognise staff were operating under extreme pressure at this time, and this may have been a contributing factor.

39. It was possible to move Mr Q off the ambulance by 8.40am. At this point he was still awaiting first treatment. His NEWS2 scores during this period remained at 3 (low risk). Mrs Y’s account indicates that when family members arrived around 2pm he had no IV fitted. The family suspected he still had not had any fluids or antibiotics at all at that point.

40. There is sufficient evidence in the medical records to show Mr Q received an initial first dose of IV Flucloxacillin antibiotics by 12 noon. There is also some indication in nursing notes there had been problems keeping his cannula in place. On the balance of probability, we found Mr Q did receive his initial treatment of antibiotics and some fluids by that point.

41. The records document that Mr Q received regular doses of antibiotics from this point forward. We see no clinical evidence that Mr Q had progressed to sepsis at this point, as his NEWS2 score was still low, but the point at which we can see antibiotics were given is still 13 hours later than Sepsis guidance recommends.

42. The Trust has acknowledged this failing. Its responses say that the delay occurred due to services being overwhelmed and the escalation measures also being over capacity. It accepts the doctor did not prescribe the medications initially, as would usually be the case, and that the nurses did not chase the prescribing up due to extreme pressures on the ED department. It has reiterated to staff the need to ensure timely prescribing has been done. It also explained it does not consider this contributed to Mr Q’s later death.

43. We found there is evidence that the Trust failed to put a treatment plan into action within a reasonable timeframe. The Trust has accepted this but not the impact claimed. We consider the impact, and whether the Trust has done enough to address it, later in this report.

Shortages of working drip equipment and significant delays addressing the problem leading to excessive waits for treatment 44. As mentioned above, Mr Q’s family saw no signs of him being cannulated when they arrived to visit at around 2pm. We were unable to find records to confirm when he was cannulated or given his first fluids, potentially due to staff not having much opportunity to focus on documentation due to the pressures on care.

45. Mrs Y states the ambulance crew said Mr Q was still responsive, talking and drinking water on the ambulance prior to moving into the hospital. We note that a nurse gave him a drink at 9.40am but they identified that he was struggling to swallow and ‘holding drinks in mouth’. From this, we can see Mr Q was likely reasonably hydrated at the point he entered the hospital at 8.40, but his dysphagia was setting in by this point, and he was unable to rehydrate orally from this point.

46. There is some secondary evidence which suggests times when Mr Q was cannulated. A blood sample was taken at 8.41pm the previous evening suggests he was cannulated at that time to facilitate the sample being taken, and the notes at 12pm state ‘IV antibs given 12 MD, Cannula insitu R arm’. Additionally, the prescription charts support that antibiotics were delivered via an IV infusion, not oral or intramuscular injection which would be the only alternative ways of administering.

47. On balance of probability, we think Mr Q did have a cannula fitted prior to his family’s observations at 2pm. This may have been dislodged and refitted at times, but he is likely to have at least received at least some IV fluids prior to their visit at 2pm during those initial hours prior to their visit. These would be necessary to deliver the antibiotics into his body but would not be the generous amounts of IV fluids sufficient for anti-sepsis treatment.

48. The evidence from 2pm onwards is similarly unclear. Mrs Y states the drip was out of charge at 3.22pm when she took a photo. A further litre of fluids was prescribed and started at 3.26pm according to the records. At 3pm the records state ‘IVF infusing, cannula in situ’. However, at 3.30pm Mrs Y says a nurse had to go to find an extension lead to plug in the IV pump due to a lack of available plug sockets to charge the equipment. She says the nurse was gone for a significant time. Eventually, an extension was located in the hospital chaplain’s office, and the IV pump got working again.

49. The lack of documentation does not allow us to identify what times the IV pump was infusing or the length of periods where it was not. The records show Mr Q received his second dose of IV antibiotics at 10.15pm, which indicates the issue must have been resolved by that time.

50. Still, this indicates a period of up to 7 hours where it may not have been possible to provide IV fluids to Mr Q. We note Mr Q’s NEWS2 scores during this period remained at 3 (low risk) which suggests that, even if he was not getting enough IV hydration, it was not resulting in any measurable adverse effect in his vital signs.

51. We recognise the uncertainty this leaves Mrs Y over whether Mr Q received enough IV fluids during his first day in hospital when he was on the ED corridor. It is clear the Sepsis guidance was not met regarding timescales for providing IV fluids, but the impact of this is less certain.

52. The Trust has apologised for the problems getting Mr Q’s drip working but it does not accept this contributed to Mr Q’s later death. It explained the situation unfortunately arose due to the department being overwhelmed, but extra electrical leads have now been placed on the corridors to help manage better in case of future critical incidents.

53. We consider this is a reasonable and proportionate improvement to make. This particular problem could not have been anticipated. Placing patients on corridors was, in itself, an emergency measure turned to as a last resort. The situation appears to have exceeded all contingency plans in place, but the Trust has taken learning from it to make organisational improvements where it can. If a future critical incident did occur that exceeded all OPEL contingency plans, we are reassured there is now extra provision for powering medical equipment on corridors.

54. We agree there was a shortage of working drip equipment and significant delays addressing the problem leading to excessive waits for treatment. We found this should not be considered a resourcing failing, as the lack of working drips was due to factors outside the Trust’s control.

55. We have noted the difficulties delivering IV fluids to Mr Q, and how this may have prevented him being fully hydrated. In relation to the individual impact on Mr Q of not getting enough fluids, we consider this later in this report.

Failing to recognise deterioration and act when Mr Q became unresponsive 56. Mrs Y says her father’s condition was worse than had been recognised by staff on the overflow corridor during his time there. She says his deterioration had not been identified, and this led to escalation of his care being delayed, causing his sepsis to become more entrenched.

57. Escalation would depend on Mr Q’s NEWS2 scores, which should be significantly increased in the event a patient’s level of consciousness is compromised. These remained at 3 until 11pm on 30 December 2022 when they jumped to 7, Mr Q’s care was then escalated, and he was moved to a side room. Mrs Y does not complain about the care following this escalation, but that it should have occurred much sooner.

58. In support of this view, Mrs Y explains that her father was always respectful of NHS staff and his behaviour during this period (he was non-compliant and resisting personal care), when alert, was significantly out of character and a sign of confusion. She said at other times family members witnessed he was slumped and unresponsive, which indicates reduced consciousness. She says his NEWS2 scores were inaccurate due to missing these signs.

59. This is in contrast to the Trust’s interpretation as noted in its records, as staff considered Mr Q’s interactions with the nursing staff to show he was alert. Times when he was unresponsive were considered likely to be due to him being exhausted and sleeping, rather than having reduced consciousness. The Trust did not agree the NEWS2 scores were inaccurate, or that there was a deterioration prior to 11pm that was missed.

60. Our review of the available records shows that, prior to entry to hospital, Mr Q was documented by the ambulance crew as resisting care and not tolerating medical equipment. This was during the period Mrs Y says the crew said he was talking, responsive, and drinking water. We note signs of this in his later records too. We understand he would have been tired, feeling very unwell, and may have wanted to be left in peace to rest at times.

61. On balance of probability, we do not think there is evidence to indicate the nursing staff scored Mr Q’s NEWS2 wrongly during his period of care on the corridor. His resistance to personal care was consistent with his behaviour during earlier times prior to the period on the corridor. This does not suggest a change in behaviour from earlier NEWS2 scores. We are unable to form a view on whether he was unresponsive due to sleeping or some other reason at other times. This would not be possible to determine either way from the available evidence of how he appeared to be at those times.

62. We therefore looked at Mr Q’s other physiological observations (breathing rate, oxygen saturations, if the patient is on oxygen, blood pressure, pulse, temperature) to check for signs of changes which could cause a reduced level of consciousness or new confusion. Mr Q’s NEWS2 scores were consistently 3 during his time on the corridor, prior to the change which prompted his care being escalated.

63. His initial, relatively high, NEWS2 scores recorded by the ambulance crew before moving into the hospital were due to his blood pressure and body temperature being below normal range. These had improved by the time he entered the hospital around 8.40am on 30 December 2022. His later NEWS2 scores reflected that these, and his other physiological observations, were now back within normal ranges for some time. This remained the case until the score documented at 11pm on 30 December 2022.

64. We note all the NEWS2 scores during this period indicated Mr Q’s level of consciousness was not compromised. There is nothing in his other physiological observations suggestive of a deterioration. We have seen nothing in any of the nurse assessments to indicate otherwise.

65. By contrast, there was an identifiable cause of the increase in NEWS2 score at 11pm. Mr Q was observed to have become more confused and less responsive than before. At the same time his oxygen levels dropped significantly, which is a known cause of cognitive impairment. New onset confusion would add another three points to a NEWS2 score, reduced oxygen saturations another 3, and his pulse slightly increasing another 1 point.

66. This brought the NEWS2 score to 7 and prompted immediate escalation of care. Part of this was to put him on oxygen to support his breathing and oxygen saturations. As Mr Q’s infection now suspected to come from multiple possible sources (cellulitis, UTI and/or now also respiratory illness) his antibiotics were changed to respond to this new information.

67. We note these changes would also be flags associated with triggering the sepsis protocol of providing IV antibiotics and fluids. Despite the initial long delays, Mr Q had been on the required treatment for at least 11 hours by this point. Prior clinical information indicated Mr Q was at risk of developing sepsis, but this deterioration marks the first appearance of clinical signs associated with sepsis.

68. The underlying cause of this change was subsequently identified as a chest infection. As noted earlier in this report, Mr Q’s chest was clear initially. This appears to have been a new infection, possibly hospital acquired, that was just becoming symptomatic. From this, we found Mr Q did not significantly deteriorate until some point between his observations at 6.40pm and 11pm.

69. We recognise this is a period of several hours, and Mrs Y’s concern is that her father’s deterioration may have been missed for some time. We note there was a family member visiting from around 9pm who would have been able to alert staff to a deterioration, in the event this started earlier in that timeframe. That this did not appear to happen is reassuring.

70. We have not seen evidence that staff failed to recognise deterioration and act when Mr Q became unresponsive. Staff appear to have acted in line with RCP NEWS2 guidance in assessing his clinical need and his risk of deterioration.

71. On balance of probability, we think it more likely than not that Mr Q’s condition started to deteriorate shortly before that increased NEWS2 score, and this is what prompted the intervention of staff. Based on this, escalation of care looks to have been reasonably timely in the circumstances and in response to a new infection taking hold.

Leg ulcer dressings were left unchanged for a significant length of time 72. The initial district nursing visit to Mr Q at the start of the events in question was arranged to change his dressings. The nurses visited at 11.44am on 29 December 2022 but due to him being unwell they did not change them and instead advised him to call an ambulance. The medical records document the first instance his dressings were changed was 12.30am on 31 December 2022, which is over 36 hours later.

73. The Trust said changing Mr Q’s leg dressings was not prioritised when he was on the corridor due to the lack of nursing capacity given the ongoing Critical Incident situation or the privacy required to complete the task. It says the need to change Mr Q’s dressings was noted when he was moved to a cubicle at 11pm on 20 December 2022 but this was not done initially as managing the deterioration in his condition was prioritised first. It says the delay in changing his dressings would not have worsened his infection further.

74. Our nurse adviser did not agree with this view. They said that there were several clear indications that changing Mr Q’s dressings should have been more of a priority. This includes his history of cellulitis and him being identified as being at risk of developing sepsis from in his assessment on the ambulance, the dressings overdue for being changed, the account from his relatives that they had started to smell, and becoming soaked in urine at some point during his corridor care.

75. Our nurse adviser said there were clear indications Mr Q's dressings needed renewing, but this was not dealt with. On arrival at 8.40am on 30 December, his dressings were overdue for change, and this need would only become more urgent after they were soiled with urine later.

76. Our nurse adviser said a lack of examination and sample taking from his ulcers, meant additional information to aid diagnosing the source of any infection was not collected. Mr Q was suspected of reoccurring cellulitis infection and had been identified as being at risk of developing sepsis. The source of the suspected infection, his leg ulcers, not receiving any personal care to help manage infection would have hindered efforts to treat the cause for a time sensitive condition such as sepsis.

77. Our nurse adviser said this was not in line with NMC’s The Code guidance, specifically: • 1.2 make sure you deliver the fundamentals of care effectively • 1.4 make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay • 2.1 work in partnership with people to make sure you deliver care effectively • 3.1 pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages.

78. Our nurse adviser also did not agree inaction would not contribute to a worsening Mr Q’s infection. They said not changing and dressing his ulcers would increase the level of bacteria entering his bloodstream from any infected skin. Therefore, stating it would not worsen his infection is incorrect.

79. We acknowledge it would not be possible to establish to what extent this influenced Mr Q’s sad clinical outcome, and that he was receiving antibiotic treatment for some time before his dressings were changed. This would provide a level of resistance to a cellulitis infection. We can see the Trust’s statements on this, while attempting to be reassuring, are unsupported. There remains some question over whether changing Mr Q’s dressings sooner may have been a more urgent task than acknowledged by the Trust. It may have at least reduced his discomfort and provided reassurance to his family that he was being managed adequately while he waited for a bed to become available.

80. We uphold this part of the complaint as we found, as NMC guidance was not followed, there is a clear failing. The Trust has not yet acknowledged this or the potential clinical impact. In order to decide if the Trust has done enough to address the impact of this failing, we consider those factors next when looking at the injustice caused, and any recommendations we should consider making.

Trust responses to her complaint lacked compassion 81. As we understand it, Mrs Y’s concerns are that her father died from sepsis after acknowledged delays in initially delivering treatment for that condition when suspected. The Trust’s responses do not agree Mr Q’s death was connected to the delay in starting treatment, as he died some weeks later. We note the Trust does not explain why it came to its conclusion.

82. Mrs Y considers the Trust has not recognised the impact on her family of how potentially damaging the delay was. She says that her father would not have developed dysphagia, or his infection become entrenched, if not for the delays. In her view these two factors increased her father’s vulnerability to aspiration pneumonia, which he died from three weeks later. We recognise that the Trust does not agree with this view of the impact of failings. We do not consider a difference of opinion on this to be a sign of lacking compassion.

83. We see the responses contain a lot of clinical detail, due to Mrs Y asking many specific questions. This led to the responses focusing on the clinical detail of Mr Q’s care rather than addressing the emotional impact on Mrs Y or her family of her loss. Our Principles of Good Complaint Handling do say organisations should be ‘Being customer focused’. We have not identified any aspect of the Trust responses that is not in line with our Principles, so the Trust responses appear to be of an adequate standard.

84. After careful consideration of the Trust’s responses, we found the responses do accept failings where there were mistakes made, apart from in failing to acknowledge the potential impact of delays in treatment and lack of dressing care on Mr Q’s outcome. While we may consider this inaccurate, as we go on to explain in the next section, we do not consider this constitutes a lack of compassion for Mrs Y’s loss, or that the Trust dismissed her concerns.

Consideration of impact from failings 85. We sought input from our geriatrician adviser to help us decide if the established failings in care are linked to Mr Q’s later death.

86. We note from this input Mr Q’s advanced age, frailty and multiple heath challenges prior to his admission. He had limited mobility and a reduced capacity for self-care. He had been unwell for 10 days before an ambulance was called. He also had a history of cellulitis infection in his legs as he had chronic ulcers, which were not healing with time and courses of antibiotics.

87. In this context, frailty refers to a specific health condition associated with aging, where various bodily systems gradually deplete their reserves. Our geriatrician adviser explained this leads to an increased risk of severe adverse outcomes following seemingly minor stressors or changes. This means Mr Q had little resilience to ward off infections or heal from injury.

88. He began to feel unwell over a week before he was hospitalised. During his stay, Mr Q was treated for sepsis of an unclear origin, initially believed to be caused by infected leg ulcers and a chest infection, but possibly also a UTI. The potential for sepsis was identified early but there was a delay in the administration of antibiotics, which the Trust has acknowledged.

89. Significantly, over the following days, Mr Q exhibited some improvement, stating that he felt ‘alright’, with observations and blood tests showing positive changes. This indicates his treatment, while delayed initially, was working and the infection that led to his admission infection had now been brought under control. However, he experienced difficulties with swallowing and oral intake. A neurology consultation concluded that the swallowing difficulties might have been a result of sepsis. The evidence indicates this dysphagia had started before his entry to hospital.

90. Due to this he needed tube feeding to ensure he received sufficient nutritional intake. However, this does not eliminate the risk of aspiration. Our geriatrician adviser cited a comparative study from Archives of Internal Medicine which supports that it is widely acknowledged that tube feeding in elderly patients presents significant challenges. These include aspiration, which could pose a life-threatening risk if it progressed to pneumonia, which in Mr Q’s case it did.

91. Sadly, Mr Q's condition continued to worsen over the following days, leading the palliative care team to conclude during their assessment on 24 January 2023 that he was in the process of dying, and Mr Q died later that same day.

92. Considering the various issues outlined above, we have not seen anything to indicate that an earlier administration of antibiotics would have altered the final outcome for Mr Q or prevented his dysphagia. He may still have died due to his overall frailty and lack of physical reserves, even if he had not lost his ability to swallow.

93. We also note there is evidence Mr Q’s dysphagia had already taken hold at quite an early point. While we acknowledge the account of him drinking water on the ambulance, one of the first things noted by the nursing staff upon him moving into the hospital was his struggle to swallow and him holding drinks in his mouth. This places the onset of dysphagia as happening before the delay in treatment.

94. We acknowledge Mrs Y’s concern that delays in care led to the dysphagia becoming entrenched. We are unable to say, based on the evidence available to us, this permanent loss of swallow could have been avoided if not for the delay. This also means we cannot say her father would not have needed tube feeding or avoided aspiration pneumonia later.

95. There is also some question as to whether the chest infection that became symptomatic during Mr Q’s corridor care was a separate infection to the one he later died from. The first was considered to be community acquired pneumonia, which improved with antibiotics. The second was considered to be aspiration pneumonia thought to be contracted later. This calls into doubt whether there was a single infection that became entrenched due to failing to treat it fast enough. In addition to these infections, Mr Q had repeated cellulitis infections and a suspected urine infection.

96. There is significant evidence to suggest that, sadly, Mr Q’s health and ability to resist infection was failing. This is consistent with our geriatrician adviser’s views on his overall frailty. He was acquiring infections increasingly frequently from different sources, despite increasing use of antibiotic therapy.

97. Taking all of this into consideration, we found we cannot say Mr Q’s death would have been avoidable if not for the delay in treatment. However, we also see the failings we have provisionally identified have left Mrs Y with ongoing uncertainty and distress about whether anything might have been different for her father.

98. This leaves Mrs Y with doubts over how much of her father’s illness and discomfort was avoidable, if not for the delays in treatment and dressing care. While we cannot say Mr Q would have survived if not for the failings, we can say her doubts on this matter could have been avoided.

99. We found the Trust has not acknowledged this impact on her as it has taken the view that the failings did not influence the outcome for Mr Q. We cannot see the evidence available supports a definitive view here, and so Mrs Y is left with questions. This is an emotional injustice to her that remains unremedied.

1. We found that there were significant avoidable delays in providing treatment to prevent sepsis, and in changing soiled leg dressings. We are unable to say these failings contributed to Mrs Y’s father dying several weeks later, as there are too many unknowns to make that link. However, we do consider the length of the delays significant enough to not be able to reassure her we could rule out that possibility.

2. While we did not see seeing evidence of an avoidable death, we can see the doubts she has been left with could have been avoided, if the failings in care had not occurred. This emotional impact will have added to her bereavement. We recognise that the Trust was under significant service pressures at the time of care and this compromised care standards, and that it has accepted many of the failings and taken learning where possible for future crisis management. Nonetheless, we found the Trust does not appear to have adequately recognised the emotional impact of the failings on Mrs Y.

3. We partly uphold the complaint, as the impact is greater than acknowledged but not as severe as Mrs Y feared.

4. We have made recommendations to ensure the Trust recognises and apologises for the avoidable added distress and uncertainty caused by failings in care. We also have made a recommendation for a financial remedy as it is not possible to fully resolve Mrs Y’s doubts over whether a better outcome for her father was lost due to delays in treatment.