University Hospitals Coventry and Warwickshire NHS Trust

3. Ms A complains about University Hospital Coventry and Warwickshire’s (the Trust) management of her father, Mr A’s, dialysis treatment between February 2024 and December 2024. Specifically, she has concerns this was due to the Trust prescribing levels of intravenous iron and vitamin D that were too high for her father to tolerate.

4. Ms A says this caused her father to have severe episodes of diarrhoea which she says contributed to his deterioration and death. This caused immense distress and suffering.

5. Ms A would like the Trust to apologise, make service improvements and provide a financial remedy.

6. Mr A was a renal dialysis patient from 2007. Renal dialysis is a life-sustaining treatment for kidney failure.

7. He attended the Trust for regular dialysis, three times a week.

8. On 15 December 2024 Mr A was admitted to the Trust and tested positive for influenza A (an acute respiratory viral infection) and received treatment with oseltamivir (an antiviral medication) and clarithromycin (an antibiotic medication used to treat bacterial infections).

9. He sadly died on 30 December. His cause of death was 1a) chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood as well as they should), 1b) type two diabetes mellitus (a chronic metabolic disorder where the body either resists the effects of insulin or does not produce enough to maintain normal glucose levels).

14. When we look at a complaint we consider whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indications that something went wrong.

15. Ms A told us Mr A developed severe diarrhoea and loss of appetite in February 2024. She said from previous experience she suspected this was because his ferritin (a protein that stores iron inside the cells) level and vitamin D level was higher than he could tolerate. His ferritin test results showed it was 792, but he could only tolerate 400.

16. She told us over the next few months, he continued to have diarrhoea on a frequent basis. Her family kept reporting it to the renal consultant overseeing his care, but the issue was never resolved and she feels this caused his deterioration and death.

17. The UK Kidney Association Clinical Practice Guideline on Anaemia of Chronic Kidney Disease 2020, provides guidance on the use of intravenous (IV) iron in haemodialysis patients. Haemodialysis is a medical treatment for kidney failure that filters waste products and excess fluid from the blood. This guidance recommends IV iron unless ferritin levels are below 700mcg/L.

18. Our consultant nephrologist adviser told us Mr A’s ferritin levels were within the recommended levels of 800mcg/L and when they were outside of this on two occasions in May and July 2024, his dose was appropriately altered. Mr A’s iron prescriptions were therefore in line with the with the above guidance.

19. When Mr A presented in February, he was experiencing vomiting and during the admission reported feeling better and back to his normal self. At his review in April, his records show he was given IV iron fortnightly, instead of oral iron to reduce any chances of stomach upset. In August, Mr A reported no diarrhoea or vomiting and there were no issues whilst he was on dialysis.

20. Following request, the Trust appears to have adjusted Mr A’s iron in September to monthly. The records show his haemoglobin was 103 g/L and his ferritin was 459mcg/L. A doctor explained that low iron can cause anaemia which would run the risk of Mr A needing a blood transfusion and high haemoglobin helped to keep his heart working and made him feel well.

21. Our consultant nephrologist adviser explained it is highly unlikely that a medication which was given monthly, for example, would contribute to severe and daily diarrhoea. He carefully considered Mr A’s test results and explained his haemoglobin and blood count (which is what the iron was prescribed to maintain) were in keeping with the guidance. There is no indication of any adverse management and we have seen no indications of failings in relation to the levels of iron Mr A was prescribed.

22. Our consultant nephrologist adviser highlighted Mr A was measurably a very frail man in his nineties with a wide range of comorbidities. A life expectancy for someone in his clinical condition would generally unfortunately be very poor. The fact that Mr A was still tolerating dialysis for 15 years in the clinical context would exceed clinical expectations.

23. In relation to vitamin D, The Renal Association’s ‘Commentary on the KDIGO guideline on the diagnosis, evaluation, prevention and treatment of CKD-MBD’ states the aim is to keep calcium within the normal range and parathyroid hormone (PTH) less than four times greater than the higher end of the normal range. For the hospital in this case, this would be less than 34 pmol/L.

24. Mr A was given alfacalcidol a form of vitamin D used for kidney patients. This supplement is used to protect bones and enable the body to absorb calcium. It is also used to reduce elevated PTH levels. This was being measured in Mr A’s monthly blood tests and our consultant nephrologist adviser told us the test results show that his PTH levels were at an acceptable level (between 16-56). He explained the local target would be less than 34. Higher than target levels suggest that he was not being given excess vitamin D. His calcium levels were also reasonable and within normal range. This supports there is no evidence Mr A was receiving an inappropriate prescription of vitamin D and we consider his management was in line with guidance.

Conclusion

25. There is no evidence to suggest there were any issues with Mr A’s dialysis management, iron or vitamin D levels that caused him to suffer with diarrhoea. As mentioned above, Mr A was a 90 year old patient with a range of comorbidities who was very frail. He unfortunately became very unwell with an infection. There is no evidence to support his dialysis management was linked to any deterioration. Therefore, we will not be considering this complaint further.

26. We thank Ms A for bringing her complaint to us and the detailed information she provided about her concerns. We understand this period was very difficult for her and we know how important her complaint is. We hope the explanations in this statement provide some reassurance about the clinical care Mr A received.

1. We have carefully considered Ms A’s complaint about University Hospitals Coventry and Warwickshire NHS Trust. We have seen no indication that anything went wrong in relation to the prescribing levels of intravenous iron or vitamin D, therefore we have decided not to consider her complaint further.

2. We thank Ms A for sharing her concerns with us. We recognise the events cause Ms A considerable ongoing upset and distress. We hope our decision does not cause any further distress.