St George's University Hospitals NHS Foundation Trust

4. Mrs R complains about the care her mother, Mrs O, received from St George’s University Hospitals NHS Foundation Trust in December 2024 before she sadly died on 6 May 2025. She complains during a dialysis session on 11 December 2024, the machine malfunctioned and she lost a circuit (lost a pint of blood). Mrs R says they were not made aware of this until her 3 monthly review on 31 January 2025 when the nurse said this had happened.

5. Mrs R says due to the blood loss, her mother’s health declined and her haemoglobin (Hb) levels were very low compared to usual. She says during the last few months of her life she had no energy, was always tired and lost her strength and appetite. She also dislocated her shoulder and whilst she says she does not know if the blood loss contributed to this, she believes if they had been told about what happened sooner, she could have sought medical advice to help improve her health and quality of life. Mrs R strongly believes the blood loss contributed to her mother’s death.

6. As a result of bringing this complaint to us, Mrs R is seeking service improvements in the form of training to better deal with these types of situations.

7. Mrs O suffered with Polycystic kidney disease since 1998 and had been a dialysis patient at the Trust for just over 7 years before she died.

8. Her daughter, Mrs R says during a dialysis session on 11 December 2024, the machine malfunctioned and she lost a circuit (lost a pint of blood).

9. Mrs R says they were not made aware of this until her mother’s 3 monthly review on 31 January 2025 when the nurse said this had happened.

10. Mrs R complained to the Trust on 20 May 2025 and the Trust sent its response on 12 August 2025. Mrs R brought the complaint to us on 27 August 2025.

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are sings the organisation has got something wrong. We have done this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

15. Complaints give us a valuable insight into the organisations we investigate, and we recognise this was a very distressing time for Mrs R and her family. We would like to thank her for sharing her experience with us.

16. Mrs R says during her mother, Mrs O’s, dialysis session on 11 December 2024, the machine malfunctioned and she lost a circuit (lost a pint of blood). Mrs R says they were not made aware of this until her mother’s 3-monthly review on 31 January 2025 when the nurse said this had happened.  17. Mrs R says due to the blood loss caused by the machine malfunction, her mother’s health declined and her Hb levels were very low compared to usual. She says during the last few months of her life she was always tired and lost her strength and appetite. She believes if they had been told about what happened sooner, she could have sought medical advice to help improve her health and quality of life. Mrs R strongly believes the blood loss contributed to her mother’s death.

18. In its complaint response, the Trust says it could not find any record of any dialysis session being terminated early due to a clotted circuit, records of lost blood circuits, or inability to reinfuse the circuit. It says staff at the dialysis unit routinely ask every patient if they have bleeding or bruising prior to giving them Fragmin (a low molecular weight heparin used as an anticoagulant to thin the blood and prevent and treat blood clots) which supports the circuit by preventing clotting during treatment.

19. The Trust says the records show Mrs O did not report any bleeding, but she reported pain, often in her right shoulder. It says during December 2024 staff at the dialysis unit were consistently reporting Mrs O was starting to need the support of a wheelchair rather than mobilising by walking either with or without support which indicated increased frailty.

20. The Trust says its consultant recalls during the routine review on 31 January 2025 it was noticed by the doctor that Mrs O’s Hb levels had dropped since December and asked whether it could be related to a ‘clotted circuit’, to which the doctor agreed ‘could’ have been possible.

21. The records from the dialysis treatment Mrs O had on 11 December 2024 show it was uncomplicated. Mrs O’s observations were recorded as stable and there was no recorded clotting of the circuit or blood loss. Hourly checks were done, her vital signs were stable, and Mrs O was able to go home afterwards.

22. Our adviser says a patient’s haemoglobin is checked pre-dialysis only and can give artificially high or low levels if checked post dialysis as major body fluid and substance changes happen during dialysis which only settle after a few hours post-dialysis. Therefore, there are no records of Mrs O’s Hb levels immediately after dialysis.

23. The records from the review appointment on 31 January 2025 show the consultant noted Mrs O was feeling more tired than usual and shorter of breath and had a lower Hb level (87 with the normal being 115–150 g/L for women), but not at a level that a blood transfusion would usually be required. The doctor increased her dose of NeoRecormon (treatment for anaemia) to 2000 units twice a week and agreed to monitor how this went.

423. The records show Mrs O’s haemoglobin (blood count) levels then slowly but steadily went up after January 2025. On 22 January, 7 February and 3 March 2025, her Hb level was recorded as 87. On 10 March 2025 it was recorded as 90 and then on 2 April it was recorded as 104 which was within her expected target range.

25. Having reviewed the medical records, our adviser says the dialysis treatment carried out for Mrs O on 11 December 2024 was routine and uncomplicated.

26. Section 1.7.1 of NICE guidance on diagnosing and assessing anaemia says consider investigating and assessing anaemia in adults, children and young people with chronic kidney disease if their haemoglobin (Hb) level falls to 110g/litre or less or if they develop symptoms attributable to anaemia (such as tiredness, shortness of breath, lethargy and palpitations).

27. The Government dialysis guidance and the NHS Standard Operating procedures (SOPs) say to document and report any dialysis incident as appropriate.

28. We can see from the records that no incident was documented or reported as having happened. Therefore, we have seen no evidence to suggest that the dialysis machine malfunctioned on 11 December.

29. Our adviser says haemoglobin can drop due to multiple reasons for example low iron levels, associated infection, any other systemic illness like myeloma which is an abnormal protein in blood. Therefore, Mrs O’s drop in Hb in January does not mean that there was an issue with the dialysis in December.

30.We can see from the review Mrs O had in January that the consultant considered Mrs O’s symptoms combined with her drop in Hb level and sent her for investigations as per the above NICE guidance.

31. Mrs R says they were told in January that the machine had malfunctioned. We have seen nothing in the medical record from Mrs O’s review on 31 January 2025 to support Mrs R’s recollection of being told the machine had malfunctioned during the dialysis appointment on 11 December.

32. We can see from the Trust’s complaint response that at the review appointment the doctor suggested it was possible that there could have been an issue with the dialysis in December, however they did not say that this had happened. We understand that this may have caused some confusion.

33.We have considered the evidence available including the records and accounts from all involved and have found nothing to indicate Mrs O’s drop in Hb levels was as a result of a machine malfunction during her dialysis session. We consider the Trust investigated and treated Mrs O’s drop in Hb levels appropriately and in line with the above NICE guidance, which did lead to an increase in her levels.

34. We understand this may not be the outcome Mrs R had hoped for, and it is not our intention to cause her any further distress. We hope our explanations go some way to reassure Mrs R that her concerns have been taken seriously.

1. We have carefully considered Mrs R’s complaint about St George’s University Hospitals NHS Foundation Trust (the Trust). We were very sorry to hear about the circumstances of the complaint and the sad loss of her mother, Mrs O.

2. We have not seen any indications of failings in relation to the actions of the Trust during Mrs O’s dialysis session in December 2024.

3. We thank Mrs R for bringing her concerns to our attention. We hope this statement reassures her we have considered this matter fully and carefully before reaching our decision to take no further action in relation to her complaint.