Blackpool Teaching Hospitals NHS Foundation Trust

4. Miss L complains about the care and treatment provided by the Trust during her first admission and later attendance at its Emergency Department (ED) in early December 2024. She specifically complains the Trust:

• falsified her medical records • offered her a blood thinning injection, despite concerns of a brain bleed • removed her 24–hour Holter monitor too early against her and the doctors’ advice • suggested her symptoms were due to psychotic episodes without formal psychiatric assessment or involvement of its mental health team • discharged her too early • made an unfounded safeguarding referral about her partner • ED staff were slow to respond to her deterioration of health while in the waiting area and gave the impression her symptoms related to her mental health rather than physical.

5. She says the offer of a blood thinning injection was a potentially dangerous action. She explains the removal of the Holter monitor too early resulted in not recording a significant cardiac event, potentially delaying her diagnosis of Postural Orthostatic Tachycardia Syndrome (POTS).

6. Miss L says the Trust’s suggestion that she may have had a psychotic episode caused her distress and detracted from the investigation of her physical condition. The early discharge resulted in her readmission to the ED the day after.

7. She explains the actions of the Trust resulted in a significant impact on her and her partner’s mental health, as well as having a negative effect on her children. She explains her partner received treatment for post-traumatic stress disorder (PTSD). She says her work and income has been negatively affected due to the lack of diagnosis at the time. She says she incurred financial costs from seeking private clinical investigations due to her loss of trust in the hospital.

8. Miss L says the safeguarding referral caused additional stress and worry during an already very difficult time for both her and her partner. The lack of compassion, poor standard of care, and inconsistent support led to disrupted sleep and exacerbated her partner’s bowel issues, which ultimately resulted in a diagnosis of irritable bowel syndrome (IBS).

9. Miss L would like, an acknowledgment of what went wrong, apology for the impact caused, service improvements to minimise the risk of this happening again and a financial remedy.

Medical records

14. Miss L complains the Trust falsified her medical records. She refers to clinicians wrongly recording she refused skin checks and documented incorrect recording of her blood pressure (BP). She explains an incorrect score was entered on her NEWS2 chart, which was only rectified after she and her partner intervened.

15. Within the Trust’s complaint response dated May 2025, it said the intentional rounding charts show multiple entries that record ‘patient states skin intact’. It said that on three dates during her admission in early December 2024, the body maps record that Miss L refused a full skin check.

16. Regarding the BP recordings, the Trust said the observation charts are legal documents and cannot be altered. It explained that unfortunately it is unable to determine what was incorrectly charted, but it is has reminded staff of the importance of correct documentation.

17. On review of the observation charts [NEWS2], the Trust said there were no changes made to the recording of Miss L’s observations however, there were alterations made to the total score, where the staff member had unfortunately calculated an incorrect score. It said there is currently training that is being rolled out in the Trust around observations and it will ensure that staff on the unit attend the training.

18. It acknowledged Miss L’s comment that she made staff aware of errors at the time and apologised staff did not rectify the errors immediately or clarify why they did not.

19. There are two NEWS2 scores recorded during her admission in early December 2024 which shows an alteration to the total score from 0 to 1 (low risk), the rest of the scores are 0. Miss L and the Trust both confirm there was a mistake in the total score and this was rectified after it was brought to the staff’s attention.

20. We understand Miss L’s concerns. Because the score was corrected after it was brought to the staff’s attention, we do not consider the isolated mistake was so significant to indicate a failing. The Trust acknowledged the mistake, apologised and has put in place service improvements to minimise the risk of this happening again.

21. Regarding the BP readings and skin check documentation, we do not consider there is sufficient evidence which demonstrate these are incorrect. Medical records are a legal document. The readings taken by the staff would more than likely have been taken at the time of the observation. The BP readings - recorded within the observation charts - show they were taken at different times of day, throughout Miss L’s admission by different members of staff (based on the different signatures on the charts).

22. In relation to the skin check records, the intentional rounding documentation shows at least two different staff (based on the different signatures and handwriting) recorded four occasions where Miss L declined a skin check. These were on four different days at different times. The weight of the evidence does not indicate a failing.

23. We cannot require an organisation to amend medical records when a patient disagrees with their contents. However, Miss L can ask the Trust to add an addendum to her records. If she wants to pursue this further, she could raise this matter with the Information Commissioners Office (ICO) or the Courts.

Blood thinning injection

24. Miss L complains the Trust offered her a blood thinning injection, despite concerns of a brain bleed. She says this occurred during her admission in early December 2024.

25. Within the Trust’s complaint response, it said the consultant reviewed Miss L’s medical records and confirmed there is no mention of suspected bleeding. The working diagnosis since her admission in early December was ‘collapse (blackout) query cause.’

26. The Trust said it only prescribed Miss L two medications when she was in hospital, in addition to her regular medications. These were propranolol for her heart rate and enoxaparin, a blood thinning injection. It explained enoxaparin is a routine blooding thinning injection that is prescribed to a patient while they are in hospital to prevent blood clots.

27. The relevant guidance is NICE: NG89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. This says clinicians should:

‘Assess all patients to identify the risk of venous thromboembolism (VTE) and bleeding… Balance the person's individual risk of VTE [venous thromboembolism] against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to surgical and trauma patients. [2018].’

28. Pharmacological thromboprophylaxis is a set of medications to prevent blood clots.

29. The medication chart shows the Trust prescribed 40mg enoxaparin, during her admission. Staff documented doses as ‘missed’ or ‘withheld’ on a couple of days during the early part of her admission but administered later.

30. Our adviser said although there was initially a concern about a possible bleed on the brain when Miss L attended the Trust the first time - prior to her admission - in early December 2024, clinicians ruled this out following a computed tomography (CT) head, lumbar puncture and CT venogram (helps to detect conditions such as blood clots).

31. CT scans are highly detailed X-ray tests. CT venogram clearly assesses the vessels in the brain and a lumbar puncture removes a sample of the fluid around the spine and brain. The Trust carried this out to assess for blood cells that should not be present. The results were normal.

32. Our adviser said by the time of Miss L’s second attendance and admission in early December, the Trust was not considering a brain bleed as a possible diagnosis. To reduce the risk of hospital acquired deep vein thrombosis or pulmonary embolism (blood clots which can be fatal that develop during a hospital stay), the Trust prescribed Miss L with enoxaparin in line with the above NICE guidance.

33. We are sorry to learn of Miss L’s complaint. We have carefully considered all the relevant evidence. This shows the Trust initially considered whether Miss L had a bleed on the brain during her first attendance at the Trust in early December. However, it ruled this out following investigations. The Trust therefore did not consider this as a possible diagnosis when it admitted Miss L a few days later. We consider it prescribed Miss L with blood thinning medication in line with NICE guidelines. There is no indication of a failing.

24-hour Holter monitor

34. Miss L complains the Trust removed her 24–hour Holter monitor too early against her and the doctors’ advice. She says this occurred during her admission in early December 2024.

35. The Trust explained it fitted Miss L with a 24-hour heart monitor in early December, which it removed after 18 hours as the device was needed by its Cardiac Investigations Team. It said the recording results were reassuring and showed nothing of note.

36. It said the consultant who saw Miss L was reassured after looking at her heart recording that an occasional fast heart rhythm was captured. However, no serious heart rhythm issues were noted. This was discussed with the cardiology team, and they were happy to discharge Miss L.

37. Since being seen by its Cardiology Team during Miss L’s admission, the Trust explained the plan was followed through to perform an inpatient echocardiogram (scan that looks at the structure of the heart) and outpatient tilt table test (procedure to check how the body responds to standing upright for a long time).

38. The Trust said it was sorry the 24-hour heart monitor did not remain with Miss L to catch her episode and for any upset caused. It explained a further heart tape recording for 48 hours was undertaken in February 2025 as an outpatient.

39. A 24-hour tape is a procedure where electrodes are attached to a patient to record an electrocardiogram (reading of the electrical signals of the heart) for a 24-hour period. It is performed to assess for potential arrythmias (abnormalities in heart rhythm) that may not be there all the time.

40. Our adviser says it is clearly documented in the medical notes that the 24-hour tape was removed after 18 hours, which is referenced several times in the notes and also on the 24-hour tape report. However, in the Trust’s response, it clarified this was the decision of the cardiology team, not the medical team treating Miss L.

41. Miss L subsequently underwent a 48-hour electrocardiogram (ECG) in February 2025 as an outpatient, under the care of the cardiology team.

42. Our adviser said that although it would have been ideal that the initial investigation would have been allowed to complete the full 24 hours, in this case the equipment was needed by the cardiology team who would have been able to justify this decision.

43. The on-call cardiology registrar also reviewed Miss L as an inpatient during her admission who referred to POTS (postural tachycardia syndrome - an abnormality of the nervous system resulting in issues with heart rate and blood pressure which can lead to the symptoms Miss L was describing). They also suggested an inpatient echocardiogram (a focussed ultrasound scan looking at the heart for structural abnormalities), which the Trust undertook during the admission and was normal.

44. Our adviser said the Trust appropriately referred Miss L to the cardiology team who assessed her both as an inpatient and continued to investigate her as an outpatient.

45. Our adviser said, there is no specific guidance regarding removal of these devices early. In Miss L’s case it was removed by the cardiology team who were suitably reassured by the findings. They would have had a look at the tape prior to authorising removal to make sure that no events had been recorded.

46. We recognise Miss L’s concerns about the Trust removing the monitor early. However, we cannot say the Trust did anything wrong. This is because there is no specific guidance to say a 24-hour heart monitor cannot be removed early. Prior to removal, the cardiology team reviewed the readings, were reassured by the findings and therefore considered it safe to remove the monitor.

47. Even if we found an indication of a failing, we cannot say there was any clinical impact.

48. Miss L explains the removal of the Holter monitor too early resulted in not recording a significant cardiac event, potentially delaying her diagnosis of POTS.

49. Our adviser explained that POTS is a chronic condition that can be difficult to diagnose. Confirming the diagnosis is usually done as an outpatient as it includes tests such as a tilt table that often have a significant waiting list. An ongoing stay in hospital is not required once other more acute conditions have been ruled out.

50. Although the tape was not completed for the full 24 hours, our adviser said the report was reassuring. There was no clinical impact.

Symptoms

51. Miss L complains the Trust suggested her symptoms were due to psychotic episodes without a formal psychiatric assessment or involvement of its mental health team.

52. Within the Trust’s August 2025 complaint response, it acknowledged Miss L’s frustration with the suggested diagnosis of ‘psychotic symptoms’ and explained that functional symptoms can sometimes be severe and affect the quality of life. It said in an attempt to obtain a correct and final diagnosis, functional cause (where nothing is wrong with the body systems) is usually considered among other causes. This is where anxiety or stress can cause significant body symptoms.

53. It said its Neurologist also suggested this during Miss L’s admission. Its Neurology team suggested this seems to be anxiety related and appeared to be ‘panic limb parathesis’ (paresthesias is abnormal sensory symptoms typically characterised as tingling, prickling, pins and needles) and advised to increase the dose of amitriptyline (medication to help treat, nerve pain, depression for example).

54. The Trust apologised for the miscommunication and if this gave Miss L the impression this was a final diagnosis. It explained it was one of the considerations that were subject to confirmation.

55. The medical records show an entry which references a neurology review (remote). The neurologist considered Miss L’s symptoms to be related to anxiety, with possible migraine.

56. There is documentation comparing her experience to ‘panic limb paraesthesias’ which can be triggered by anxiety. They recommended no further investigation was needed as she had undergone significant tests, and that she should increase her dose of amitriptyline (an antidepressant that also helps with pain and symptoms causing nerve symptoms, that can take a while to get to the optimal dose). Our adviser said there is no mention of psychosis in this entry.

57. There is further reference within the medical records to a possible psychological cause of Miss L’s symptoms (along with other options) in a consultant ward round during her admission. Again, there is no reference to psychosis.

58. Our adviser said that neither of these entries mention a psychiatric diagnosis. There are conditions which cause significant symptoms for which no underlying physical cause can be found. Not all of these patients need an acute review by a psychiatrist.

59. Our adviser said the Trust extensively investigated Miss L as an inpatient, which continued under the care of the cardiology team as an outpatient. There was no delay in any of the investigations it carried out, nor was there evidence the medical team considered her to have a psychiatric illness.

60. We recognise Miss L questioning whether the Trust suggested her symptoms were due to psychotic episodes without a formal psychiatric assessment or involvement of its mental health team. Informed by clinical advice and relevant medical records, we are of the view the Trust did not consider Miss L had a psychiatric illness but instead was appropriately exploring alternative explanations for her presentation.

Discharge

61. Miss L complains the Trust discharged her too early in early December 2024.

62. The Trust said it discharged Miss L after a review by the ward consultant who documented she was medically optimised to go home. There was an extensive safety netting plan in place that was discussed with Miss L which included the cardiology plan, what to do in case of reoccurrence of symptoms, discussion around the new medication propranolol and what to do in relation to driving.

63. It said there was no acute reason to keep Miss L in hospital as further management could be provided in an outpatient setting.

64. The relevant guidance is:

• GMC: Good medical practice. This says doctors should:

‘adequately assess a patient’s condition, promptly provide (or arrange) suitable advice investigation or treatment where necessary…propose, provide or prescribe drugs or treatment.. that meet their needs….consult colleagues or seek advice from supervising clinician where appropriate…refer a patient to another suitability qualified practitioner when this serves their needs.’

• NHS England: Statutory guidance: Hospital discharge and community support guidance, updated January 2024. This says clinicians should:

‘support people to be discharged in a timely and safe way as soon as they no longer require care in NHS acute hospitals.’

65. Our adviser said the Trust thoroughly investigated Miss L, with specialist reviews during her admission. This is in keeping with collaborative working outlined in the GMC guidance.

66. Any acute issues were ruled out, and the Trust appropriately determined it should continue its investigations of Miss L as an outpatient. This was ensured with a clearly documented referral to cardiology.

67. Our adviser explained that unfortunately, some chronic conditions will have relapsing symptoms. These can continue for long periods of time. However, it is not practical to keep patients in an acute medical setting for the duration, despite the fact that the patient may complain of ongoing symptoms.

68. The role of an acute hospital medical team is to assess and rule out acute life-threatening conditions that require inpatient treatment. Our adviser said Miss L underwent this process and the Trust discharged her appropriately in line with NHS guidance, with the right safety netting advice. Her investigations continued as an outpatient under the care of the cardiology team.

69. We acknowledge Miss L’s concerns on whether the Trust discharged her too early. Taking into account the relevant evidence, we consider the Trust discharged her in line with the NHS guidance. We cannot be critical of the Trust.

Safeguarding referral

70. Miss L complains the Trust made an unfounded safeguarding referral about her partner.

71. Within the Trust’s complaint response, it said it has a duty of care to ensure patients are free from harm both in hospital and at home. If concerns are escalated or it feels there is a possible abuse, it must raise an incident to its safeguarding team who will review this. It said if staff have any concerns around a patient’s safety, they have a duty to report them and escalate to the correct teams to ensure patients are safe.

72. The Trust apologised if Miss L felt the timing of this referral was when her partner had stated he was going to raise a complaint as this was not the case. The concerns were escalated to safeguarding as soon as staff were concerned, and the correct actions were taken. It apologised if this was not explained to her and for any stress and upset this safeguarding referral caused Miss L and her partner.

73. When we investigate complaints about safeguarding referrals, our general position, is that we do not go further than to ascertain whether a referral was made in line with the relevant guidance. We do not investigate the details of the referral, but whether the organisation – the Trust in this case – had concerns and acted upon them.

74. The Trust’s Safeguarding Adults Guidance and Procedures explains that staff at the Trust must act on any concerns they have about an adult who may be at risk of, or suffering, abuse or neglect. It explains that ‘Sharing of information is vital for early intervention to ensure that adults with care and support needs get the services they require….In all situations where an adult is considered to be at significant risk of harm a safeguarding concern must be made in their best interest.’

75. A concern that an adult at risk is or could be abused may have arisen from …. ‘An observation of the behaviour, the presentation of the adult or the circumstances within which they find themselves.’

76. An ‘adult at risk’ is defined in the Care Act 2014, as a person aged 18 and over who:

• has care and support needs • is experiencing or at risk of abuse and neglect • is unable to protect themselves from abuse or neglect because of their care and support needs.

77. During Miss L’s December 2024 admission a nurse recorded that Miss L’s partner had taken an ‘obs’ machine into Miss L’s bed area and closed the curtains. On speaking to Miss L’s partner, the nurse documented he said Miss L was not feeling well and he was going to do the obs. The nurse asked him not to do this, but to inform nursing staff.

78. The nurse then recorded that Miss L’s partner questioned the nurse why they, as Miss L’s ‘carer’, could not take observations. The nurse explained to Miss L’s partner that ‘we would never allow any ‘carer’ to undertake any kind of medical observations.’ It is recorded that Miss L’s partner said Miss L did not like to disturb staff. The nurse then spoke to Miss L but recorded that her partner kept answering for her and that she was tearful throughout the conversation.

79. The notes indicate the nurse reported their concerns to the Trust’s Safeguarding Team. On the following day the safeguarding team spoke to Miss L.

80. The evidence shows the nurse had concerns and acted upon these in line with the Trust’s own safeguarding policy. There is no indication of a failing.

Emergency department (ED)

81. Miss L complains that a day after she was discharged from the Trust she attended the ED. She says staff were slow to respond to her deterioration of health while in the waiting area and gave the impression her symptoms related to her mental health rather than physical.

82. In health cases, section 4(4) and (5) of the HSC Act 1993 prevents us from conducting an investigation unless we are satisfied the complaints process has been used and exhausted, or it was not reasonable to expect the complainant to have done so.

83. There is no evidence that Miss L raised these concerns in her initial or second complaint to the Trust. She did not raise this in the complaint form, and the Trust did not refer to these complaints in its responses.

84. In line with the HSC Act, we cannot investigate this aspect of Miss L’s complaint. This is because there is no evidence she raised this with the Trust and given it opportunity to respond. Her complaint is not yet ready for us.

85. The HSC Act 1993 (Section 9(4)) also says we cannot accept a complaint if it is made more than a year after the day on which the person aggrieved first had notice of the matters in the complaint, unless we consider it reasonable to do so.

86. Even if Miss L raised this with the Trust now and brought her complaint to us, it is more than likely we could not investigate. This is because the complaint is significantly outside of the statutory time limit time for us to investigate, in line with the HSC Act 1993.

87. We are sorry to learn of Miss L’s complaint about the Trust and the impact this had on her. Our primary investigation decision is not made without recognition of the impact these events have had on her and her family, and we are sorry if our decision causes any further upset. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. We are sorry to learn of Miss L’s experiences with the Trust. We acknowledge the difficult circumstances around this complaint, and the impact this has had. We acknowledge this was, and continues to be, a difficult time for her and her family.

2. We have carefully considered the complaint about the Trust. Having done so, and for the reasons set out in this statement, we have decided not to investigate this complaint further.

3. Our decision is not made without recognition of the distressing circumstances around the events.