The Royal Wolverhampton NHS Trust

6. Miss S complains about the care the Trust provided her mother, Mrs S, in October 2024. She specifically complains the Trust: • failed to provide dialysis • failed to treat high potassium • failed to carry out observations on the night of 30 October • delayed taking her for a CT scan on 31 October.

7. Miss S says the failure to provide dialysis resulted in opiate toxicity. She feels this, and the failure to treat her potassium led to her mother’s stroke and death.

8. She feels the lack of observations and delayed CT scan led to a missed opportunity for earlier intervention or different treatment for her mother’s stroke.

9. Miss S says the loss of her mother caused her father’s health to decline and he sadly passed away. She is left with immense grief and anxiety and suffers flashbacks of her mother being in hospital.

10. As an outcome, Miss S is seeking an admission of responsibility from the Trust, service improvements so others do not suffer, and a financial remedy.

11. Mrs S was in her seventies. She had a background of heart failure, atrial fibrillation (AF- an irregular heartbeat) and end stage kidney failure. She had dialysis three times a week. Dialysis is a medical procedure that filters patients’ blood when their kidneys are no longer able to do so.

12. She had a fall and the Trust admitted her on 29 October 2024. The Trust performed scans which showed a neck injury and a fractured pelvis. She missed her usual dialysis appointment the following day.

13. On 31 October, she had an acute, severe stroke. Staff made the decision to keep her comfortable. She sadly died the next day.

Dialysis 18. Mrs S was dependent on dialysis three times a week and she was due to have it the day after the Trust admitted her.

19. When a doctor in the emergency department (ED) saw her, they did not document the fact she had end stage kidney failure nor her dialysis requirement.

20. Our adviser explained that in general, staff should notify the renal team as soon as they admit a dialysis patient to a hospital.

21. Mrs S’ records indicate no one seemed to be aware of her dialysis until 10pm on 30 October. GMC guidance says doctors should adequately assess patients, taking account of their history. It says treatment should be provided when doctors have adequate knowledge of the patient’s health.

22. Our adviser explained Mrs S had an arteriovenous fistula (a noticeable blood vessel created in the arm, used to connect to a dialysis machine), which would have been obvious when staff performed a blood pressure or blood tests. We have seen no indication that Mrs S was confused on admission to the Trust, so there is no reason she would not have told staff that she was a dialysis patient.

23. A different Trust provided Mrs S’ regular dialysis. The Trust informed us the usual process when dialysis patients are admitted, is for it to inform its own renal unit, but it does not have a specific policy on this.

24. From the Trust’s complaint file, we note there was a renal registrar available that week, but staff did not contact them to discuss Mrs S.

25. Based on the Trust’s usual process, GMC guidance and our adviser’s comments, we have found the Trust failed to notify the renal team of Mrs S’ admission as a dialysis dependent patient.

26. The Trust acknowledged in its complaint response that it should have referred Mrs S to the medical team on admission to the ED. It apologised for the lapse in documentation, omission of a referral and communication. It advised it would share learning at directorate governance meetings.

27. Our adviser explained, if the Trust had referred Mrs S to the renal team on admission, it is likely they would have arranged for her to receive dialysis the following day, in line with her usual requirements. The Trust’s renal team supported this view in its complaint response.

28. We will consider the impact of this failing later in our report.

High potassium 29. On 29 October, when Mrs S was in the ED, she had blood tests which showed a high potassium of 6.2. The Trust’s policy says at this level, staff should check an ECG and monitor blood tests. Our adviser confirmed Mrs S’ ECG showed no concerning features. The evidence indicates the Trust acted in line with its policy on this day. Her repeat blood test showed her potassium lowered to 5.73, requiring no further action.

30. On 30 October, Mrs S’ potassium level was 7.1 at 8.10pm. The Trust’s policy says at this level, staff should check an ECG and provide medical treatment. It says if the potassium is persistently high, or a patient has kidney disease, staff should refer to the renal team.

31. Our adviser explained the doctors followed this policy in part, by providing the first line of medications and requesting an ECG. Staff did an ECG at 9.56pm. Our adviser explained this showed changes consistent with high potassium. This needed further action in line with the Trust’s policy.

32. A different doctor reviewed Mrs S at 10.14pm and prescribed further medications. They noted she was not passing urine and had missed her dialysis appointment. The plan was to continue to treat her medically, repeat her blood tests and arrange dialysis the next day. The medications were successful in lowering her potassium to 6.09. However, the doctors did not refer Mrs S to the renal team as per the policy.

33. The Trust’s complaint response indicates staff did not tell the renal team about Mrs S until 31 October. Our adviser explained staff did not seem to recognise the importance of dialysis in a patient with Mrs S’ condition.

34. We have found the Trust failed to act in line with its hyperkalaemia (high potassium) policy by not contacting the renal team on 30 October.

35. Our adviser explained that if staff had referred her to the renal team, it is likely they would have arranged dialysis for the following day. This is because her potassium settled with medical management, and it is safer to provide dialysis during the day in a stable patient. Unfortunately, the next day Mrs S had a stroke and was too unwell for dialysis.

36. Overall, we have found the Trust failed to contact the renal team on 30 October regarding Mrs S’ high potassium, but there was no impact from this.

Observations on 30 October 37. On the evening of 30 October, Miss S is concerned that staff missed signs of her mother’s stroke. Her medical records show she had observations taken at 5.06pm, 9.18pm, 9.54pm. On the morning of 31 October, she had observations at 3.55am, 6.25am, 7.14am, 8.30am, 8.34am and 8.45am.

38. The NEWS score is a method of assessing patients at risk of deterioration based on their observations. If the score is one to four, the NEWS guidance says monitoring should happen every four to six hours. If the score is five or more, it should be rechecked in an hour. Mrs S’ NEWS score was between zero and four throughout 30 October. Her score went up to five at 6.25am on 31 October, which triggered it to be rechecked at 7.14am in line with the guidance.

39. Mrs S medical records show she had a doctor review at 10.14pm on 30 October. The doctor examined her, and there are nursing entries noting she was settled and comfortable at 4.05am on 31 October. There is a nursing note at 8am indicating Mrs S was drowsy and the medical team were alerted.

40. Having reviewed Mrs S’ medical records and the NEWS guidance, we have found the Trust carried out Mrs S’ observations in line with guidance.

CT scan on 31 October 41. Staff noted Mrs S was drowsy at 8am. Staff gave her naloxone (a drug to reverse the effects of opiates) and she became more responsive. At 8.40am, doctors noted she had new left sided weakness. They requested a CT scan of her head and discussed her with the stroke team. The CT scan took place at 1.14pm and showed an acute stroke.

42. NICE guidance on strokes says staff should perform an immediate scan for patients if they would meet criteria for specific time sensitive treatment, are at risk of bleeding, or have other concerning features. All other patients should have a scan within 24 hours.

43. The stroke team saw Mrs S at 9.55am and determined she did not meet criteria for treatment as the risks outweighed the benefits for her.

44. The Trust did Mrs S’ CT scan within six hours of the onset of her symptoms, so well within the 24-hour target. Our adviser explained, the scan was confirmatory and would not have changed her management.

45. Taking this into consideration, we have found the Trust acted in line with guidance in carrying out Mrs S’ CT scan.

Impact 46. Miss S says the failure to provide dialysis resulted in opiate toxicity. She feels this, and the failure to treat her potassium led to her mother’s stroke and death.

47. We have found the Trust failed to refer Mrs S to the renal team on 29 October and this would have allowed her to have dialysis as planned on 30 October.

48. The Trust prescribed morphine for Mrs S’ pain. The BNF says in renal impairment, clinicians should avoid using or reduce the dose of morphine. This is because its effects are increased and prolonged in these patients. Our adviser explained dialysis clears morphine and so reduces the risk of opiate toxicity.

49. Mrs S’ records show a nurse found she was drowsy at 8am on 31 October. They gave her naloxone to reverse the effects of morphine, which made her more responsive. When the renal team saw her at 11.30am, they noted she had reduced responsiveness and a slow breathing rate. Her pupils were small. They noted she had opiate toxicity and advised staff to give her further doses of naloxone.

50. Miss S was distressed to recognise the Trust had not performed her mother’s dialysis and there had been a missed opportunity to clear her blood of the build up of morphine.

51. If the renal team had been involved earlier, they would likely have advised staff not to prescribe morphine and suggested a drug that was less toxic to manage her pain. When the renal team did see her on 31 October, they gave this advice.

52. Dialysis also removes excess potassium from the blood. If Mrs S had received dialysis as planned on 30 October, we have found she would have avoided the high potassium and opiate toxicity.

53. Her high potassium was managed medically so there were no ill effects of this, but she did require treatment that may have been avoided. The opiate toxicity was reversed by medication, but this did cause short term drowsiness.

54. Our adviser explained Mrs S had a significantly increased risk of stroke based on her underlying conditions. She had atrial fibrillation (AF). This is an irregular heartbeat that can make patients prone to having blood clots. She was usually on blood thinning medication to prevent this, but this had recently been stopped due to her having some bleeding. NICE explains AF increases the risk of stroke five-fold. UKKA explains up to a quarter of patients on dialysis can develop AF and this can lead to a stroke.

55. Our adviser explained it cannot be said with any degree of certainty that earlier dialysis would have prevented Mrs S’ stroke. This is because she had two conditions that greatly increased the likelihood she would have a stroke.

56. We have found the failings by the Trust led to Mrs S requiring medical management of her high potassium, and a period of drowsiness from her opiate toxicity. We have not found these failings led to Mrs S’ stroke or her death.

57. Miss S told us the events leading to her mother’s death were devastating to her and her family. They have had a huge impact on her daily life as she has been trying to process how things might have been different if the Trust took earlier action. We have found the failings contributed to the distress she experienced here, which added to her bereavement.

58. We note the Trust has made some changes since Miss S’ complaint. It now has a renal specialist nurse co-ordinator. They are responsible for reviewing all inpatients to ensure their dialysis is scheduled as appropriate. It has implemented a twice daily alert to identify all dialysis patients it admits. We have considered this and found there are further actions the Trust could take to remedy the impact on Miss S.

1. We were very sorry to hear of the circumstances of Miss S’ complaint, and we extend our sincere condolences on the loss of her mother, Mrs S. She told us of the immense grief she feels, and we understand this has been a difficult process for her.

2. We have carefully considered all the available evidence. We have found the Trust failed to act in line with guidance on arranging dialysis and treating Mrs S’ high potassium. This led to her needing medical treatment and experiencing opiate toxicity. This is a reduced level of consciousness from too much of a strong painkiller, such as morphine.

3. We found the impact on Miss S to be significant distress at witnessing her mother’s deterioration and knowing the Trust did not provide her usual treatment.

4. We have found the Trust acted in line with guidance in carrying out observations and arranging a CT scan when Mrs S had signs of a stroke.

5. We therefore partly uphold Miss S’ complaint. We recommend the Trust apologises to her and creates an action plan. We also recommend it pays Miss S £700 to remedy the distress she has faced.

59. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

60. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

61. We have identified failings in relation to a referral to the renal team and arranging dialysis. We consider this led to the development and treatment of high potassium levels, and opiate toxicity.

62. With that in mind, we recommend that following this final report the Trust: • writes to Miss S by 21 July 2026 to acknowledge the failings we have identified and apologise for the impact of these • pays Miss S £700 by 21 July 2026 in recognition of the distress she experienced, knowing there were inadequacies in her mother’s care prior to her death • explains what action it will take, or has taken, to address these failings by 22 September 2026 - it should do this in the form of an action plan which should be shared with us, Miss S, CQC and NHSE • The Trust should send us evidence it has completed all of the recommendations we have made. We will check the action plan includes the reason for the failing, what the Trust does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.