Walsall Healthcare NHS Trust

5. Mr A complains on behalf of his wife, Mrs A, about the care and treatment she received from Walsall Healthcare NHS Trust (the Trust) in May 2020. He complains the Trust:

• discharged Mrs A from A&E on 13 May 2020 before she had fully recovered • refused to send Mrs A to Hospital A to receive dialysis treatment • wrongly put Mrs A on end-of-life care, and communicated this inappropriately with Mrs A and the family • PALS did not respond to his complaint in a timely way and • took too long to arrange the second resolution meeting and did not follow through after agreeing to hold it.

6. As a result of these failings, Mr A states the Trust’s actions resulted in the premature death of his wife, as he believes his wife could have lived for at least another 12 months. Mr A says he has experienced significant trauma and emotional distress, which has affected his physical and mental health. He also says the prolonged complaint process has caused him further distress and left him unable to move forward with his life.

7. As an outcome to his complaint, Mr A is seeking a written apology, acknowledgement of failings and evidence of the implementation of service improvements. He also seeks financial remedy for the emotional distress caused by the Trust’s actions, and the delay in the Trust’s complaint handling process.

8. Mrs A was a renal patient for over 10 years at Hospital A. She had heart issues, emphysema, Multiple Sclerosis and was registered blind.

9. On 13 May 2020, during one of her routine dialysis appointments, Mrs A’s blood pressure dropped. She was taken by ambulance to hospital as her blood pressure could not be normalised. She was discharged home the same night.

10. Mrs A became unwell at home. She was taken back to hospital via ambulance, where she was admitted. Mr A had requested Mrs A be moved to another hospital, but this was denied due to Mrs A’s blood pressure and health. Mrs A was put on end-of-life care on 14 May 2020. She sadly died on 20 May 2020.

11. Mr A first raised concerns about his late wife’s care with the Trust’s Patient Advice and Liaison Service (PALS) in July 2020. PALS responded in August 2020, but Mr A remained unhappy with the response and the Trust’s handling of his concerns.

12. In December 2020, Mr A contacted his Member of Parliament (MP) for support, and his MP sent the formal complaint to the Trust. The Trust sent its final response in February 2021, and Mr A received this in March 2021.

13. Mr A went back to the Trust with further concerns, and the Trust arranged a resolution meeting to discuss things further. The first meeting took place in September 2021, during which the Trust agreed to arrange a follow-up meeting to address the outstanding matters.

14. Over the following months, Mr A and his advocate repeatedly contacted the Trust to ask for updates and dates for the further meeting. Although the Trust said it would provide new dates, no meeting was arranged.

15. Mr A’s advocate continued to pursue updates throughout 2022 and 2023, and the Trust gave minimal responses. The Trust later confirmed a new meeting date in early 2024, but this was subsequently cancelled by the Trust.

16. Mr A and his advocate continued to ask the Trust for progress and alternative dates. In March 2025, the Trust sent a further written response, apologising for the delay and acknowledging it had not followed up on earlier commitments. Mr A brought his complaint to us, saying the Trust had not resolved his concerns and had taken far too long to respond to his complaint.

20. Before we decide if we should investigate a complaint in more detail we look at whether there are signs an organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing.

21. When we see indications of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try and put things right.

Discharge from A&E

22. Mr A says the Trust discharged Mrs A from A&E on the night of 13 May 2020 before she had recovered. He says he did not think she was well enough to leave hospital, but he trusted the clinicians treating her. Because of COVID-19 restrictions, he had to wait outside the hospital and could not be with her.

23. Mr A says Mrs A looked unwell on the journey home and he wanted to return to hospital, but she wanted to go home. He says that once they arrived home, she struggled to walk and became seriously unwell, so he called an ambulance. She returned to hospital within hours and was admitted.

24. Mr A believes the Trust should not have discharged Mrs A and that this would have avoided her deterioration and readmission.

25. The records show Mrs A attended A&E at about 7.30pm after becoming unwell following dialysis. She had low blood pressure of 67/44 mmHg, and staff treated her with fluids.

26. Staff also carried out regular observations, blood tests and an ECG, and a clinician reviewed the results. Mrs A had an IV with fluids to help increase her blood pressure. Staff recorded her chest was clear with no added sounds and her abdomen was soft and non-tender. The initial impression was near-fainting due to dehydration following the dialysis.

27. NEWS is a tool clinicians use to identify patients at risk of deterioration. The records show staff considered Mrs A’s condition had improved. At 7.30pm when Mrs A attended A&E, her NEWS score was 4, which indicates a patient at medium risk of clinical deterioration. Mrs A was reviewed by the A&E consultant at 8pm.

28. At 9pm Mrs A’s NEWS score was 1, which indicates a low risk of deterioration, and by 9.45pm it had increased to 3, with a note for urgent review by a doctor. A NEWS score of 3 classifies a patient as low to medium risk and requires review by a ward-based doctor.

29. Mrs A was reviewed by a ward-based doctor at 10pm. The notes document Mrs A said she ‘feels better’. It said her bloods were checked and observations taken. The plan was to discharge her home with safety-netting advice. By 10pm, the notes record Mrs A said she felt better and her blood pressure had improved to 105/55 mmHg.

30. The records show clinicians considered her medically stable for discharge and gave her safety-netting advice to return if she became more unwell.

31. NICE blackout guidance recommends assessing vital signs, arranging an ECG and considering further tests such as blood tests.

32. GMC Good Medical Practice also says clinicians must assess patients properly, provide appropriate investigations and treatment, and refer on when needed. It says clinicians must recognise and work within the limits of their competence and must provide a good standard of practice and care.

33. RCEM guidance states discharge advice should include safety-netting about when to seek urgent help.

34. The records show staff assessed Mrs A, monitored her, carried out relevant investigations, reviewed the results and treated her in line with her presentation. Staff checked her observations at regular intervals, carried out blood tests and an ECG, and reviewed the results as per the NICE blackout guidance. The records also show her condition improved during her admission.

35. Our emergency medicine adviser says Mrs A improved clinically and this explains why staff discharged her. Her blood pressure and observations had improved, and Mrs A said she felt better.

36. Upon discharge, Mrs A was also provided with safety netting advice, which included when to seek urgent help. This is in line with the RCEM emergency medicine guideline.

37. Mrs A did become more unwell and returned to hospital a few hours later, as the safety-netting advice had explained she should.

38. We have seen the Trust acted in line with guidance when it assessed, treated and discharged Mrs A. She was provided with the appropriate safety netting advice. For this reason, we will not be taking any further action on this part of the complaint.

Dialysis treatment

39. Mr A says the Trust should have transferred Mrs A to Hospital A for dialysis. He says the Trust could not provide dialysis, Mrs A was a renal patient, and the decision not to transfer her led to her death. We understand this was a very distressing time for Mr A.

40. The records show Mrs A had a full four-hour dialysis session on 13 May 2020. She returned to hospital on 14 May 2020, a few hours after her discharge from the emergency department. After admission, Mrs A became acutely unwell, and her blood pressure remained severely low.

41. The records note Mrs A had been a dialysis patient for 10 years, and she had dialysis three times a week on Mondays, Wednesdays and Fridays. Mrs A had a dialysis session on 13 May, which was a Wednesday. This would indicate her next dialysis session would have been expected on Friday 15 May. By the time she was next due routine dialysis, clinicians considered her too unwell to have it.

42. Dialysis removes waste products and excess fluid from the blood. It can also lower blood pressure, especially when fluid is removed. This is important because Mrs A already had very low blood pressure.

43. Underlying heart disease and neurological problems can make these effects harder to tolerate. This means very low blood pressure is a significant concern when considering dialysis.

44. Mrs A had been on dialysis for 10 years. The dialysis review article says people on long-term dialysis often have serious health problems, a reduced life expectancy and a higher risk of complications such as heart disease and infection.

45. The dialysis management article says patients with end stage renal disease often have significant comorbidities. It also explains intensive care can sometimes provide different forms of dialysis that may suit patients with low blood pressure better than routine outpatient dialysis.

46. Dialysis also carries risks and cannot replace every function of the kidneys. Complications can include heart disease, infection, anaemia, and problems with calcium and phosphate balance.

47. The NHS dialysis guidance says there are two types of dialysis, which are haemodialysis (where blood is filtered by a machine) and peritoneal dialysis (where blood is filtered by passing it through the natural lining inside the abdomen). Mrs A had haemodialysis.

48. The NHS dialysis guidance says each dialysis session takes around four hours, and most people need three sessions a week. This means Mrs A would next have been due dialysis on 15 or 16 May.

49. Our geriatrician adviser says intensive care can sometimes provide alternative forms of dialysis, but this is challenging for someone with pre-existing end stage renal disease. The dialysis management article explains this may require invasive procedures such as a large venous catheter, arterial monitoring, and sometimes sedation and ventilation.

50. The dialysis review article says the five-year survival rate for people receiving haemodialysis is approximately 40%. It says dialysis cannot perform all the functions of the kidney, and people on dialysis can develop a range of complications, with heart issues as one of the most common. Our adviser says the survival rate is affected with the presence of additional medical conditions.

51. The clinical decision-making guidance used during the early COVID-19 period says decisions about escalating care should follow as full an exploration of the issues and context as possible.

52. We understand standard dialysis was not possible because of Mrs A’s condition at the time. Our adviser has confirmed our view. Mrs A had a number of significant medical conditions, and our adviser says end stage renal disease treated with haemodialysis and heart disease could be considered the most significant and potentially life limiting of the conditions. As previously mentioned, the survival rate for these conditions is quite low.

53. As Mrs A had just completed a full dialysis session on 13 May, there was no clinical reason to transfer her to Hospital A for dialysis on 14 May as her next session would have been due on 15 or 16 May. Our geriatrician adviser agrees and says there would have been no clinical benefit to having further dialysis at this stage.

54. Given Mrs A’s severe illness, very low blood pressure and existing conditions, guidance around observations/ NEWS scores etc and based on the above-mentioned guidance, it was not reasonable to transfer her for dialysis. Mrs A was not suitable for dialysis whilst acutely unwell with severely low blood pressure, and the records show this remained the case throughout her admission.

55. Based on the above-mentioned guidance and Mrs A’s medical records, we can see she was extremely unwell when she was admitted to the Trust on 14 May. We can see the Trust acted in line with expected guidance and standards and provided the appropriate care and treatment for Mrs A. We have not seen indication the Trust failed to provide Mrs A with dialysis as unfortunately, by the time Mrs A was next due dialysis, she was just too unwell to have it.

56. We asked our geriatrician adviser whether dialysis would have changed the outcome. The adviser said it would not. Our geriatrician adviser also says Mrs A was very unlikely to survive intensive care because of the severity of her acute illness. Given her end stage renal disease and long dialysis history, intensive care dialysis was also unlikely to succeed.

57. We appreciate Mr A believed dialysis would have helped his wife recover. But the records, our adviser’s opinion and the guidance we have considered show Mrs A was too unwell for dialysis by the time she would next have needed it. The decision not to transfer her to Hospital A was based on her clinical condition and was in line with the relevant guidance and standards. We have not found the Trust acted against the relevant guidance and standards in this part of the complaint, so we will not investigate it further.

End of life care

58. Mr A says the Trust wrongly placed Mrs A on end-of-life care and did not communicate this appropriately with her or the family. He believes the Trust could have done more to help her. He says Mrs A told him she was dying before staff had properly explained this to him, and he believes staff should have waited until a family member was present before discussing this with her.

59. It tried ward-based treatment, including fluids, IV albumin to support her blood pressure, and IV antibiotics in case infection or sepsis was causing her deterioration.

60. An ICU doctor reviewed Mrs A at 6.30am on 14 May and a Do Not Attempt Resuscitation (DNAR) form was completed the same day. The DNAR checklist notes the ‘patient’s condition is deteriorating’ and discussions were had with Mr A where he ‘understands that in the event of cardiorespiratory arrest CPR would not be appropriate’ given Mrs A’s current condition.

61. The records show staff recorded on 14 May that Mrs A lacked capacity to make decisions about her treatment.

62. The records show a consultant called Mr A on 14 May to explain Mrs A’s poor prognosis and warn that her condition might worsen. The consultant also explained that CPR would not be appropriate if she had a cardiac arrest.

63. The records also show clinicians recognised early in her admission that Mrs A had a poor chance of survival. This can be seen from the ICU doctor’s review on 14 May as well as the decision to prepare the DNAR due to Mrs A’s condition deteriorating. The records also evidence this through the telephone call made to Mr A on 14 May. The staff tried treatment, such as the IV fluids, the IV albumin and the IV antibiotics to see whether Mrs A would improve, but she did not respond. That is why they moved to end-of-life care.

64. Mrs A was referred to the palliative care team on 14 May.

65. On 15 May, a palliative care nurse recorded that Mrs A was able to discuss some aspects of her care, including where she would prefer to be cared for at the end of her life.

66. The palliative care team had a discussion with Mrs A at 11.30am on 15 May and noted she was fully alert and her family were not currently present.

67. Later the same day, on 15 May, staff had a further discussion with Mr A and his daughter about Mrs A’s deterioration. They explained that intensive care was not appropriate and that, if she did not improve, starting end-of-life care might be in her best interests. The records further note the family understood the ‘limitations of treatment’ and noted if Mrs A’s blood pressure did not respond, it might be in her best interest to stop active treatment and start end-of-life care. Mrs A was subsequently referred to the palliative care team, and the records document a discussion between the palliative care nurse and Mrs A’s family at 4.50pm.

68. The palliative care team were involved and provided ongoing support to Mrs A and her family. We can see staff began end-of-life care on 15 May.

69. On 16 May, clinicians again explained to Mr A why dialysis could not be given and why intensive care was not appropriate. It documented Mr A was concerned why his wife was not being given dialysis. The notes show the consultant informed Mr A that Mrs A had end stage renal failure and her blood pressure is too low for dialysis. It says it explained to Mr A that the intensive care unit had reviewed Mrs A and did not feel she was a candidate for dialysis. As Mrs A was experiencing multi-organ failure it should aim to keep her comfortable. It also told him Mrs A was receiving end-of-life care, and a palliative care nurse reinforced that discussion.

70. The records further show, on 16 May, the palliative care team had a long discussion with Mrs A with Mr A present. The discussion included prognosis, preferred place of death and Mrs A’s wishes.

71. Mr A also complains about how staff communicated the decision. He says they should not have discussed dying with Mrs A while she was alone and did not explain matters properly to the family.

72. We understand this must have been extremely distressing for Mr A and his family.

73. The One Chance to Get it Right document says staff should recognise when a person may be dying, communicate this clearly, and make decisions based on the person’s needs and wishes, while keeping those decisions under review.

74. It also says a competent doctor should assess whether deterioration may be reversible. If the person is likely to be dying, staff should explain this sensitively to the person, if appropriate, and to those important to them, then document and review a plan of care.

75. NICE care of dying adults’ guidance says staff should discuss prognosis with the dying person, unless they do not want this, and with those important to them. It also says staff should give accurate information, explain uncertainty, and explore any preferences about care in the last days of life.

76. The records show clinicians recognised her poor prognosis early and involved the intensive care team early on following Mrs A’s admission.

77. The records and our adviser’s opinion show the Trust acted in line with the guidance mentioned above. Staff recognised Mrs A’s poor prognosis early, involved more than one team, tried active treatment first, and only started end-of-life care when she did not improve. The intensive care team were involved early in the admission. A senior doctor discussed Mrs A’s prognosis with Mr A on 14 May, with the possibility of focusing on palliative care if she did not improve. When Mrs A did not respond to the fluids or antibiotics, and as her blood pressure was not improving, she was put on end-of-life care. This is in line with the above-mentioned guidance as staff recognised Mrs A was nearing the end of her life, and to review a plan of care.

78. Our geriatrician adviser says this decision was clinically appropriate because Mrs A was acutely unstable and was unlikely to survive intensive care. This can be seen from the records, which showed Mrs A’s condition was not improving and her blood pressure was not stabilising. Consideration must also be given to Mrs A’s frailty and multiple comorbidities as previously mentioned.

79. The records show the Trust acted in line with this guidance. Staff discussed Mrs A’s condition with Mr A as her prognosis became clear, involved his daughter, and kept the family updated. They also involved the palliative care team and discussed Mrs A’s own preferences when she was able to take part on 16 May.

80. We have seen evidence the Trust acted in line with relevant guidance when it started end-of-life care and communicated that decision. For that reason, we will not be taking any further action on this part of the complaint.

Complaint handling

81. Mr A and his advocate made significant efforts to pursue the complaint over several years. The Trust’s communication was inconsistent, and there were long delays before it provided final responses or arranged the meetings it had promised.

82. We can see Mr A first raised concerns about his late wife’s care with PALS in July 2020. The Trust responded in August 2020, but he remained dissatisfied and escalated the complaint through his MP in December 2020. The Trust issued its final response in February 2021. Mr A received the final response in March 2021.

83. Mr A raised further concerns which led to a resolution meeting in September 2021, where the Trust agreed to a follow-up meeting. This was never arranged despite repeated requests from Mr A and his advocate throughout 2022 and 2023. The Trust provided minimal updates and cancelled a rescheduled meeting in early 2024.

84. In March 2025, the Trust issued a further response, apologising for delays and acknowledging it had not followed up on earlier commitments. Mr A then brought his complaint to us, citing unresolved concerns and excessive delay.

85. The Trust accepted the delays in its complaint handling were unacceptable. In its most recent response from March 2025, it apologised for the poor communication and the impact this had on Mr A. It told us it has since reviewed its complaint processes and spoken to the staff involved to reinforce expectations about timely and effective communication with complainants.

86. Mr A says the Trust’s complaint handling process caused him long-term stress and worry as he was constantly chasing the Trust for a response. We can see Mr A complained from the resolution meeting in September 2021 onwards and only received the final written response in March 2025, around three and a half years later.

87. As an outcome to his complaint about the delays in the Trust’s complaint handling, Mr A told us he wanted an apology and acknowledgement of the failings, service improvements and a financial remedy.

88. Our ‘NHS Complaints Standards’ explain when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’ Further, it says we expect organisations to ‘take action to make sure any learning is identified and used to improve services.’ Finally, our standards say organisations should be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’.

89. NHS England complaints policy states ‘We will aim to provide a full response to the person raising the complaint within 40 working days. Unless we have agreed a longer timescale with the person raising the complaint within the first 6 months, we will inform them if we cannot conclude the investigation and issue a final response within 6 months.’

90. We can see as Mr A first began his complaint in 2020, and only received a final written response in 2025, which was almost five years later. We consider it reasonable Mr A would have experienced distress and uncertainty while waiting such a significant length of time.

91. Our ‘Guide to Financial Remedy’ sets out our severity of injustice scale (our scale). This is a guide which helps us decide an appropriate amount of financial remedy, depending on the injustice the person has suffered. Level three of our scale explains in cases where there has been ‘very poor complaint handling, that is delays of over a year’, or ‘distress, upset or worry lasting for around 6-12 months’, or a ‘single traumatic or highly distressing experience’. Level three also refers to a moderate impact on the person affected, and the impact would have been experienced over a significant period of time. We also considered other cases where the impact was similar to that suffered by Mr A.

92. As part of this process, we contacted the Trust. We explained given the distress and stress Mr A had suffered as a result of its complaint handling, we felt it needed to do more to put his complaint right. The Trust has agreed to make a payment of £900 to recognise the emotional impact the poor complaint handling had on Mr A.

93. Taking all this into account, we are satisfied the Trust has now ‘taken full accountability’ for its failings. It apologised, acknowledged the failings, has taken learning from the complaint, offered Mr A the meeting, and offered an appropriate financial remedy in line with our severity of injustice scale. The Trust’s apology and its offer of a meeting are positive actions that support learning and accountability.

94. We are satisfied we have been able to successfully resolve this part of Mr A’s complaint. We would like to thank both parties for their cooperation and understanding during this process.

1. We have carefully considered Mr A’s complaint about Walsall Healthcare NHS Trust (the Trust). We were very sorry to hear how Mr A has been affected. It is clear he has had a difficult and upsetting experience with the loss of his wife six years ago and the length of time waiting for the Trust to respond to his complaint. Understandably, he is now seeking a remedy to put things right.

2. We have seen evidence the Trust acted in line with guidance in its care and treatment of Mrs A. We have identified indications of service failures in the Trust’s complaint handling.

3. As a result of our work, the Trust confirmed a second meeting will be arranged with Mr A to discuss his outstanding concerns and pay him £900 to recognise and put right the upset and distress caused to him as a result of the significant delay in its handling of his complaint. We are satisfied these actions are appropriate to resolve this part of his complaint. We explain this in more detail below.

4. We are very grateful for Mr A’s time and effort in bringing this complaint to our attention. Complaints give us a valuable insight into the organisations we investigate, so we would like to thank Mr A for sharing his experience with us.