Sandwell and West Birmingham Hospitals NHS Trust

4. Miss A complains about the care and treatment the Trust provided to her brother, Mr A, on 2 June 2025. Specifically, she complains the Trust did not take steps to access her brother’s full medical history. Had it done so, staff would have been aware he had previously suffered an alcohol related seizure and would have monitored him continuously.

5. Miss A also complains the Trust did not recognise her brother had suffered a cardiac arrest in a timely manner. She says she cannot understand how the Trust could not save her brother.

6. Miss A says she has suffered extreme distress and anxiety as a result of the Trust’s actions, which she believed caused her brother’s death. By bringing her complaint to our office, Miss A is seeking a financial remedy and service improvements.

7. Mr A presented to the Trust’s Emergency Department (ED), via ambulance, on 2 June 2025, with vomiting and abdominal pain. The medical team reviewed him and recognised he was very unwell. The doctor gave Mr A intravenous fluids and Ondansetron to ease the nausea and control the vomiting. They also arranged X-rays to check his abdomen for signs of anything that might be contributing to his condition. Sadly, Mr A suffered a cardiac arrest and died shortly after his arrival to the ED.

11. Before we decide if we should conduct a detailed investigation of a complaint, we look at 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 found any indications to suggest anything went wrong.

Mr A’s medical history

12. We have carefully considered Miss A’s concerns that the Trust did not take sufficient steps to access Mr A’s medical history and that, had it done so, staff would have been aware of a previous alcohol related seizure and monitored him continuously.

13. Our adviser said access to a patient’s electronic, or paper records is variable and differs from each Trust. In general, if a patient has attended the same hospital before, the records would be available to the clinician. If not, they often rely on information provided by the patient, their family, or other healthcare professionals involved in their care.

14. When someone is unwell, doctors are expected to use their clinical knowledge and judgment to assess patients based on their presenting symptoms and the information available to them. The GMC’s good medical practice guidance says doctors must adequately assess a patient’s condition, carry out a physical examination where necessary and promptly arrange suitable advice, investigation, or treatment.

15. In this case, Mr A attended the ED via ambulance. Clinicians had access to the ambulance records, which documented his presenting symptoms of vomiting and abdominal pain. The medical team assessed him and started treatment based on those symptoms and the clinical information available at that time. It appears the Trust acted in line with GMC guidance.

16. The GMC’s good medical practice guidance also talks about the importance of gathering information from a range of sources to provide safe and effective care. Mr A deteriorated very shortly after his arrival to the ED. There was limited opportunity for the Trust to obtain additional background information beyond that which was available from Mr A and the ambulance service.

17. Our adviser explained even if staff were aware of Mr A’s previous alcohol related seizure, this would not have altered the care he received during this time. He attended the ED because of vomiting and abdominal pain, and we have seen no evidence he had suffered a seizure. Given the circumstances and the short period between his arrival and cardiac arrest, we do not consider that access to this information would have changed the treatment plan or level of monitoring.

Cardiac arrest

18. We have carefully considered Miss A’s concerns that staff in the ED did not immediately recognise her brother had suffered a cardiac arrest.

19. Mr A arrived at the Trust’s ED at 3.49pm. The medical team reviewed him at 4.16pm. At 5.02pm, Mr A suffered a very sudden and unexpected cardiac arrest. The evidence in the medical records indicates staff witnessed the cardiac arrest and immediately commenced cardiopulmonary resuscitation (CPR). Despite these efforts, Mr A sadly died.

20. We recognise how distressing it must have been for Miss A to learn of the circumstances surrounding her brother’s death.

21. We have seen no indication to suggest there was a delay in staff recognising the cardiac arrest or in starting CPR. The records show that staff responded immediately. There were no clear signs that this was imminent, and the Trust could not have foreseen this.

22. We understand why Miss A has questioned why the Trust could not save her brother. We recognise how difficult it can be to understand and come to terms with such an unexpected death. It is not always possible to determine with certainty why resuscitation efforts are unsuccessful.

23. We understand how upsetting this is for Miss A. We have not seen any indications to show Mr A’s death was due to any failings in the Trust’s actions. For this reason, we do not consider we need to carry out a detailed investigation or make any recommendations.

24. We were sorry to hear the circumstances of her complaint and offer our sincere condolences on the loss of her brother. We appreciate this was a difficult time for Miss A and we thank her for sharing details of her experience with us.

25. We hope this statement provides reassurance that we have considered the evidence carefully. We hope this clearly explains the reasons for our decision.

1. We have carefully considered Miss A’s complaint about Sandwell and West Birmingham NHS Trust (the Trust). We were sorry to hear her concerns about the care her brother, Mr A, received at the Trust before he died.

2. Having considered all the available information in relation to Miss A’s complaint about the Trust, we have seen no indication that anything went seriously wrong.

3. We recognise how deeply Miss A has been affected by what happened. We do not underestimate how difficult this time has been for her. Although we are unable to investigate her concerns further, we thank her for taking the time to raise them with us.