Manchester University NHS Foundation Trust

Trust A

5. Mr G complains about the care and treatment his partner, Mr F, received at Trust A in March and April 2024.

6. He specifically says Trust A:

• did not admit Mr F for medically supported alcohol withdrawal on 28 March and 8 April • did not administer intravenous fluids (IV) on 28 March • did not carry out a chest X-ray on 8 April despite the GP referral saying he needed one.

Trust B

7. Mr G says when Mr F self-referred to Trust B’s alcohol support and recovery service on 3 April, it did not book him in for an appointment until 2 May.

8. Mr G says as a result, he lost his partner suddenly and believes his death was avoidable. He says this has caused him immense distress and made the grieving process harder. He also says this has affected his mental health severely, and he is taking anti-depressants and has bereavement counselling.

9. Mr G would like an explanation from the Trusts so he can gain closure and a financial remedy.

10. This background is intended to place the key events in context, not to provide a full account of everything that happened.

11. Mr F was in his early fifties and was struggling with alcohol misuse. He had a background of depression and anxiety.

12. On 28 March 2024, Mr G took his partner to Trust A’s emergency department (ED), as his GP had referred him. He was worried about his alcohol dependency. Trust A did blood tests, an electrocardiogram (ECG, non-invasive test recording heart activity) and monitored blood pressure. Trust A made an outpatient referral to the Alcohol Care Team (ACT). Mr F self-discharged on the same day.

13. On 3 April, Mr F self-referred to Trust B, for support in relation to alcohol use. Trust B booked him in for the next available appointment which was 2 May.

14. On 8 April, Mr F attended Trust A’s ED for alcohol misuse and ED staff gave him advice on how to cut back alcohol slowly and discharged him.

15. On 3 May, Mr F attended the ED via ambulance in a critical condition. He died the same day.

Trust A

20. Mr G is concerned he took Mr F to Trust A on 28 March and 8 April and it did not admit him for a detox. He says Trust A missed two opportunities to admit Mr F despite the GP referring him. Mr G is frustrated that if Trust A had listened to him there is a chance his partner would still be here today.

21. Trust A said in its complaint response it did not feel an admission was necessary on either occasion. This is because Mr F did not have symptoms of alcohol withdrawal. It also said it gave Mr F advice on how to cut back slowly and referred him to the ACT for a further assessment so he could access support for his drinking.

22. NICE guidance for alcohol use says that inpatient or residential assisted withdrawal should be considered if a patient meets one of the criteria listed below:

• drink over 30 units of alcohol per day • SADQ (Severe alcohol dependence questionnaire) score exceeds 30 • history of epilepsy, withdrawal-related seizures, or delirium tremens (severe confusion, disorientation and agitation occurring 48 hours after withdrawal) during past assisted withdrawals • require simultaneous withdrawal from alcohol and benzodiazepines (group of anti-depressants) • regularly drink 15 to 30 units of alcohol per day and have • significant psychiatric or physical health conditions • significant learning disability or cognitive impairment.

23. Trust A’s internal policy was created after the events complained about, but it has confirmed the same recommendations were in place at the time. The policy says offer an admission when:

• there is a high risk of seizures or delirium tremens • vulnerable patients (e.g frail, cognitively impaired, with multiple comorbidities, lacking social support, or aged 16–17) • decompensated liver disease and/or major electrolyte abnormalities • signs of Wernicke’s encephalopathy (serious brain disorder from lack of thiamine).

24. Mr F attended ED on 28 March at 6.16pm. Initial assessments showed an elevated heart rate of 119bpm and slightly raised blood pressure of 140/93. Staff did an ECG at 6.20pm and blood tests at 6.43pm. Mr F’s blood results were normal and staff observed no withdrawal symptoms. There is no evidence in the records of Mr F showing other criteria in either the NICE guidance or Trust A’s policy we have set out above.

25. Mr F self-discharged before an ED clinician reviewed the results.

26. Trust A made an outpatient referral to the ACT who attempted to contact him the next day (within 24 hours as per the Trust’s internal policy). The team could not reach Mr F.

27. Our adviser has reviewed the notes. They told us, based on the results, we can see there is no indication Trust A should have admitted Mr F for a detox. The actions Trust A took with regards to referring him to the ACT, and not admitting Mr F, were in line with the Trust’s internal policy and the NICE guidance.

28. On 8 April Mr F returned to Trust A at 4.38pm. The notes show his GP referred him to attend ED for consideration of an admission to an inpatient facility for detoxing. The nurse did a blood test at 4:38pm and an ED clinician reviewed Mr F at 11.45pm.

29. Our adviser explains Mr F’s observations were of an elevated heart rate at 108, blood pressure of 150/100. They explained all other parameters were within normal limits, including oxygen saturations and respiratory rate. The notes say he did not have withdrawal symptoms.

30. Trust A prescribed thiamine (vitamin which helps metabolism and the function of the brain, heart and nervous system) and vitamin B and advised on how to safely cut down on his alcohol intake. Trust A referred him to the ACT who needed to contact him within 24 hours.

31. Trust A has told us based on normal practice, unless there was evidence of alcohol withdrawal seizures, delirium tremens/ Encephalopathy (disorder that affects the brain), telling the patient to continue drinking with a gradual reduction until an outpatient follow up is arranged is appropriate.

32. We already know, with the help of our adviser, Mr F did not meet the criteria for an admission (on both occasions) due to his clinical symptoms and the fact that he did not have withdrawal symptoms.

33. Our adviser explained it is rare for hospitals to admit patients purely for alcohol detox unless there are other medical concerns, such as evidence of delirium tremens or those suffering from withdrawal seizures. So far, we have not seen any evidence of this.

34. In addition to this, attempts to engage Mr F through the ACT were unsuccessful, as he disconnected the calls and Trust A lacked consent to involve Mr G. On 9 April further attempts to contact Mr F failed, preventing an assessment.

35. Taking the above into account, the evidence shows Mr F did not need an admission. After consulting our adviser, the notes confirm he was not in alcohol withdrawal. Our adviser also verified that the referrals made to the ACT were appropriate and that there is documented evidence of the ACT contacting Mr F multiple times. This is in line with NICE guidance and the Trust’s local policy. We have found no failings here.

36. We understand this must have been an extremely distressing situation for Mr G, and we do not underestimate how difficult it must have been for him.

March – IV fluids

37. Mr G is concerned Mr F was not eating and drinking anything other than alcohol prior to attending ED on 28 March. He says on 28 March Trust A should have provided him with IV fluids to help with his dehydration.

38. Trust A has said in its final response, the blood tests did not show any evidence of dehydration.

39. We have not referred to guidance for this part of the complaint because our adviser has not told us there is specific guidance that is relevant. Rather, we have used the adviser’s professional opinion.

40. Our adviser explains Mr F did not wait to be assessed by a doctor and had self-discharged. Despite this, the blood tests measuring haemoglobin (iron containing protein in red blood cells that transports oxygen to and from the lungs) and haematocrit (blood test that measures the proportion of red blood cells in total blood volume) were within normal parameters. These did not show he was dehydrated and therefore he did not need IV fluids.

41. In considering this, the evidence shows it was appropriate to not administer IV fluids to Mr F as his clinical results show he was not dehydrated. We have found no failing here.

8 April – chest X-ray

42. Mr G is concerned Trust A did not conduct an X-ray. He says Mr F’s oxygen saturations were 92% and he had a bilateral wheeze and decreased air entry in his lungs according to his GP records from earlier that day.

43. GMC guidance advises that, in providing clinical care clinicians must:

a. ‘adequately assess a patient’s condition(s), taking account of their history, including:i. symptomsii. relevant psychological, spiritual, social, economic, and cultural factorsiii. the patient’s views, needs, and values

b. carry out a physical examination where necessary.’

44. We have reviewed the records with the help of our adviser. We noted the GP letter written at 2.50pm on 8 April documents a face-to-face appointment with Mr F. The letter says he was continuing to drink heavily and was confused, lethargic, and weak. He was slightly tachypnoeic (high respiratory rate of more than 20 breaths per minute), his heart rate was mildly elevated, and his oxygen saturation was slightly low at 93%.

45. Mr F had decreased air entry at both bases and a bilateral wheeze. Our adviser notes there is no documentation that the GP enquired about other respiratory symptoms such as a fever, cough, or shortness of breath.

46. The notes show when Mr F attended ED, there was no documented history of respiratory symptoms, and there is no mention of the GP letter.

47. The notes also show Mr F’s observations at the time of assessment in ED showed an oxygen saturation of 95% and a respiratory rate of 18. Our adviser confirms these observations are within normal range.

48. Our adviser explains Mr F’s heart rate was mildly elevated, however this was similar to his previous attendance on 28 March. Trust A examined his chest and found it was clear.

49. Our adviser explains given that the GP had documented wheeze and decreased air entry on examination, it would have been good clinical practice for the ED doctor to perform and document a respiratory and cardiovascular examination. However, there is no guidance to confirm this should have happened.

50. Our adviser explains the notes show Mr F’s examination and observation findings were in normal limits at the time he presented to ED. This includes review of his respiratory rate, oxygen saturations and temperature. The notes also show he had no history of asthma or other chronic respiratory disease, nor a condition that would cause a wheeze.

51. Our adviser helped us understand staff found no respiratory abnormalities on examination, therefore a chest X-ray was not indicated.

52. Based on the above evidence, it is clear Mr F’s observation findings were normal. Trust A acted in line with the GMC guidance when not conducting a chest X-ray. We have found no failing.

Trust B

53. Mr G says his partner should have received more support for his alcohol dependence. He says Trust B did not assess Mr F in time to provide him with a detox he desperately needed. He thinks if Trust B had assessed Mr F in time he would still be with us today.

54. Trust B said in its final response that Mr F self-referred to it on 3 April for support in relation to alcohol use. It booked him in for the next available appointment which was 2 May.

55. Trust B has explained its local target date to complete a full comprehensive assessment is 21 days. Mr F received his appointment in 29 days. It has explained to us it uses 21 days as a local benchmark, and this is not referred in any internal formal policies or national guidance. It told us its alcohol support service is a community-based service and cannot offer immediate inpatient detoxification.

56. Trust B confirmed decisions about urgent detox interventions must be made via the local ED. Access to its structured treatment pathway requires planned pre-detox psychosocial interventions and clinical assessments to ensure suitability and safety.

57. Trust B acknowledges there was a delay and explains it was due to mitigating factors such as staff shortages which were affecting its services in the region.

58. We have seen evidence provided by Trust B that between the self-referral and the appointment scheduled for 2 May, it liaised with Mr F’s GP to obtain information about his alcohol use. It also informed his GP on 8 April via telephone call it does not provide immediate detox services, and this route should be taken through ED.

59. Our Principles of Good administration says, ‘public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot. They should meet their published service standards or let customers know if they cannot.’

60. In considering this and our Principles, we have found Trust B did provide support to Mr F in the context of the pressures it faced at the time. While it did not meet its own target date of 21 days, 29 days appears reasonable given the circumstances and mitigating factors, such as staff shortages.

61. We are satisfied with the evidence we have seen which shows Trust B took proactive steps to liaise with Mr F’s GP, gathering information about his alcohol use and signposting a potential route for a detox through ED (we have already explored above that Mr F did not meet the criteria for an admission).

62. In conclusion, we recognise Mr G was understandably concerned about the care his partner received from both Trusts. We hope our findings provide reassurances Trust A and Trust B provided care in line with the relevant standards.

63. We have found the evidence above does not show any failings in care and treatment provided by Trust A and Trust B. For this reason, we do not uphold this complaint.

1. We have carefully investigated Mr G’s complaint about Manchester University NHS Foundation Trust (Trust A) and Greater Manchester Mental Health (Trust B). We were very sorry to learn about his concerns and offer our sincere condolences for the loss of his partner, Mr F. We recognise this has been a very distressing time for Mr G.

2. We have not found failings in Trust A’s decision not to admit Mr F or the investigations and support it provided him with.

3. We have not found failings in how long Trust B took to arrange an assessment for Mr F after he self-referred to its service.

4. For this reason, we do not uphold Mr G’s complaint. The reasons for our decision are set out in this report.