Hull University Teaching Hospitals NHS Trust

4. Mr L complains about the care and treatment provided to his mother, Mrs L by the Trust in April 2024. He specifically complains that:

• the Trust failed to inform his mother that it diagnosed her with a hernia in 2023 • its Emergency Department (ED) failed to investigate the seriousness of his mother's hernia during her first attendance in April 2024 • the ED staff prescribed too much morphine to his mother causing her to vomit • staff discharged his mother from the ED when she was not in a fit state and at an inappropriate time of day, without taking into account her age and health conditions • doctors during her second ED attendance and subsequent admission gave her and her family contradictory information about her hernia • during his mother's admission, clinical staff removed and did not administer the medication she was taking when she was at home • there was a lack of communication from ward staff about his mother's condition and when her health began to deteriorate.

5. Mr L believes his mother may have lived longer if the Trust had cared for and treated her better. Its actions and the death of his mother caused him and his family distress and a loss of faith in the Trust.

6. Mr L would like an acknowledgment of what went wrong, an apology for the impact caused and service improvements to minimise the risk of this happening to anyone else.

Diagnosis

11. Mr L complains the Trust failed to inform his mother that it diagnosed her with a hernia in 2023.

12. Within its July 2025 complaint response, the Trust said Mrs L’s medical records show the presence of a right sided hernia. This was diagnosed on a computed tomography (CT) scan in late April 2023. It said the Trust sent out a letter to Mrs L and her GP in mid-July.

13. We have seen evidence within Mrs L’s medical records of a clinical letter from the Trust’s Consultant in Colorectal Surgery, addressed to Mrs L dated mid July 2023, with a copy going to her GP.

14. This explained that Mrs L had a CT scan in April 2023, which showed a right sided groin hernia. The consultant said, ‘normally we would offer you surgery for this which is the reason for your clinic appointment. If you do wish to be reappointed please contact me as I understand from my secretary that you are not keen to have a further appointment at this stage..’

15. The weight of the evidence indicates the Trust informed Mrs L and her GP in July 2023, that she had a hernia. Even if Mrs L did not receive the letter, she was aware she had a CT scan in April and had opportunity to contact her GP or the relevant hospital to find out the result. We consider there is no indication of a failing.

First attendance at the ED

16. Mr L complains the Trust:

• ED failed to investigate the seriousness of his mother's hernia during her first attendance in mid-April 2024 • ED staff prescribed too much morphine to his mother causing her to vomit • discharged his mother from the ED when she was not in a fit state and at an inappropriate time of day without taking into account her age and health conditions.

17. Mr L says he was present during his mother’s ED admission and her assessment. He said she was in pain, hence the admission, but the vomiting did not occur until after a large dose of morphine had been administered. He says the hernia was not identified or communicated during the initial ED.

18. Mr L said his mother was over 80 years of age, in a confused and vulnerable state at approximately 2am. The decision to discharge shows a serious lapse of duty of care. He said at 4am the ED rang him informing him that his mother was to be discharged by transport and could he meet them at the property as he had the keys. Mr L said he told the ED he would go to the hospital and collect his mother.

19. In the Trust’s complaint response, it said Mrs L attended the ED with sudden onset severe abdominal pain. This was initially felt in the centre of her abdomen and had later become widespread. She was nauseous and had vomited. She did not report any altered bowel habit or other acute symptoms. It noted she had a right sided groin hernia, which had been present for almost a year.

20. On clinical examination, Mrs L’s abdomen was soft. The hernia was palpable and hard but non-tender. It carried out a CT scan and this showed a right inguinal hernia containing a knuckle of bowel, but no evidence of obstruction and no cause identified for Mrs L’s symptoms.

21. It said it reviewed Mrs L after the CT report at which point her pain had settled. Her abdomen was soft on examination. It said Mrs L’s symptoms improved, and she was pain free, so it discharged her with advice to seek further medical attention if she developed severe abdominal pain, vomiting or fever.

22. We will address Mr L’s complaints separately below:

Investigation of hernia

23. The relevant guidance is the GMC: Good medical practice. This says:

‘7 In providing clinical care you must:

a.adequately assess a patient’s condition(s), taking account of their history.

b.carry out a physical examination where necessary… c.promptly provide (arrange) suitable advice, investigation or treatment where necessary…’

24. The medical records show that Mrs L was known to have a hernia prior to attending ED in April 2024 (July 2023 clinical letter). The presence of the hernia is acknowledged in the ED notes and records the Trust told Mrs L of this during her attendance.

25. A clinician assessed and examined Mrs L and took account of her medical history. They carried out blood tests and a CT scan of Mrs L’s abdomen to assess for pathology and the cause of her symptoms. The scan showed a right inguinal (groin) hernia but no evidence of intestinal obstruction or any other pathology. Our ED adviser said the medical records show Mrs L was assessed appropriately by a clinician in the ED in line with GMC guidance.

26. We understand Mr L questioning whether the ED investigated his mother’s hernia during her first attendance in April 2024. We have carefully taken into consideration Mr L and the Trust’s account, the medical records and independent clinical advice. The evidence shows the ED staff were aware of Mrs L’s hernia and carried out assessment/examination and investigations to find out the cause of her symptoms, in line with GMC guidance. We cannot see the ED did anything wrong.

Morphine

27. Our ED adviser said there is no obvious prescription of morphine administered to Mrs L while she was in the ED. However, the medical records show Mrs L had 6mg of morphine before she attended the ED (Mrs L was brought to the ED via ambulance). Our adviser said in patients with acute pain, the dose of morphine administered intravenously is titrated to effect.

28. The evidence indicates that Mrs L was administered with morphine prior to her attendance at the ED. Mr L’s agreed complaint summary relates to the actions of the Trust not the ambulance service, therefore we cannot comment on the actions of the paramedics.

Discharge

29. Our ED adviser said that from a clinical perspective, Mrs L’s symptoms had improved by the morning of the day of her discharge – the day after her attendance at the ED - and investigation results did not reveal a sinister pathology. A clinician appropriately gave safety netting advice in the early hours on the day of discharge, ensuring a safe discharge. A clinician discussed Mrs L’s management plan with the ED Registrar on duty, in line with paragraph 7g of the GMC: Good medical practice, which says:

‘consult colleagues or seek advice from your supervising clinician where appropriate.’

30. Although the question about time of the day, patient’s age and physical state is relevant, the Trust explained in its complaint response that:

‘usual practice to arrange to discharge a patient if, on review, there is not an acute need to keep them in hospital. If Mrs L’s family could not have collected her, the hospital would have provided safe transport home for her in the form of either a taxi or an ambulance. If it was deemed unsafe to discharge a patient overnight, they would remain within the hospital until the following morning and then be discharged.’

31. Our ED adviser said this is appropriate and usual practice within most EDs and is also in line with the RCEM: Best Practice Guidelines, point 25 regarding discharge advice. There is also no noted entry to suggest an issue with discharge on the morning of Mrs L’s discharge.

32. Although the Trust’s complaint response letter said a surgical clinician could have been requested to review Mrs L before her discharge, our adviser said in the absence of an acute pathology noted on the CT scan it was unlikely to have resulted in the Trust admitting Mrs L.

33. We acknowledge Mr L’s concerns on whether the Trust discharged his mother from the ED when she was not in a fit state. Informed by clinical advice, we consider the Trust discharged Mrs L in line with GMC, RCEM guidance and clinical experience.

34. Mr L believes his mother may have lived longer if the Trust had cared for and treated her better.

35. Even if we had found an indication of a failing, our adviser said it would not be reasonable to link Mrs L’s discharge with the claimed impact. The ED managed Mrs L appropriately. They assessed and investigated for the symptoms she presented with, in line with guidance.

36. Mrs L re-presented to the ED with worsening symptoms and a follow up CT scan showed intestinal obstruction due to complications of her inguinal hernia. These findings were not present during her first attendance at the ED in mid-April.

Second attendance at ED

37. Mr L complains the Trust’s doctors during his mother’s second ED attendance and subsequent admission gave her and her family contradictory information about her hernia.

38. Mr L said the doctors initially said to them that they were going to operate to fix the hernia, then said his mother’s hernia was inoperable due to her age. He said they were then told she had a bowel movement which removed the blockage, the hernia had retracted due to this movement as well as pressure from the doctor. He says they were told it was a miracle and she was no longer on the end-of-life plan.

39. The Trust said it did explore the possibility of surgery and arranged an anaesthetic review. It said Mrs L was clinically unfit for surgery and the plan was to continue with non-surgical supporting treatment in the form of naso-gastro (NG) tube drainage and intravenous (IV) fluids. This was with a view to help resolve the obstruction, which can be achieved without surgery.

40. It apologised for the terminology used, this was not appropriate and it recognised as a team this would been confusing for Mrs L’s family.

41. The Trust said the decision not to perform a further scan to verify the blockage had moved was made on a clinical basis. A scan is only necessary if it will change the treatment plan, as a plan for surgical intervention. It apologised this was not explained to Mrs L’s family.

42. Our ED adviser said the documentation from Mrs L’s second attendance primarily concerns the Trust’s Medical and Surgical Teams and not the ED. There is no obvious mention within the medical records of discussion of clinical findings with the family while Mrs L was in ED, before her admission.

43. We therefore sought advice from a consultant general and colorectal surgeon (our surgeon adviser).

44. The relevant guidance is the GMC: Good medical practice. This says patients have the right to be involved in decisions about their care. That doctors must provide clear, accurate, evidence-based information and offer compassionate support to those close to a patient.

45. Our adviser said there is a lot of evidence within the medical notes to show the Trust communicated with Mrs L and her family during her admission and involved them in the decision making, in line with the above GMC guidance.

46. Mrs L’s clinical situation changed throughout her admission and clinicians updated her and her family when these changes occurred.

47. For example, the Trust, on Mrs L’s admission, was initially considering the possibility of surgery for her hernia and the bowel obstruction. It arranged a review by the anaesthetist to see if she was fit for surgery.

48. A day later the records show a detailed discussion between the Trust’s Anaesthetist and Mrs L’s family on whether Mrs L was fit enough for surgery. Her medical history included, chronic kidney disease 3 (mild to moderate damage of the kidneys), asthma, chronic obstructive pulmonary disease, high blood pressure, transient ischemic attack, diabetes.

49. The anaesthetist explained that having the operation was high risk, and they considered Mrs L would not survive the operation. It is recorded the anaesthetist and Mrs L’s family agreed surgery was not in Mrs L’s best interest.

50. Our surgeon adviser said this advice not to proceed with the operation was appropriate and in line with good clinical practice.

51. Due to her clinical situation, the clinical team appropriately referred Mrs L to the palliative care team for end-of-life (EOL) care.

52. The Trust explained this further to Mrs L (with her daughters present).

53. Three days after Mrs L’s admission, Mrs L’s clinical situation changed. It is recorded within her notes her clinical situation had improved, she had opened her bowel, the hernia seemed to have reduced, she was able to eat and drink, and so following discussion with the palliative care team, it took her off EOL for the time being. The Trust explained to Mrs L she could still deteriorate and would not be suitable for surgery.

54. Clinical staff spoke Mrs L’s daughter on the same day about the change in Mrs L’s clinical situation and the reasons why they had taken her off EOL.

55. The Trust reviewed Mrs L in the morning the following day and recorded her bowels had opened and her hernia had reduced. The plan was that she was still not fit for surgery for her hernia.

56. Unfortunately, Mrs L’s health deteriorated, she was placed back on EOL and sadly died two days later.

57. Our adviser said in line with GMC guidance, there is no evidence the Trust gave Mrs L and her family contradictory information.

58. We are sorry to learn of Mr L and his family’s experiences with the Trust at an already difficult time and the impact this had. We recognise this was worrying time for Mr L and his family. The medical records show Mrs L’s clinical situation changed throughout her admission and clinicians updated her and her family when these changes occurred, in line with GMC guidance. We do not consider contradictory information was given by staff. There is no indication of a failing.

Administration of medication

59. Mr L complains that during his mother's admission, clinical staff removed and did not administer the medication she was taking when she was at home.

60. Mr L said his mother was on various medication to assist in her heart condition, her diabetes, and her old age. He says the clinical staff removed this medication from her on admission to the ward. He says he has no information as to whether she received this medication during her time in hospital, which may have assisted in the contributing factors of her death.

61. Within the Trust’s complaint response, it said that due to Mrs L’s palliative status it is documented in the medical notes for all unnecessary medication to be stopped. Mrs L was on EOL care requiring medication for pain and symptoms control only.

62. Medication was given intravenously to control her diabetes. It would not have been possible to give oral medication whilst the NG tube was in place. It apologised this was not more clearly explained to Mr L and that this left him with the concern Mrs L was not being well cared for.

63. The relevant guidance is NICE [NG142]: End of life care for adults: service delivery, and Care of dying adults in the last days of life: NICE guideline [NG31]. This says:

‘When it is recognised that the patient may be entering the last days of life, review their current medication and, after discussion and agreement with the dying person and those important to them (as appropriate), stop any previously prescribed medicines that are not providing symptomatic benefit or that may cause harm,’

64. The day after Mrs L’s admission, the Trust referred her to the palliative care team for EOL care. The following day the Trust recorded a conversation with Mrs L and her daughters and that, ‘unnecessary medication stopped.’

65. Our surgeon adviser explained the Trust stopped a range of medication, including blood pressure tablets, blood thinning tablets and cholesterol medication.

66. These are prophylactic medication, which are long term medication used to prevent diseases or health conditions before they occur. Our surgeon adviser explained that because the Trust placed Mrs L on EOL palliative care this medication would not be necessary.

67. Furthermore, Mrs L also complained of vomiting and therefore it would be unlikely she would keep this medication down.

68. Our surgeon adviser explained that in a patient on a palliative care pathway where the patient is expected to die within a short period of time, there is no benefit to the patient continuing some of their regular medication such as a cholesterol lowering tablets. These medications are given to reduce the long-term risk of heart disease or stroke and in this context where a patient is on a palliative care pathway, this benefit of the medication is irrelevant and can never be realised. It causes unnecessary discomfort for a patient with bowel obstruction and symptoms of nausea to have to swallow medication that has no immediate benefit.

69. Our surgeon adviser said in line the NICE guidance and good medical practice it was correct for the Trust to withhold non-essential medication. Withholding this medication did not cause Mrs L’s deterioration. Had it been given, it would not have improved her health at this time.

70. We consider the Trust withheld Mrs L’s medication during her admission in line with NICE guidance. We cannot be critical of the Trust.

Communication

71. Mr L complains there was a lack of communication from ward staff about his mother's condition and when her health began to deteriorate.

72. The Trust, within its December 2024 complaint response said that Mrs L’s notes have several entries about informing her family about the plan of treatment and her condition.

73. However, as a team, it regrets that Mrs L’s family did not receive daily communication. It recognised this was not good practice and does not support its ethos of delivering compassionate care to patients and their loved ones. It recognised as a service it needs to improve and has shared Mr L’s family experience with the wider team for reflection and learning. It apologised for the distress this caused Mr L and his family.

74. Based on the Trust’s and Mr L’s account we consider there was at times, a lack of communication from the Trust.

75. Having seen indications of failings, we looked at whether this had a negative impact on Mr L and his family, and, if so, whether the Trust has put things right. We do not normally progress complaints to detailed investigation where we find appropriate action has been taken to put things right or if we cannot link the impact to the failing.

76. We recognise the lack of communication caused Mr L and his family distress at an already difficult time.

77. Our Principles explain there are a range of appropriate remedies available to an organisation when it has done something wrong, which has led to an injustice. These include apology, explanation, acknowledgement of responsibility and remedial action, for example service improvements to minimise the risk of this happening again

78. Mr L would like an acknowledgment of what went wrong, an apology for the impact caused and service improvements.

79. The Trust acknowledged that communication should have been better and apologised for the distress caused. It took action to minimise the risk of this happening again, including:

• Providing feedback and learning to the relevant ward staff.

• Discussed at the Trust’s Acute Surgical Governance and Morbidity and Mortality in late May 2025 to improve communication both with families and within its clinical teams.

80. We consider the action taken by the Trust is in line with our Principles. We will not progress this to our detailed investigation stage.

81. We are sorry to learn of Mr L’s complaint about the Trust. Our decision is not made without recognition of the impact his and his family’s concerns have had, 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 Mr L and his family’s experiences with the Trust. We acknowledge the difficult circumstances around this complaint, and the impact this had. We recognise this was, and continues to be, a difficult time for him and his 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.