East Sussex Healthcare NHS Trust

4. Mrs A complains that the Trust did not carry out face-to-face consultations with her son from April 2023. She says by the time the consultant saw him face-to-face in March 2024, his condition had already deteriorated significantly. Mrs A says the lack of in person assessments contributed to the progression of his illness and, ultimately, his death in June 2024.

5. Mrs A also complains the Trust did not adequately communicate the seriousness of her son’s illness with him. As a result, she feels the Trust did not give her the opportunity to understand and come to terms with the severity of his illness and the likelihood of a poor outcome.

6. By bringing her complaint to our office, Mrs A is seeking a sincere apology and a financial remedy.

7. Mr A had a telephone consultation with a consultant gastroenterologist in April 2023. He had high liver enzymes and hepatosplenomegaly, indicating an enlarged liver and spleen. The consultant arranged further liver function tests and advised Mr A to stop drinking alcohol and reduce his weight.

8. The consultant had another telephone consultation with Mr A in October. The tests showed Mr A had alcohol related liver disease. The consultant arranged an MRI scan of his liver and sought a second opinion from another Trust.

9. The consultant then saw Mr A face-to-face in March 2024. Mr A’s care had been discussed in a recent multi-disciplinary meeting, who confirmed he had chronic liver disease. The plan was to review him in due course after a lymph node biopsy.

10. Mr A was admitted to the Trust on 12 June, with acute chronic liver failure. He sadly died on 16 June with decompensated chronic liver disease.

14. Mrs A says the consultant should have arranged to see her son face-to-face, either in April 2023, and before March 2024. She says the lack of face-to-face clinical assessments contributed to the progression of his illness.

15. The GMC’s good medical practice guidance says doctors ‘must provide safe and effective clinical care whether face to face or through remote consultations, via telephone, video link, or other online services. If you can’t provide safe care through the mode of consultation you’re using, you should offer an alternative if available.’

16. In essence, telephone consultations are appropriate provided the absence of a physical examination does not compromise the quality or safety of the clinical assessment.

17. In April 2023, the results of Mr A’s liver blood tests showed normal bilirubin and albumin levels, which are important indicators of how well the liver is functioning. In patients with liver disease, the primary purpose of a physical examination is to identify signs of liver failure, known as decompensation.

18. Our adviser said there is no evidence to suggest Mr A had signs of chronic liver failure at that time. We have also seen no evidence to suggest a remote consultation would not be sufficient to assess his condition safely and effectively. Therefore, we consider the Trust’s decision to carry out a telephone consultation in April 2023 was in line with GMC guidance.

19. The ability to make a proper assessment had changed by October. While his bilirubin level had been normal in April at 10 (with the normal range being up to 21), it subsequently increased to 25 and had risen further to 33 by October. This deterioration suggested the possible development of early liver failure, making a physical examination significantly more important.

20. Given the rise in bilirubin to 33, our adviser said a baseline physical examination should have been carried out. This would have allowed the consultant to check for signs of decompensation, such as fluid retention in the ankles or abdomen. The failure to do this was not in line with GMC guidance, as it became increasingly difficult to provide a safe and effective assessment through a remote consultation alone. A face-to-face consultation would have allowed a more comprehensive clinical assessment and would have been the more appropriate mode of consultation in the circumstances. This is a failing.

21. We do not consider this failing caused or contributed to Mr A’s death. Our adviser said even if a physical examination had been carried out in October, we have seen no evidence to suggest this would have changed the outcome.

22. The consultant had already provided the correct advice to Mr A in April 2023, regarding the importance of abstaining from alcohol and making lifestyle changes to improve his health.

23. Mrs A told us her son stopped drinking in January 2024, following an admission to hospital. By that stage, his liver disease had progressed to the point where abstinence was unlikely to allow his liver to recover. There was also insufficient time for liver transplantation to be seriously considered as an option.

24. For these reasons, we do not consider the lack of physical examination in October 2023 had a significant impact on the clinical outcome. We have seen no indication to suggest this would have changed the course of Mr A’s illness or prevented his death.

25. We have, however, identified concerns regarding communication throughout stages of Mr A’s care. Mr A had a telephone consultation in April and October 2023, admission in January 2024 and another follow up telephone consultation the same month. He also had two more hospital admissions in April and June.

26. Mr A’s clinical records indicate a clear pattern of deterioration during this period, and it would have been apparent to the treating clinicians that Mr A’s prognosis was poor. Despite this, we have seen no evidence to indicate the Trust discussed the seriousness of his condition, the likelihood of further deterioration, or the possibility of death, with Mr A and his family.

27. This poor standard of communication was not in line with GMC guidance which says patients should be provided with clear and honest information about their health so that they can make informed decisions about their care and prepare for the future. Mr A was entitled to receive clear and honest information which would have helped him to understand the seriousness of his condition, participate in discussions about his care and share his final wishes to those close to him.

28. The absence of such discussions also left Mrs A unprepared for her son’s death, resulting in the shock and distress of what felt like a sudden and unexpected loss.

29. We recognise how difficult and upsetting this experience must have been for Mrs A. Losing a loved one is profoundly distressing, and Mrs A’s concerns that important information about the seriousness of her son’s condition was not clearly communicated by the Trust, has significantly compounded her grief. This had not yet been acknowledged or remedied by the Trust.

1. Mrs A sadly lost her son, Mr A, on 16 June 2024. We are incredibly sorry for her loss. We know our investigation cannot change what happened or take away her pain. We sincerely hope our report addresses the concerns she has about what happened.

2. We found the Trust should have carried out a face-to-face consultation with Mr A in October 2023. We have seen nothing to suggest this had an impact on him. We also found the Trust failed to communicate the seriousness of Mr A’s illness with him and his family. Had it done so, we consider Mrs A would have had more time to come to terms with the severity of his illness and the likelihood of a poor outcome.

3. Considering the significance of our findings, we have decided to partly uphold the complaint. We recommend the Trust pays Mrs A £600 to recognise the impact this failing had on her. We appreciate no amount of money can change what happened.

30. 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.

31. 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.

32. We have identified failings in the Trust’s communication with Mr A and his family. The lack of effective communication left Mrs A unprepared for her son’s death, resulting in the shock and distress of what felt like a sudden and unexpected loss.

33. With that in mind, we recommend that following this final report the Trust:

• writes to Mrs A, by 30 July 2026, to acknowledge the failing we have found and apologise. This means acknowledging the failing, accepting responsibility and expressing sincere regret for the resulting injustice.

• pays Mrs A, by 30 July 2026, £600 to recognise the immense distress our findings have caused.

• explains what action it will take, or has taken, to address the failing by 24 September 2026. It should do this in the form of an action plan which should be shared with us, the complainant, the Care Quality Commission (CQC) and NHS England.

• 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, (if possible) what the Trust will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.