Shropshire Community Health NHS Trust

11. Mrs P complains about aspects of care and treatment her father, Mr B, received at Shropshire Community Health NHS Trust (the Trust) during his inpatient stay in August 2024 and following his discharge. She specifically complains:

• the amount of physiotherapy Mr B received was inadequate • Mr B had a stroke during his stay at hospital, and the Trust failed to provide him with the appropriate care • an outpatient MRI should not have been offered if the results of his CT scan were normal • Mr B deteriorated from walking into hospital to being stretched home • there was delay in receiving the discharge summary for Mr B.

12. The experience has affected the family significantly, as the strain and stress on the family has been enormous. This is ongoing today as they remember the experience of what Mr B went through. It has been heart-breaking and the family feel the experience was unnecessary.

13. By bringing her complaint to us, Mrs P wants no one else to go through a similar experience.

14. A computer tomography (CT – a medical imaging test that uses X-rays and a computer to create detailed images of internal organs, bones, blood vessels and soft tissues) scan of Mr B’s head and neck were undertaken at the end of July 2024 at hospital.

15. The results showed significant age-related cerebral atrophy. Cerebral atrophy is the loss of connections within the brain, which often results in a reduction of brain volume and function.

16. There were no signs of bleeding within the skull or an indication of a stroke.

17. Mr B was admitted by the nursing staff at the beginning of August, and he required rehabilitation following a fall.

18. In the lead up to his admission, Mr B had several falls, and he informed the staff he fell when his knee gave way.

19. Mr B assessed by the physiotherapist, who noted he required maximum assistance from one person to transfer from lying to sitting on the edge of the bed. He could mobilise short distances with a Zimmer frame and assistance from one staff member but experienced his right knee giving way.

20. The physiotherapist identified reduced muscle power and attributed his poor mobility to deconditioning.

21. The therapy plan focused on mobilisation and lower limb strengthening exercises.

22. Mr B was also assessed with a frailty score of five, indicating mild frailty which suggested he was slowing down and may require assistance. He had no other significant health conditions affecting his cardiovascular, respiratory, gastrointestinal, or central nervous systems.

23. A reablement package of care and therapy support at home was suggested by the occupational therapist.

24. At the beginning of August, the physiotherapist noted Mr B sitting balance had improved.

25. Shortly after his stay, Mr B had a medical review by the doctor and raised concerns about hip pain but did not require pain relief. The plan going forward was to administer regular paracetamol (pain relief) and to discontinue dose of tamsulosin (treats symptoms of enlarged prostate and kidney stones) to avoid the dropping of his blood pressure when standing up after lying or sitting down.

26. Mr B was assessed by the physiotherapy team where he had mobilised and sat out in the chair. His standing blood pressure measured there was no postural drop. He had pain in his hips and lower back while weight bearing.

27. Postural drop is a drop in blood pressure when standing from a sitting or lying position.

28. Throughout his stay, Mr B received regular physiotherapy and occupational therapy input. He participated in bed exercises, mobilisation with a Zimmer frame, and strengthening exercises, while therapists made adaptations to meet his needs.

29. His progress included improved sitting balance, although he experienced ongoing challenges with mobility and discomfort during weight-bearing.

30. Concerns about Mr B’s balance, reduced muscle strength, and knee pain were escalated by therapists to the attending doctor, who adjusted Mr B’s treatment plan.

31. Further assessments showed he experienced dizziness, leaning to one side, and discomfort in all chairs provided. It was also documented there was muscle wasting and longstanding osteoarthritis (common condition that affects the joints, causing pain, stiffness and problems moving) of his back.

32. Around mid-August Mr B was noted to not progressing as well with his physiotherapy and was assessed as having a National Early Warning Score (NEWS2) score as 0.

33. NEWS2 is a system where physiological measurements (including respiratory rate, oxygen saturations, temperature, systolic blood pressure, pulse rate and level of consciousness) are taken and given a score. A high NEWS2 does not provide a diagnosis but it helps identify a sick patient who is deteriorating and requires urgent clinical review in a standardised way.

34. Around the same time, observations of minor facial changes raised concerns about a possible stroke, but these were reviewed by a doctor who found no consistent evidence of a stroke or transient ischaemic attack (TIA).

35. A transient ischaemic attack (TIA) or ‘mini stroke’ is caused by a temporary disruption in the blood supply to part of the brain. A stroke is when blood stops flowing to a part of the brain. It can affect things like speech and movement and takes a long time to recover. A stroke needs urgent medical help in hospital because it can be life-threatening.

36. Discharge planning was coordinated by the therapy and occupational therapy teams. Recommendations included a reablement care package and adjustments to his home environment, such as a profiling bed and a riser recliner chair. Home visits were conducted by the therapy team in mid-August to assess equipment needs and ensure they were set up for his return.

37. Mr B declined to mobilise out of bed in the morning on one occasion but was able to sit out for lunch later that day. As his mobility became inconsistent, requiring assistance to transfer with a wheeled Zimmer frame and two staff members, a Sara Steady (a sit-to-stand aid) was ordered to ensure he could be safely supported at home should his mobility deteriorate further.

38. The therapy team conducted another home visit to check and adapt equipment to ensure they were set up for his discharge.

39. Later in the month, Mr B was assessed as ready for discharge, but transport delays postponed his return home by a day. He was discharged the following day.

40. Once discharged, the community therapy team attended Mr B’s home. After the carers had left, he slipped and fell out of his chair. The family called the agency to the carers to come back help to put him into bed.

41. Mr B required assistance of two people to mobilise to the edge of the bed, and he had very poor sitting balance. It was noted as Mr B was very unsteady and wavering to the right and forward.

42. It was also documented by the therapists Mr B stood using the Sara Steady but did require encouragement to remain standing.

43. Following Mr B’s discharge, his daughter requested his discharge summary from the ward.

44. The therapy team contacted Mr B’s home towards the end of August and was informed by Mr B’s wife he was admitted into hospital.

Physiotherapy

48. Mrs P complains the amount of physiotherapy and rehabilitation her father received was inadequate.

49. In its complaint response of October 2024, the Trust outlined when Mr B was transferred to the ward, he had a right sided weakness and had fallen at home when his right knee gave way. He has been transferred to the hospital for rehabilitation following his fall.

50. The Trust explained rehabilitation is undertaken by the Trust’s team of therapists and support workers. The Trust said when they are not on the ward, the plan for each patient is continued by other professions including the nursing staff.

51. The Trust outlined the clinical records detail which shows Mr B was seen by the occupational therapy and physiotherapy team at the beginning of August. It also outlined he had a plan of bed exercises, and he received input from both the therapy team.

52. We considered whether Mr B received the appropriate rehabilitation services.

53. The records show upon Mr B’s admission at the hospital, he was assessed on the Frailty Assessment Unit. The assessment records show Mr B had experienced worsening mobility difficulties since a total knee replacement in February 2024.

54. The evidence also indicates Mr B’s mobility had regressed from walking with one elbow crutch to a wheeled Zimmer frame. The medical notes show his knee had been giving way and this was a contributing factor to an increase in his falls. Mr B had four falls in the month prior to admission to hospital.

55. As an inpatient in the hospital, the notes show Mr B was reviewed by a physiotherapist 11 times and received input from occupational therapists and therapy assistant staff during his stay.

56. Though no national guidelines specify how often older individuals should receive rehabilitation, Mr B’s records show he was regularly supported with an exercise programme to address his muscle weaknesses and mobility issues.

57. Health and Care Professions Council’s (HCPC) ‘The standards of proficiency for physiotherapists’ state in section 4.3 physiotherapists should ‘make reasoned decisions to initiate, continue, modify or cease treatment, or the use of techniques or procedures, and record the decisions and reasoning appropriately’.

58.  Throughout the physiotherapy records, our physiotherapist adviser says the physiotherapist assessed and noted Mr B’s muscle weakness, mobility and balance, any changes in this, and modified treatment appropriately.

59. The above is also in line with HCPC’s guidance as noted in paragraph 52 which says ‘evaluate intervention plans to ensure that they meet the physiotherapy needs of service users, informed by changes in circumstances and health status’.

60. The physiotherapist provided exercises which Mr B could do in bed or in his chair, and sourced alternative seating where available to enable Mr B to sit more comfortably.

61. For example, the occupational therapy notes state ‘exercise routine discussed and aim for regime of three times daily bed and chair. The exercises will build strength and hopefully maintain function for a microenvironment’.

62. The records show the physiotherapist discussed Mr B’s balance and mobility deterioration with the GP in mid-August.

63. This is in line with General Medical Council’s (GMC) guidance on ‘Good Medical Practice’ which says, ‘refer a patient to another suitably qualified practitioner when this serves their needs.’

64. Additionally, the occupational therapist and nursing staff addressed family concerns about Mr B’s low mood, possibly linked to being in a side room, by moving him to a bay.

65. GMC in ‘Good Medical Practice’ recommends practitioners to ‘being alert to signs of pain or distress and taking steps to alleviate pain and distress whether or not a cure may be possible.’

66. From the therapy records, our physiotherapist adviser explains there is no indication Mr B received sub-standard therapy treatment. The evidence shows he was seen regularly, provided with one-to-one physiotherapy and exercises and opportunities to carry out exercises without direct supervision both in bed and in a chair.

67. The records also show transfers out of bed were encouraged, and appropriate moving and handling equipment was suggested. In the event of changes in Mr B’s condition, treatment was modified accordingly.

68. As such, we cannot see anything went wrong in this aspect of Mr B’s care and treatment.

69. We understand and deeply appreciate Mrs P’s concerns about the level of physiotherapy and rehabilitation provided to her father at the time. We recognise how the care and treatment Mr B received may have been a source of significant worry and distress for the family, and we acknowledge the impact this may have had on their emotional wellbeing.

Stroke

70. Mrs P says she and her father’s visitors during his stay in hospital, noticed a change in him early in August. They noticed he was not moving his legs properly and struggling to pull himself up on the bed as he only had his arms to aid him. She says he had not filled in any of his exercise forms.

71. She adds couple of days later, it was noted her father was sleeping a lot more, not eating well and had no interest in watching television. His speech was slurred, and he was using urine bottles as he could not get to the toilet.

72. Mrs P raises her concerns about nothing is documented about her father’s facial changes.

73. Mrs P says her father arrived home later in the month of August, and he was incontinent, unable to move his legs at all, unable to speak, and he could only move his leg uncoordinatedly. She says the family had carers coming in four times a day to assist him in daily functions.

74. Mrs P further says Mr B’s GP came to see him and said he had a stroke.

75. In its complaint response, the Trust explains there is no evidence of a stroke occurring around in mid-August. His clinical observations showed he was stable.

76. He was reviewed by the medical doctor who documented although minor facial changes had been remarked by a member of staff, these changes had not been consistently observed, had fully resolved and there were no other signs or symptoms of a stroke.

77. It also referred to a previous CT scan which did not show any evidence of a stroke.

78. The Trust was assured Mr B was assessed appropriately and treated accordingly during his stay.

79. In its further response, the Trust says had the family’s concern at the time been highlighted to him, this would have triggered a discussion and an appropriate change in plan would have been taken if necessary.

80. We considered whether Mr B should have received an assessment for a suspected stroke based on his presentation during his stay in hospital.

81. The records note in mid-August at 12.35pm a doctor reviewed Mr B, and recorded ‘Physio concerns re mobility, facial changes earlier in week, BP [blood pressure] erratic… P MRI to check’.

82. Our physician adviser says the combination of the minor facial changes, change in mobility, and erratic blood pressure would add to concern about a possible stroke.

83. While it is not reflected in the medical records, the family report they had significant concerns about a deterioration in Mr B’s condition.

84. GMC’s Good Medical Practice 2014 guidance states doctors must:

• ‘adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’

85. Our physician adviser says the clinical changes and the family’s concerns should have warranted a detailed clinical history and examination. We cannot see any evidence of this taking place, and as such indicates a failing.

86. Our physician adviser notes the importance of considering the expectations from the wider multidisciplinary team, as Mr B was being cared for in a nurse-led community rehabilitation unit.

87. In such settings, any significant change in Mr B’s functional abilities could have been observed by members of the nursing, therapy, or medical team, who would be expected to raise concerns if any notable changes in an individual’s abilities were documented over a short period of time.

88. Around the time the changes were noticed by the family member, the evidence show there were clinical findings of concern raised by a physiotherapist on one occasion. The physiotherapist noted Mr B’s mobility had changed.

89. Having previously been able to sit on a side of a bed and mobilise two meters with a frame and assistance, by mid-August Mr B was ‘struggling with sitting balance at the edge of the bed [and leaning] to the right side.’ The records also report he felt unwell in sitting.

90. On subsequent review by the doctor, an acute stroke does not appear to have been considered.

91. Our physician adviser explains this was a complex presentation of stroke, and it is not possible to determine retrospectively the exact time of onset of the stroke, which was diagnosed less than two weeks later.

92. According to the National Institute for Health and Care Excellence (NICE) guidelines on ‘Stroke and transient ischaemic attack in over 16s: diagnosis and initial management’ recommends people with sudden onset of symptoms suggestive of a stroke or a TIA should be assessed clinically at the earliest opportunity.

93. Our physician adviser also comments the subsequent events strongly suggest the stroke may have occurred during this admission. The symptoms Mr B experienced during this time were significant enough to warrant an urgent clinical review. We cannot see the above took place, and this indicates a failing.

94. Our physician adviser highlights there are alternative factors to consider in Mr B’s presentation. His degree of frailty, previous episodes of delirium (a sudden change in a person’s mental function), which can be triggered by a change in environment such as hospitalisation, multiple joint problems and back pain could have impacted his mobility.

95. Additionally, his recent history of poor mobility, falls, and deconditioning (a rapid decline in physical and physiological function due to inactivity) are all conditions which could cause a deterioration or fluctuation in his abilities. These factors represent possible diagnoses aside from a stroke.

96. While we recognise Mr B’s presentation may have been influenced by other potential differential diagnoses, these possibilities did not remove the need to consider and exclude an acute stroke. Given the nature of his symptoms, an urgent clinical assessment based on Mr B’s clinical changes, an urgent clinical assessment to evaluate for stroke would have been appropriate. This is line with the NICE guidance ‘Stroke and transient ischaemic attack in over 16s: diagnosis and initial management’ as referred to in paragraph 92.

97. The evidence does not indicate a review took place at the time the clinical changes were observed to rule out a stroke. We consider this significant considering the subsequent clinical timeline, which confirms Mr B was diagnosed with a stroke shortly afterwards.

98. Although we cannot definitively conclude Mr B’s earlier symptoms were solely attributable to a stroke, the absence of an urgent assessment meant this time-critical diagnosis was not promptly investigated or excluded. As such, we consider this indicates a failing.

99. We took our concerns to the Trust on 8 July 2026 to outline the indications of failings. The Trust acknowledged our concerns and said it ‘will ensure [the Trust] fully support[s] in reaching an effective resolution and implementation of an action plan.’

100. The above is in line with NHS Complaint Standards which say ‘Organisations openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They make sure staff can offer a range of ways to put things right for the individual. Staff also look at what action will be taken to learn from the experience to continuously improve services and help support staff.’

101. We consider the Trust has taken sufficient steps to put things right for Mrs P and her family.

102. We recognise the impact of noticing changes in a loved one can be challenging and distressing. We also understand the uncertainty surrounding whether an earlier assessment may have altered the course of Mr B’s care can be deeply distressing. We acknowledge the anxiety, frustration and emotional burden Mrs P and her family may have experienced. It is important concerns such as these are carefully considered to ensure these issues do not arise again.

Outpatient MRI

103. Mrs P questions why an outpatient MRI was considered and offered if the results of his CT scan were normal.

104. In the Trust’s response of October 2024, an MRI scan was booked as it can sometimes identify types of stroke or other brain injuries which cannot be seen on a CT scan. This was due to be performed after Mr B’s return home.

105. In its complaint response of March 2025, the Trust explains the medical doctor visited Mr B in mid-August and reviewed the results of the CT scan. The doctor noted Mr B had significant muscle wasting on his right side and made the decision to investigate further.

106. We considered whether the correct decision was made to offer an MRI scan following Mr B’s CT scan results.

107. Our physician adviser explains the MRI head scan was requested to identify chronic brain changes, such as previous strokes or other brain injuries, which may not have been detected on the earlier CT head scan. They advise this was a reasonable decision given Mr B’s' multiple comorbidities and the various possible causes of his reduced mobility.

108. While our physician adviser comments it was reasonable to test to consider if there were any ongoing concerns about Mr B’s physical abilities and mobility, it was not an appropriate test if an acute stroke occurring in the last day or days was suspected.

109. The appropriate test would either be an urgent CT head scan or an urgent MRI scan along with an assessment in a hyperacute stroke centre.

110. The National Clinical Guideline for Stroke for the United Kingdom and Ireland in ‘Acute care’ recommends:

‘A) Patients with suspected acute stroke should be admitted directly to a hyperacute stroke service and be assessed for emergency stroke treatments by a specialist clinician without delay. [2016]

B) Patients with suspected acute stroke should receive brain imaging as soon as possible (at most within 1 hour of arrival at hospital). [2023]

F) MRI brain with stroke-specific sequences should be considered in patients with suspected acute stroke when there is diagnostic uncertainty. [2023]’

111. While we consider the decision to offer an outpatient MRI scan to be reasonable in the context of investigating potential long-term contributors to Mr B’s mobility issues, we also recognise this approach did not meet the requirements for managing a suspected acute stroke. As such, this indicates a failing.

112. In these circumstances, immediate imaging and an urgent referral to a hyperacute stroke service would have been appropriate. The management of Mr B’s suspected stroke and his clinical condition is discussed in the ‘Stroke’ section, and the Trust has agreed to take further action to resolve this issue with service improvements.

113. We recognise Mrs P and her family were worried about why a further imaging investigation took place, especially when the family were already experiencing worries about the changes in Mr B’s clinical presentation. We do not wish to undermine their worries with our consideration.

Deterioration

114. Mrs P complains her father arrived home unannounced on a stretcher on 20 August 2024. On arriving home, the family found he was now incontinent, unable to move his legs at all, unable to speak, they could not understand him at all, and he could only move his left arm uncoordinatedly.

115. She says her father walked into the emergency department at the end of July and could have walked into the hospital at the beginning of August but during the 20 days in the hospital, he was stretchered out of there.

116. In its complaint response of 3 March, the Trust acknowledges the photos the family provided of Mr B before he was admitted into the hospital, and some from when he was discharged from the hospital.

117. The Trust says it is possible Mr B may have deteriorated in appearance due to deconditioning which is a functional decline which occurs as a result of prolonged bed rest and associated loss of muscle strength. It says this is commonly experienced through hospitalisation.

118. The Trust says the staff should have seen signs of this and acted upon it. It says this can be prevented by encouraging patients to sit up in a chair, get dressed in their own clothes and by encouraging them to move and walk.

119. While the Trust acknowledges Mr B was mobilising and undertaking his exercises, he did start to decline in his participation with this.

120. It states the care and communication on the ward could be better and earlier physically for his discharge.

121. We considered whether the care and treatment provided to Mr B was appropriate in terms of his deterioration.

122. Our physician adviser says a clear deterioration in his condition over the short period of his admission was documented, but there was a lack of acknowledgement of the significance of these changes, investigations were not requested to be certain of the cause, and to exclude serious causes such as a stroke.

123. The British Geriatrics Society (BGS) in ‘Silver Book II: Geriatric syndromes’ states ‘non-specific presentations, which are specific for older people with frailty, challenge models of care that are based on single system problems. Traditional signs and symptoms of illness can less obvious (or are less frequent) in older people with frailty. Therefore, acute illness can present with non-specific signs and symptoms such as functional decline or weakness in older adults with frailty.’

124.   As such, the unexplained deterioration in Mr B’s condition should have raised concerns about potential serious underlying causes such as a stroke as part of a holistic clinical assessment.

125. The records show there was a concern raised from a physiotherapist assessment on one occasion, and our physician adviser says there appears to be a lack of recognition by the wider multidisciplinary team of Mr B’s deterioration.

126. Mr B was in a community rehabilitation unit, under the care of a multidisciplinary team yet there was an indication of failing to recognise the significance of his deterioration or to investigate its cause.

127. We considered the Trust’s explanation about Mr B’s deterioration.

128. The Trust’s second response acknowledges that if the doctor had been made aware of the family’s concerns, adjustments to the management plan would have been considered if necessary.

129. It also recognises Mr B’s deterioration during his admission but attributes this to deconditioning. The Trust accepts that care and communication on the ward could have been improved.

130. The response notes that changes have been implemented following these events but does not provide specific details.

131. We would have expected the Trust’s response to demonstrate a clearer focus on communication with the family and between health professionals, alongside reference to the policies for raising and escalating concerns when there is clinical uncertainty or deterioration.

132. As such, we consider the actions of the Trust fall short of what we would expect from an organisation.

133. We raised our concerns with the Trust on 8 July 2026, outlining indications of failings. The Trust acknowledged these concerns and committed to supporting an effective resolution and implementing an appropriate action plan.

134. This approach aligns with the NHS Complaint Standards, which state that organisations should identify when things have gone wrong, take ownership, provide remedies, and learn from experiences to improve services.

135. Based on the evidence, we consider the Trust has taken sufficient steps to put things right for Mrs P and her family.

136. We deeply understand how distressing it can be to witness the rapid deterioration of a loved one, and we acknowledge how important timely reassurance and communication from medical professionals would have been in alleviating the family’s concerns during such a difficult time.

137. We also recognise the lack of early recognition of Mr B’s deterioration may have affected the care and treatment he received in the hospital. We want to assure Mrs P and her family we do not wish to diminish the family’s concerns, and we appreciate the courage it takes to raise these matters with us.

Discharge summary

138. Mr B was discharged from hospital on 20 August 2024.

139. Mrs P says she visited her father at home and was shocked at his appearance and condition. She called the GP surgery for someone to assess him that day, but she was informed the GP could not do this until they received the discharge summary from the hospital.

140. Mrs P had to call the hospital to get the discharge summary sent to the GP surgery. She was informed by ward staff they would have to ask the doctor in charge if it was okay to forward the discharge summary to the GP surgery.

141. The GP visited Mr B on 23 August.

142. The Trust explains in its response of October 2024, the discharge documentation was prepared on 21 August and completed on 22 August. It apologised for the lack of clarity about the ward’s ability to provide one. The Trust says it has spoken to the ward team who will ensure they can provide clear information when asked regarding discharge summaries in the future.

143. NICE guidance on ‘Transition between inpatient hospital settings and community or care home settings for adults with social care needs’ states ‘the hospital-based doctor responsible for the person's care should ensure that the discharge summary is made available to the person's GP within 24 hours of their discharge. Also ensure that a copy is given to the person on the day they are discharged.’

144. From the available evidence, it was identified the discharge summary for Mr B was not completed until two days after his discharge. This was not shared with his GP within 24 hours as per NICE guidance above, and an intervention from his family was required to expedite its delivery. As such, we consider this is an indication of a failing.

145. The Trust has agreed to take further action by writing to Mrs P with an apology and will initiate an action plan to ensure this does not happen again. This approach is in line with NHS Complaint Standards, which state ‘Organisations openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these.’

146. We fully appreciate how frustrating and worrying this situation must have been for Mrs P and her family, particularly when they had to contact their GP for care and support but were unable to proceed without the discharge summary. We understand how crucial it is to ensure that key documents, such as discharge summaries, are provided promptly to enable seamless and effective continuity of care.

147. Complaints give us valuable insight into the organisations we investigate, and we recognise this has been an emotionally challenging process for Mrs P. We would like to thank her for sharing her experience with us.

148. It is important to acknowledge where we have not identified any indications that something went wrong, it does not detract from Mrs P and her family’s experience, nor the impact this has had on them.

1. We have carefully considered Mrs P’s complaint about Shropshire Community Health NHS Trust (the Trust) and we would like to thank Mrs P for her patience and understanding as we completed our consideration of her complaint.

2. We are truly sorry to hear about the distress and difficulties caused by the care and treatment provided to Mrs P’s father, Mr B, and the concerns raised by the family as part of this. We deeply regret the additional upset and strain which has been caused during what we understand was already an incredibly challenging and emotional time for Mrs P and her family.

3. We fully appreciate the significant and lasting impact this experience has had, particularly on Mr B, who we understand was directly affected by the care he received, and on Mrs P, who has been understandably distressed by what her father endured. We are grateful to Mrs P for bringing these important concerns to us so that they could be considered further.

4. The evidence suggests Mr B received appropriate physiotherapy during his stay in hospital, and there are no indications of failing in this aspect. We acknowledge how concerning this was for Mrs P, and we do not wish to minimise the worry and anxiety this caused her and her family.

5. Having carefully reviewed the available evidence and expert advice sought, we found appropriate clinical assessments, and a review did not take place at the time Mr B’s clinical changes were observed to rule out a stroke.

6. While the Trust’s decision to offer an outpatient imaging scan was reasonable in the context of investigating potential long-term contributors to Mr B’s mobility issues, we recognise this approach did not meet the urgent requirements for managing a suspected acute stroke.

7. We also identified there was a failure to recognise the early signs of Mr B’s deterioration and to adequately investigate its cause.

8. We found that Mr B’s discharge summary was not completed until two days after his discharge. This document was then not shared with his GP within 24 hours, which falls short of national guidance.

9. The Trust has agreed to write to Mrs P to acknowledge the failings identified and to outline the actions it is taking to ensure improvements are made.

10. We fully recognise how distressing and difficult this experience has been for Mrs P, Mr B, and their family. We sincerely hope our consideration of these concerns offers some reassurance and contributes to providing a measure of closure to the complaint issues raised.