Mersey and West Lancashire Teaching Hospitals NHS Trust

1. Mrs B complains when her husband was in hospital on 25 February 2023, the Trust failed to appropriately escalate his care in response to his high national early warning score (NEWS), delayed taking a chest X-ray and arterial blood gas (ABG) test, and delayed restarting antibiotics.

2. Very sadly Mr B died in hospital on 26 February 2023. Mrs B thinks her husband’s death could have been avoided, if not for these failings and delays in his care. She is left devastated by the loss of her husband.

3. To resolve her complaint, Mrs B would like the Trust to acknowledge its failings and apologise for their impact. She seeks improvements, for lessons to be learned and action taken to ensure these failings do not happen to anyone else in future. Mrs B is open to receiving a financial payment, in recognition of the impact caused by these Trust failings.

9. Mr B was admitted to the Trust on 15 February 2023 for a planned surgery for his colon cancer. Mr B remained admitted following his surgery.

10. This complaint is about events on 25 February. When Mr B’s vital observations were checked at 5.45am that morning, he had a national early warning score (NEWS) of 6. NEWS is a national tool where six physiological measurements are recorded and given a score, to help identify an acutely unwell or deteriorating patient. A further NEWS at 6.35am was also a 6.

11. Mr B was reviewed at a ward round at 10.02am when his NEWS remained 6, and he complained of breathlessness. The plan was for chest X-ray and an arterial blood gas (ABG, a blood sample taken from an artery to test the function of the lungs), and a CT scan depending on the results of those two tests.

12. At 3.37pm Mr B’s NEWS was 5. The chest X-ray was booked as urgent at 4.28pm and taken at 8.47pm.

13. Mr B’s NEWS was 9 at 9.57pm and the medical emergency team (MET) were called, attending at 10.05pm. They noted the chest X-ray findings of bilateral consolidation (when air in the small airways of the lungs is replaced with fluid) and worked on the diagnosis of aspiration pneumonia (a lung infection caused by inhaling food, liquid, saliva or vomit into the lungs).

14. The MET plan included an ABG. Results of the ABG were documented at 10.27pm, reviewed at 10.35pm, and indicated Mr B had type 1 respiratory failure. The medication chart shows two types of antibiotics were prescribed at 10.34pm and the Trust’s complaint response says both were administered at 11pm.

15. An intensive care unit (ICU) consultant review at 11pm concluded Mr B would not benefit from critical care due to his multiple comorbidities (health conditions present at the same time) and likely multiorgan failure. This was discussed with the medical specialist registrar at 11.20pm and at 12.09am into 26 February, an entry notes family were informed the team were seeking a second ICU opinion.

16. At 12.20am the second opinion concluded that admission to ICU for ventilation support would sadly not be of benefit. News that Mr B was to remain on ward-based care was delivered to family at 12.45am when a ‘do not attempt resuscitation’ order was put in place. Mr B sadly died at 3.26am, with the record of inquest documenting this as due to aspiration pneumonia.

17. Remaining unhappy with the responses received to her complaint, Mrs B asked us to investigate.

21. Mr B likely aspirated in the early morning of 25 February, as indicated by the sudden and acute nature of his deterioration, resulting in a NEWS of 6 at 5.45am. NEWS2 guidance explains that scores of 5 or more should trigger an urgent response. In line with guidance, the nurse should immediately inform the medical team and request urgent clinical assessment, with minimum hourly onward monitoring.

22. This is what should have happened when Mr B’s NEWS was 6 at 5.45am and again when it was rechecked and remained 6 at 6.35am. Whilst the minimum hourly monitoring was adhered to initially by the repeated NEWS check at 6.35am, there is no evidence to show any escalation of Mr B’s care on either occasion, nor onward hourly monitoring after the second NEWS of 6.

23. We cannot see that he was seen by a clinician until 10.02am, and this was due to the morning ward round and not because the appropriate earlier escalation had been made. We identify service failure on both occasions, in the failure to respond and escalate accordingly in line with NEWS2 guidance.

24. Our surgical and intensivist advisers say on both occasions Mr B’s NEWS should also have triggered the sepsis protocol. This says when NEWS is 5 or 6 and the patient has one of a list of certain factors, they should be considered at high risk and the Sepsis Six started. One of those factors is ‘deterioration since last assessment’, which applied in Mr B’s case, considering his NEWS when checked at 4.40am was 2.

25. The sepsis protocol outlines six actions for treatment – the Sepsis Six – that should be taken within one hour of awareness of the patient being at high risk. These are: inform a senior clinician; give oxygen if required; send bloods; give antibiotics; give intravenous fluids; monitor. We do not find evidence to show any of these actions were taken within an hour of either 5.45am or 6.35am NEWS observations. We identify service failure on both occasions, in the failure to act in line with the sepsis protocol.

26. Our intensivist adviser says a request for input from a senior clinician within the intensive care or critical outreach team should also have been made at 6.35am, when NEWS was repeated. This was due to Mr B being found to have a raised respiratory rate of 30, a high temperature of 38.5⁰C and requiring supplemental oxygen to achieve an oxygen saturation level of 96%.

27. This would have been in line with NICE CG51. This says for those patients at a medium risk of clinical deterioration, which applies here, not only should an urgent call be made to the primary treating team but also: ‘a simultaneous call to personnel with core competencies for acute illness’. We do not find evidence this occurred. We identify service failure, in the failure in act in line with NICE CG51.

28. At 10.02am Mr B’s NEWS was again 6, with a score of 3 for high respiratory rate, and a temperature of 38.1⁰C. NEWS2 guidance explains a score of 3 in any single parameter itself should trigger an urgent response. Whilst there was no need for the required escalation to clinical staff under NEWS2 guidance, owing to this being a direct clinical review at the time, the raised NEWS still required minimum hourly onward monitoring. Records do not show this occurred. We identify service failure, in the failure to respond accordingly in line with NEWS2 guidance.

29. Our surgical adviser says these findings at the 10.02am ward round should have triggered a concern for possible sepsis. Mr B’s breathlessness, high temperature, increased oxygen needs and his recent problem of ileus (bowel not functioning after surgery) indicated there was a respiratory problem, most likely pneumonia or aspiration.

30. Records show the clinician at the ward round did appropriately consider a respiratory problem, as their plan included chest X-ray and an ABG. With the subsequent plan for CT scan depending upon those results, it appears the clinician was considering the possibility of an embolism (blood clot in the lung). Whilst not unreasonable, our surgical adviser says Mr B should also have been examined for possible sources of infection, specifically within the respiratory system, considering NEWS findings were indicative of sepsis. This was a further occasion the sepsis protocol should have been followed. We identify service failure, in the failure to act in line with the sepsis protocol.

31. The morning ward round plan included an ABG. Our surgical adviser explains this was requested to assess the function of the lungs and would have helped determine whether a clot was more likely. Our surgical adviser explains an ABG was not an essential test to make the diagnosis of lung infection, as this can be made using clinical judgement, physical examination and NEWS findings, and should reasonably have been made at that time.

32. Although an ABG was not essential in this circumstance, our surgical adviser explains it should have been done reasonably within an hour of it becoming part of Mr B’s clinical management plan. This would have been in line with GMC guidance which says clinicians must promptly provide or arrange investigations. There is no evidence an ABG was taken at all prior to the later request made by the MET at 10.05pm. We identify service failure, in failing to enact the management plan in line with GMC guidance.

33. The morning ward round plan also included chest X-ray. Our surgical adviser says this should have been done urgently, within one to two hours of it becoming part of Mr B’s clinical management plan. Whilst there is no specific guidance for its timing, our surgical adviser says this is a reasonable timescale in line with the GMC guidance outlined above. Records show the X-ray was not booked until 4.28pm and despite being booked as urgent, was not taken until 8.47pm, constituting considerable delays. We identify service failure, in failing to enact the management plan in line with GMC guidance.

34. At 3.37pm Mr B’s NEWS remained high, at 5. In line with NEWS2 guidance, this should have triggered an urgent request for medical review and would have again indicated commencement of the sepsis protocol. We again find no evidence this occurred and identify service failure in the failure to act in line with both pieces of guidance.

35. At 9.57pm Mr B’s NEWS was 9 and NEWS2 guidance was followed with the required escalation of his care. A MET call was made with an appropriately emergent response time. The MET assessment resulted in Mr B receiving the appropriate treatment in line with the sepsis protocol, having blood cultures and tests including an ABG, and receiving antibiotics and intravenous fluids by 11pm.

36. It remains that from the first raised NEWS score at 5.45am on 25 February, we have identified numerous occasions where the Trust failed to act accordingly and follow guidance, missing several opportunities to have provided Mr B the appropriate care and treatment.

Impact 37. Had the Trust taken the appropriate action in response to the first raised NEWS at 5.45am, our surgical and intensivist advisers confirm that in line with NEWS2 guidance and the sepsis protocol, Mr B should have received a clinical review and had Sepsis Six treatment started by 6.45am.

38. Had the request for critical/intensive care review been made at 6.35am, our intensivist adviser explains this would have allowed early consideration of Mr B’s candidacy for transfer to a level 2 bed for ongoing respiratory support. Intensive Care Medicine guidelines define level 2 care as critical care. It is for patients requiring increased levels of observations or interventions of support for organ systems, to prevent further deterioration.

39. Intensive Care Medicine guidelines state: ‘Minimising delays to definitive treatment is associated with better outcomes. Escalation of care up to and including intensive care admission must be timely…’, that: ‘This is particularly relevant for patients requiring an unplanned admission…’. It goes on to say: ‘Unplanned admissions to the critical care unit must occur within four hours of making the decision to admit’.

40. Our intensivist adviser considers it highly likely Mr B would have been deemed a candidate for intensive/critical care, considering his acute deterioration from likely aspiration and his clinical baseline prior to surgery. In line with the above guidance, reasonably he should have been receiving care within an intensive/critical care environment by mid-morning on 25 February.

41. This would have meant increased levels of observation and close monitoring alongside treatment in line with the Sepsis Six. Had action been taken as it should, this would have resulted in care and treatment that would have given Mr B the best possible chance of recovery.

42. We know how concerned Mrs B is, to think her husband may not have died if not for these failings. We have considered this very carefully.

43. Mr B was 76 years of age and was in hospital for a major cancer surgery. The pre-operative anaesthetic review before surgery noted his functional capacity as ‘quite good’ and that he could walk for an hour on the flat continuously without any cardiorespiratory symptoms. Using the Rockwood Frailty Scale, our intensivist adviser says Mr B would have been assessed as having a score of 3, defined as: ‘people whose medical problems are well controlled but are not regularly active beyond routine walking’.

44. Mr B had several pre-existing comorbidities. He had hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD, a group of lung conditions that cause breathing difficulties), asthma and obstructive sleep apnoea (when breathing stops and starts during sleep).

45. Mr B also had several heart conditions. He had mild to moderate left ventricular failure with an ejection fraction of 45% (where the left ventricle weakens and pumps less blood into the body). He had aortic regurgitation (where the aortic valve does not close tightly, causing blood to leak backwards into the left ventricle). He also had atrial fibrillation (an irregular and often fast heart rate), and a right bundle branch block (when the right ventricle is not directly activated by the electrical pulses within the heart).

46. Our intensivist adviser says these conditions would reasonably classify Mr B as a Level 2 on the New York Heart Failure Classification Scale (a widely used system to categorise heart failure severity). As explained by the British Heart Foundation, this level describes patients who experience a slight limitation of physical activity, indicating the heart is working harder to keep up with the demands of the body. Mr B was not on any diuretic treatment, which our intensivist adviser explains to be one of the mainstays of symptomatic heart failure.

47. Following his cancer surgery Mr B developed an ileus (a reduction in bowel motility leading to a non-physical obstruction of the bowel and delayed gastric emptying). As a consequence, he developed an aspiration pneumonia and respiratory failure on 25 February, ten days post-operation. As evidenced by findings within Studer et al. and Sparn et al.’s research studies, post-operation aspiration pneumonia carries with it a high mortality (risk of death) of around 27-30%.

48. Increasing patient age is a risk factor for mortality in this set of patients. Mr B’s age would have increased his percentage risk, as would his comorbidities. Our intensivist adviser considers Mr B’s true mortality risk, considering all relevant factors, to have been considerably higher.

49. Taking all these factors into account it means sadly he had a significantly high chance of dying, even had he received the maximum input from intensive/critical care measures and appropriate sepsis protocol treatment without delay.

50. We cannot say, even on the balance of probabilities, that Mr B’s deterioration and subsequent death would have been avoided if not for these failings. Our intensivist adviser explains that sadly, considering Mr B’s high mortality risk, it is more likely he would have died. It remains there was a remote possibility Mr B could have survived, which was compromised because of the failings.

51. Our intensivist adviser confirms the critical care decision when obtained at 11pm alongside the second opinion at 12.20am was appropriate. By that time, Mr B was sadly not a suitable candidate for intensive/critical care.

52. However, with earlier intervention from appropriate timely treatment and critical/intensive care input, Mr B would have had the opportunity of receiving the maximum therapy possible, to have given him the best chance of survival. He was denied this opportunity, and Mrs B has been caused much avoidable distress as a result.

53. Whilst the Trust has acknowledged some failures within its response to Mrs B’s complaint, it has not acknowledged the number of failings we have seen. It does not appear the Trust has carried out any work to identify if there are systemic issues that may have led to this number of failings.

54. We can see the Trust has provided sincere apologies to Mrs B for the failures it acknowledged, yet we do not see it appropriately explore or explained the impact of the failings on Mr and Mrs B. This has left Mrs B with ongoing distress over the uncertainty of the impact to her husband at the end of his life. We consider the full extent of our findings requires acknowledgement, and action is needed to remedy the impact.

4. We identify failings in all aspects of Mrs B’s complaint. We consider there was a lack of response to Mr B’s high NEWS on multiple occasions throughout 25 February, and a delay in taking an X-ray, ABGs, and providing antibiotics.

5. We cannot say the failings led to Mr B’s death. We think, sadly, it is more likely he would have died even had there been no failings. From the evidence we have seen so far, we consider these failings denied Mr B the opportunity of receiving the maximum therapy possible, and there was a remote possibility he could have survived, which was compromised.

6. The Trust has already acknowledged some failings in Mr B’s care. We can see Mrs B has been caused considerable distress with the knowledge of these missed opportunities for better care. Further, we see Mrs B has been left with uncertainty about the impact of these failings, as this was not fully addressed by the Trust. This has continued to affect her at an already incredibly difficult time of grief. We do not think the Trust has taken sufficient action to acknowledge the failings, remedy the injustice or prevent a recurrence.

7. Based on the evidence we have seen so far, we have decided to partly uphold this complaint. We have made recommendations for the Trust to analyse what led to these failings, to produce an action plan to prevent a recurrence and to provide Mrs B with a financial remedy.

8. We were sorry to hear of the circumstances that led Mrs B to bring her complaint for our consideration. We recognise what happened over the last day of her husband’s life has caused her great distress. We hope this report provides some reassurance that changes will be made.

55. We make recommendations in line with our Principles for Remedy, which are reflected in NHS Complaints Standards. These state that where poor service or maladministration has led to an injustice or hardship, the organisation responsible should take steps to put things right. They also state organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred. In line with this, we make the following recommendations:

By 17 August 2026 56. The Trust should write to Mrs B to acknowledge the failings detailed at paragraphs 23, 25, 27, 28, 30, 32, 33 and 34, and apologise for the impact this caused, detailed at paragraphs 40, 41, 50 and 52.

57. The Trust should pay Mrs B £2,500 in recognition of the impact of the failings identified in this report. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale.

58. The Trust should send us a copy of the letter it sends to Mrs B and evidence of the payment having been made to her.

59. NHS Complaints Standards state that public organisations should look for continuous improvement and use the lessons learnt from complaints to make sure they do not repeat poor service. In line with this, we make the following recommendations:

By 16 October 2026 60. The Trust should involve its patient safety specialist in carrying out further analysis of what went wrong to have led to the failings detailed at paragraphs 23, 25, 27, 28, 30, 32, 33 and 34.

61. The Trust should produce an action plan, with the support of its patient safety specialist, setting out:

• what the Trust will do, or has done, to prevent the failings from occurring again • the name of the person or team responsible for each action • when the actions will begin and when they will be completed • how the impact of the actions will be measured and monitored.

62. The Trust should send a copy of the action plan to Mrs B and to us. It should also send an anonymised copy of our final report and the action plan to the Care Quality Commission (send to safeguarding@cqc.org.uk) and NHS Improvement (send to enquiries@improvement.nhs.uk).

By 15 January 2027 63. The Trust should bring this complaint, our report and the action plan to the attention of its Board.

64. The Trust should send us evidence it has actioned this recommendation.