Countess of Chester Hospital NHS Foundation Trust

6. Mr Z complains about the care and treatment the Trust provided his mother, Mrs Z, between 19 and 24 January 2024. Specifically, he says the Trust: • did not provide his mother and her family with enough information about possible risks, at the right time, to allow her to give her informed consent for hip surgery • failed to identify she had pneumonia prior to surgery • did not give a required blood thinner before surgery, and his mother developed blood clots in her lungs • had repeated DNACPR discussions despite Mrs Z and the family making it clear she wished to be resuscitated.

7. Mr Z says these actions led to his mother’s unexpected death. This, alongside the Trust’s communication about consent and the DNACPR, have caused him and his family great distress.

8. Mr Z wants an acknowledgement of failings, service improvements, and a financial remedy.

9. Mrs Z, aged 82, fell at home on 18 January 2024 and was taken by ambulance on 19 January the Trust’s emergency department (ED). She was admitted with several injuries, including a fractured hip, a broken arm, and a heel injury. Before admission she lived independently and had a history of asthma, osteoporosis, and acid reflux.

10. After a CT (computed tomography) scan, she was transferred to the ward. She initially declined surgery but later consented after discussions with her son. Surgeons repaired her hip on 21 January. Although the surgeon said the surgery went well, her condition deteriorated afterwards, and she remained in recovery longer than expected.

11. The Trust diagnosed a chest infection and began treatment. Two doses of dalteparin, one due before surgery and one after, were not given. A later CT scan showed she had blood clots in her lungs (known as a pulmonary embolism). This was recorded on her death certificate as a contributing factor, along with a serious chest infection she developed in hospital (pneumonia) and her long‑standing lung condition, which made breathing more difficult for her (chronic obstructive pulmonary disease).

12. The Trust discussed a DNACPR order with the family on 23 January, but it was not enacted. On 24 January, Mrs Z developed respiratory failure and then a cardiac arrest. Resuscitation briefly restored her circulation, but she could not breathe independently.

13. The team decided further invasive treatment would not be appropriate, and Mrs Z died shortly afterwards.

Informed consent (including delay to surgery)

17. Mr Z says his mother was not given enough information about the risks of surgery, the alternatives, or the consequences of delaying the operation. He feels the consent process was rushed and that he felt persuaded by the consultant. He also says Mrs Z wished to wait for him before consenting, and the Trust did not manage this well.

18. Mr Z explained when he arrived, the consultant was already in theatre, and the discussion about surgery was held by a senior house officer (a junior doctor), which added to his concern about how the process was handled.

19. The Trust says Mrs Z had three fractures, including a fractured neck of femur (NOF), and surgery was required to restore mobility and reduce the risk of complications. It says the team explained the risks of having and not having surgery, and Mrs Z wished to wait for her son before consenting.

20.  It says delays were due to her reluctance, the need for further imaging, theatre availability, and Mr Z’s travel time. It says the consent process followed the hip‑fracture pathway and the timing of surgery was within or close to the expected 36‑hour standard.

21. Our surgical adviser noted the consent form recorded major risks, including chest infection, blood clots and death. The clinical records do not document the full detail of the discussion, which limits what we can determine about exactly what was said. However, limited documentation does not in itself show the discussion was inadequate.

22. Our surgical adviser said the overall approach appeared broadly consistent with GMC consent guidance. The guidance recognises in urgent situations such as hip‑fracture surgery, the time available for detailed discussion may be limited, and clinicians must balance time pressures with the patient’s needs.

23.  We also considered the information shared during a meeting held on a meeting held on 6 February 2024 between Mr Z and members of the clinical and nursing team. This was arranged through the patient advice and liaison service (PALS) to respond to his concerns and was not a formal local resolution meeting. No minutes were taken, but the Trust’s internal investigation summarised the discussion. In that meeting, the surgeon explained the seriousness of hip‑fracture surgery and the risks associated with Mrs Z’s condition.

24. These concerns were reiterated in an official local resolution meeting on 25 January 2025, during which Mr Z again emphasised his perception that the risks and alternatives of surgery were not sufficiently explained, leading to a persistent sense of distress about the consent process.

25. Hearing this information after his mother’s death helped us understand why Mr Z felt unprepared for the decisions made at the time and why he believed more detailed explanations might have led him to advise his mother differently. While this provides important context about Mr Z’s experience, it does not change the clinical evidence about what information was required to be given or the appropriateness of proceeding with surgery.

26. Mrs Z had capacity and wished to wait for Mr Z before consenting. The team respected this, and this contributed to the delay alongside factors such as theatre availability, and further imaging. The discussions took place at the appropriate time with a suitably qualified clinician. While Mr Z wished to speak directly with the operating surgeon, this was not possible as the surgeon was already in theatre, and this does not indicate a failing in the consent process.

27.  We recognise Mr Z felt responsible for the decisions made around surgery and this added to his distress. The clinical evidence shows the decision to proceed with surgery was appropriate, and the delay while waiting for him did not increase the risk to his mother or change the outcome.

28. Our surgical adviser also noted without surgery, Mrs Z would have been at significant risk of dying from pain and infection. Attempting the operation offered the possibility of improved mobility and quality of life. This context supports the view the team were acting in her best interests.

29.  Taking all of this into account, we find the consent process met the expected standard. The documentation could have been more detailed, but the available evidence does not show a clear departure from GMC consent guidance.

30.  On this basis, we do not currently see a failing in the consent process. We recognise Mr Z felt pressured and the risks of delay were not fully explained. The limited documentation makes this difficult to test, but the available evidence does not show the Trust failed to provide the information required.

31. We also recognise Mr Z felt unprepared for the seriousness of his mother’s condition, and hearing the surgeon’s later explanations made him feel these risks had not been fully understood at the time. We appreciate why this left him believing he might have advised his mother differently.

32. Even if the risks had been discussed in more detail, the appropriate decision would still have been to proceed with surgery, as not operating would have carried a high risk of pain, immobility and life‑threatening complications. While the discussions took place at the right time with a suitably qualified clinician, we acknowledge Mr Z feels the communication did not fully meet his needs at a very distressing time.

Failure to identify pneumonia before surgery 33. Mr Z believes his mother had signs of infection before surgery and the Trust failed to identify pneumonia. He says no checks were carried out immediately before the operation and feels this was a critical oversight that left his mother unsafe for surgery.

34. The Trust says Mrs Z was assessed on admission and again before surgery. It says the clerking, anaesthetic assessment and chest Xray did not show evidence of infection, and her respiratory deterioration occurred after surgery and was related to her underlying frailty and preexisting respiratory conditions.

35. Our surgical adviser said the preoperative assessments documented a clear chest and no significant respiratory concerns. The chest Xray did not show infection. They explained that even if a mild infection had been present, urgent hipfracture surgery would usually still proceed because delaying surgery increases the risk of immobilityrelated complications. This approach is consistent with NICE CG124 guidance, which recommends early surgery unless there is a clear clinical reason to delay.

36. Our surgical adviser confirmed, additional microbiological tests are not routinely carried out unless there are clinical signs of infection. As Mrs Z’s assessments and chest Xray did not show infection, further tests were not indicated.

37. We recognise Mr Z’s concern no checks were carried out immediately before surgery. The records show multiple clinicians assessed Mrs Z on admission and again preoperatively, and none identified signs of pneumonia. The available evidence does not show the Trust missed an infection that should have been treated before surgery.Blood thinners (dalteparin omissions)

38. Mr Z says his mother was not given dalteparin before surgery, and he believes this directly contributed to her developing blood clots and suffering a cardiac arrest. He feels this reflected a lack of preparation and a failure to follow a structured process to ensure she was safe for surgery. We recognise Mr Z was deeply concerned about the seriousness of blood clots and believed the omission directly caused his mother’s sudden deterioration.

39. The Trust accepts two doses of dalteparin were missed: one before surgery and one after. It says the omission ‘may or may not’ have contributed to a suspected pulmonary embolism (a blood clot in the lungs). It says the issue was escalated after surgery and did not lead to a change in treatment. The Trust’s view is Mrs Z’s death was mainly due to respiratory infection rather than a pulmonary embolism.

40. Our surgical adviser confirmed dalteparin doses were missed and this was not in line with NICE NG89 guidance.

41. Our haematology adviser said Mrs Z should have received preventative dalteparin on both 20 and 21 January. They said there was no clear clinical reason for the first missed dose, and this was a departure from the expected standard of care. The second dose was missed because Mrs Z refused it, and our haematology adviser said she appeared to have capacity to make that decision.

42. Our haematology adviser explained the later CT scan showed several issues affecting Mrs Z’s breathing, including small blood clots in the lungs, underlying lung disease, airway narrowing, and fluid around the lung. They said the blood clots were small and would not usually be fatal on their own, but in Mrs Z’s case they would have added to her existing breathing problems.

43. Our surgical adviser noted the CT scan was not completely clear because Mrs Z was moving during the scan, which made it harder to see the lungs in detail. Even so, our haematology adviser explained the overall findings were still consistent with small blood clots being present. Taken together, the evidence suggests small clots were likely, but they were not the dominant factor in Mrs Z’s deterioration.

44. Our haematology adviser said missing two doses of dalteparin likely increased her risk of developing these clots, although clots can still occur even when preventative medication is given. Their view is the blood clots, including the impact of the missed doses, contributed to Mrs Z’s deterioration and death, but were not the main cause.

45. This is consistent with what was recorded on her death certificate. We also recognise some of Mr Z’s concerns stem from gaps in communication during his mother’s admission and in the Trust’s later explanations, which may have contributed to his understanding of the role of blood clots in her death.

46. The Trust’s internal investigation found the missed preoperative dose happened because staff were not familiar with the hipfracture (NOF) pathway and believed dalteparin should be withheld before surgery. It also found the ward did not have a system for checking when important medicines were missed, so the error was not picked up at the time. The Trust confirmed Mrs Z refused the postoperative dose.

47. These findings show the missed dose before surgery resulted from gaps in staff knowledge and from the lack of a process to monitor missed medicines. These are departures from expected safemedication practice.

48. The Trust has since provided training on the NOF pathway, delivered education on VTE (venous thromboembolism is the medical term for blood clots that form in the veins) prevention and critical medicines, and introduced an automated system to flag missed doses. It has also started monthly audits of VTErelated prescriptions.

49. These are positive and appropriate steps to reduce the chance of similar errors happening again. However, while the Trust has focused on service improvements, it has not fully acknowledged the part the missed doses played in Mrs Z’s deterioration or the distress this caused her family.

50. Overall, we find the missed doses of dalteparin were a failing in the care provided. Missing these doses likely increased Mrs Z’s risk of developing blood clots, although the clinical evidence shows the clots were only one of several factors contributing to her deterioration and were not the main cause of her death.

51. This failing contributed to Mrs Z’s deterioration and to the family’s distress, particularly as they were left uncertain about the part this played in her final illness. We go on to make recommendations to address this later in our report.

DNACPR discussions 52. Mr Z says staff repeatedly raised DNACPR despite his mother and family making it clear she wished to be resuscitated. He found the conversations distressing, pressuring and lacking empathy. He felt they resembled the Liverpool Care Pathway, creating the impression staff had given up on his mother.

53. The Liverpool Care Pathway was a former NHS framework for people thought to be in the last days of life. It was discontinued in 2014 after concerns about inconsistent use and poor communication. Mr Z felt the approach taken with his mother created similar concerns about a loss of hope and a lack of personalised care.

54. The Trust says Mrs Z was frail and at high risk of deterioration, and early DNACPR discussions were appropriate. It acknowledges the conversations were difficult for the family and may not have been experienced as being delivered well. It says the decision‑making process was in line with Trust standards and Mrs Z’s wishes were respected.

55. Our surgical adviser said early DNACPR discussions are recognised practice for patients who are clinically fragile or at risk of sudden deterioration. GMC end of life guidance emphasises these conversations should take place before a crisis, and families should be involved wherever possible. Our surgical adviser said the clinical team appeared to be attempting to address an important decision in a timely and responsible way.

56. Our surgical adviser confirmed Mrs Z’s stated wish to be resuscitated was respected and recorded. No DNACPR order was put in place because she and her son did not agree to it.

57. We recognise Mr Z’s concern about the tone and frequency of the conversations, and the distress this caused. GMC end of life guidance also makes clear that DNACPR decisions are ultimately clinical decisions made by the senior responsible clinician, taking account of the patient’s wishes.

58. The Trust’s internal investigation also identified staff needed clearer understanding of responsibility and decision‑making around DNACPR discussions, and this learning was shared with the clinical team on the ward. This indicates the Trust recognised communication could have been better, even though the clinical decision‑making was appropriate.

59. We find it was clinically appropriate for staff to raise DNACPR early, given Mrs Z’s frailty and the risk of deterioration. We also recognise the family found the conversations upsetting, and the Trust has acknowledged this. The evidence shows Mrs Z’s wishes were respected, and we have not seen a departure from expected standards in how the decision was approached.

1. We have investigated the concerns Mr Z raised about the care and treatment Countess of Chester Hospital NHS Foundation Trust (the Trust) provided to his mother, Mrs Z, between 19 and 24 January 2024.

2. We identified a failing in one part of the complaint. The Trust missed a preoperative dose of dalteparin, which was not in line with expected safemedication practice. This omission likely increased Mrs Z’s risk of developing small blood clots, and it contributed to her deterioration and to the distress and uncertainty experienced by her family. The Trust has taken steps to improve its systems, but it has not fully acknowledged the impact this failing had on Mr Z.

3. For the other parts of the complaint, informed consent, identifying pneumonia before surgery, and DNACPR (do not attempt cardiopulmonary resuscitation) discussions, the evidence does not show the Trust departed from expected clinical standards. We recognise Mr Z experienced these events as rushed, distressing, and poorly communicated, but this does not indicate a failing.

4. Taking all of this into account, we partly uphold this complaint. We are making recommendations based on what we have found. These focus on acknowledging the failing in relation to the missed dalteparin dose (a blood thinning medication) and the distress and uncertainty this caused Mr Z.

5. The Trust has already taken appropriate steps to improve its systems, so we are not recommending further service improvements.

60. 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.

61. 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.

62. We have identified failings in relation to the missed preoperative dose of dalteparin. This failing increased Mrs Z’s risk of developing blood clots and contributed to her deterioration. It also caused avoidable distress and uncertainty for Mr Z, particularly as the Trust did not provide a clear or timely apology for the omission. While the Trust has taken appropriate steps to reduce the risk of recurrence, the injustice to Mr Z remains unremedied.

63. With that in mind, we recommend that following this final report the Trust: • writes to Mr Z by 17 August 2026 to acknowledge the failing in the administration of dalteparin, acknowledge the impact this had on Mrs Z’s risk and on the family’s distress and uncertainty, and apologise for the distress and uncertainty caused • pays Mr Z £600 by 17 August 2026 in recognition of the avoidable distress and uncertainty caused by the missed dalteparin dose and the lack of a timely apology

64. The Trust should send us evidence it has completed all of the recommendations we have made.

65. We would like to thank Mr Z for bringing his concerns to us and for engaging with the complaints process during what has clearly been a very difficult time for him and his family. We appreciate how distressing these events were and how hard it has been for him to revisit them. We hope our final report helps them find some clarity about what happened and reassures him that his concerns have been carefully considered.