Sherwood Forest Hospitals NHS Foundation Trust

12. Mr A complains about the actions of Sherwood Forest Hospitals NHS Foundation Trust (the Trust) in relation to the admission of his brother, Mr B, between May and June 2022. Specifically, he complains the Trust did not:

• prescribe his brother’s desmopressin (diabetes insipidus medication) during a 48-hour period • pick up on symptoms of his brother’s decline sooner or do appropriate investigations in a timely manner • assess and apply the correct risk-rating to its subsequent investigation of what had happened • tell him about the outcome of its investigation.

13. Mr A says the medication error left his brother in a negative fluid balance. That, and the failure to pick up on his worsening symptoms, meant his brother experienced tachycardia (an abnormally fast heart rate) and was left to suffer avoidably. He says he and his family have been left distressed by the Trust’s actions. He also says the Trust caused further distress when they were trying to grieve by not keeping him updated on the outcome of its investigation.

14. Mr A wants an apology, service improvements and a financial remedy.

15. Mr B had a complex medical history of a recurrent brain tumour (mass) with post operative strokes (a condition where blood flow is stopped to the brain). He was registered as fully blind. Mr B also had Addison's Disease (a condition which impacts the body’s ability to product cortisol (steroid) on its own.

16. Mr B was a vulnerable man in a wheelchair, had extensive care needs, was in a care home and was registered blind. This meant he struggled to advocate for himself.

Diabetes insipidus

17. Diabetes insipidus is a rare condition where you urinate a lot and often feel thirsty. It stops the kidneys retaining water. It is not the same as diabetes type one or two. The main symptoms are extreme thirst and excessive urination. The condition is frequently treated with desmopressin which stops the kidneys producing urine when the body’s water content is low.

Medication

22. Mr A says the Trust did not prescribe desmopressin for his brother’s diabetes insipidus during a 48-hour period.

23. On 30 May 2022 Mr B attended the Trust by ambulance. He had a history of falls and a swollen leg. The Trust admitted Mr B following its assessment and diagnosed him with cellulitis (an infection of the skin). A doctor noted on his admission paperwork Mr B’s regular medication which included desmopressin for his diabetes insipidus. But the Trust did not add this to Mr B’s prescription charts until 1 June. There is no evidence in Mr B’s medical records to explain the reason for this.

24. GMC Good Medical Practice says: ‘promptly provide suitable treatment where necessary’.

25. We find the Trust’s action in not prescribing Mr B’s medication was not in keeping with GMC guidance. It first recognised Mr B was on desmopressin, which was necessary to treat his diabetes insipidus, and documented it for prescription. But it did not act in line with that guidance when it failed to prescribe or administer that medicine for 48 hours. This was a failing.

Delay

26. Mr A says the Trust missed chances to pick up on his brother’s decline sooner, by not assessing his symptoms correctly or doing the right investigations.

27. We found above that the Trust did not prescribe or administer Mr B’s medication for a 48-hour period. We will consider in this section if the Trust could have recognised that error any sooner than it did.

28. The NHS says one of the common signs of diabetes insipidus is excess urination, dehydration and thirst. This can lead to high sodium levels in the blood. When Mr B was admitted on 30 May 2022 his sodium levels were 138 mmol/L (normal being between 133 and 146). The Trust did a further blood test on 31 May which showed his sodium levels had increased to 147 mmol/L. Our general medicine adviser confirmed this level was abnormal.

29. The same day, a Trust pharmacy technician reviewed Mr B’s prescribed medication. They documented in the records that Mr B had not been prescribed desmopressin and sent an alert to doctors for them to prescribe it. The Trust took no action on this alert. This was a failing.

30. Nursing notes from 31 May also show Mr B was drinking ‘copious amounts’ of fluids and passing good amounts of urine. NICE CG50 guidance says ‘1.6 In specific clinical circumstances, additional monitoring should be considered, for example, hourly urine output’. NMC guidance says nurses ‘should record fluid intake and output and identify, respond to and mange dehydration or fluid retention’.

31. Mr B was catheterised the same day to allow nurses to more closely monitor his urine output. Our nursing adviser told us that at this stage Mr B needed to have hourly fluid balance monitoring. The Trust did not start hourly fluid balance monitoring at that time. Not doing so was a failing in line with NICE guidance.

32. The fluid balance charts on 31 May show Mr B had a negative fluid balance of 550mls at 8pm and by midnight on 1 June he was in a significant negative balance of 1900mls. NMC guidance says nurses should ‘accurately identify, observe and assess signs of normal or worsening physical […] health in the person receiving care’ and ‘respect the skills, expertise, and contributions of your colleagues, referring matters to them when appropriate’. Our nursing adviser told us that while nurses would not have been expected to know the cause of this negative fluid balance, they should have recognised this was abnormal and escalated it. There was no evidence in the records the nurses escalated this to the medical team.

33. By 3am on 1 June the nurses documented they would escalate Mr B’s symptoms to the medical team later that morning.

34. We also looked at the National Early Warnings Score (NEWS), a system used to identify deterioration based on clinical observations. On 1 June at 4.10am, Mr B’s observations were abnormal. His oxygen saturation levels were 88% (normal being above 95%), his heart rate was 142 (normal being between 51 and 90). This gave him a NEWS score of 6. RCP guidance says someone who scores 5 or more needs hourly monitoring and escalation within 30 minutes. The records show the Trust escalated this, but it is not clear what the specific time was. Mr B’s next NEWS score assessment was at 4.37am and his NEWS score was 5. At this stage, Mr B still needed hourly monitoring and escalation within 30 minutes. His next check was at 5.44am and his NEWS score was still 5. By 6.21am, it had increased to 7.

35. Mr B also had a further blood test on this day. It showed his sodium levels had increased to 179, from 157 the previous day.

36. There is a record Mr B was reviewed by a junior doctor at around 4am. However, it is not clear from the notes whether this review happened in person or remotely. The doctor did not make an entry in the medical records. One nursing entry says ‘reviewed by doctor’ and another says, ‘discussed this with med reg and on call doctor’. It was also noted that Mr B had not been prescribed his desmopressin, and that a task was sent to the on call pharmacy.

37. The first record evidencing that the doctor was present in person was at 6.30am. This was a six and a half hour delay from when Mr B was first in a significant negative fluid balance. It was a two and a half hour delay from him having a raised NEWS score. The Trust should have escalated an earlier request for Mr B to be seen in person by a doctor. This likely should have been at midnight on 1 June. We emphasise that we have not found that no doctor reviewed Mr B. However, our view is that a doctor should have seen him in person and not remotely. The records do not explain how this review took place, and this is a failing in the Trust’s record keeping.

38. By the time a doctor was recorded as having reviewed Mr B in person at 6.30am, he was noted as being drowsy, had lost over 3 litres of fluid, had a raised temperature and his NEWS score was 7. Mr B was noted to be in pain all over his body. The doctor noted Mr B had diabetes insipidus and had not had his desmopressin since he was admitted to hospital. The doctor prescribed this medication and it was administered at 7am. This was around three hours after the nurse and medical team noted it as being the cause of his symptoms.

39. In response to an earlier draft of this report, the Trust said that a doctor reviewed Mr B before 6.30am. Its internal nerve workflow task (part of its record keeping system) shows a task raised at 4.18am and completed at 6.43am. We reviewed these nerve records. At 4.10am, 4.37am, 5.44am, 6.21am, 7.07am and 7.52am they show the Trust escalated the care to ‘Nurse in Charge, CCOT, HOOH’. This message changed at 9.03am when the note says ‘team present’. We have taken the medical record entry at 6.30am as the time noted for a doctor review. GMC guidance on record keeping says ‘Records should be made at the time of the event or as soon as possible afterwards. This ensures that the information is accurate and reflects the actual circumstances. Clinical records should include essential details such as: Who is making the record and when it was made.’ While we have considered the Trust’s point of view, it is not clearly reflected in the records. Our view is that the Trust’s record keeping should have been clearer.

40. The Trust was concerned Mr B had sepsis due to his raised NEWS score. It did not appear to recognise initially that this might be a sign of diabetes insipidus. We asked our general medicine adviser whether, if Mr B was on his desmopressin, he would have still deteriorated. Our adviser said Mr B was being treated for cellulitis but his NEWS score remained stable and started to increase only as his sodium levels increased. Our adviser explained that, on the balance of probabilities, his deterioration was due to his missed desmopressin, as nothing clinically had changed with his cellulitis.

41. Overall, there appear to be three instances where the Trust could have recognised Mr B’s deterioration sooner but failed to take appropriate steps to stop it. The first instance was when the pharmacy technician escalated on 31 May to say desmopressin was not prescribed. The second was when Mr B was in a significant negative fluid balance on 1 June. The third was when his NEWS score was raised. These were avoidable failings.

Impact of clinical failings

42. In this part of our report, we will cover the impact on Mr B and his family of the Trust’s failings.

43. The Trust did not give Mr B his desmopressin and delayed remedying that error. We asked our general medicine adviser whether, if the Trust had given Mr B his desmopressin, he would still have lost 3 litres of fluid. Our adviser said if Mr B had received his medication from admission he would not have lost 3 litres of fluids.

44. We also asked our nursing adviser what the immediate impact on Mr B was. They said Mr B would have been in significant discomfort. The records highlight this when the Trust noted he was ‘in pain all over’ and that he was drowsy and confused.

45. Mr A says the Trust’s actions caused his brothers tachycardia. On 31 May and 1 June his brother’s heart rate rose to above normal levels. We asked our general medicine adviser if this was connected to the missed desmopressin. Our adviser said it is possible it was related to his cellulitis. But Mr B’s heart rate was normal before his sodium levels increased and his cellulitis treatment or condition did not change. Our adviser said it was more likely than not that, because his heart rate only increased when he was acutely unwell due to lost fluids and increased sodium, his high heart rate was caused by the missed desmopressin.

46. Mr B relied on the Trust to make sure he received his essential medications, such as his desmopressin. It does not appear he was able to fully advocate for himself, and he trusted the Trust to care for him at such a critical time. It failed to do this. Instead, it caused avoidable suffering to Mr B, so much so that his life was put in danger.

47. Mr A told us that his brother was frightened to go back into hospital in case he died because of missed medication, and following this incident his brother was extremely fixated on not missing medication. We think these impacts were avoidable had this incident not happened.

48. The Trust has already taken some actions following its duty of candour review in June. It said it has rebriefed staff on the importance of obtaining a full medical history and ensuring critical medications are prescribed in a timely manner. It has also added a filter on its system to identify critical medications. We think these constitute positive initial steps to make sure this incident does not happen again. We are concerned, however, that the Trust already previously had measures in place to prevent errors like this happening, and it still failed Mr B. We are not currently reassured that the Trust’s improvements go far enough to reassure us that it has learnt, and we think it needs to do more.

Investigation

49. Mr A says the Trust did not assess or apply the correct risk rating to its investigation into what had gone wrong with his brother’s medication.

50. Following the incident, the Trust undertook an investigation. The Trust has a Duty of Candour Policy which states that it is committed to ensure that its ethical, professional, contractual and statutory responsibilities and the Duty of Candor are met following a patient safety incident. The policy states:

‘The Duty of Candour places a requirement on providers of health and adult social care to be open with patients when things go wrong, ensuring that honesty and transparency are the norm. Duty of Candour became a statutory requirement for all CQC registered Trusts from 27th November 2014 meaning the Trust must be open and transparent with service users about their care and treatment, including when it goes wrong.’

…

‘The Trust must promote a culture that encourages candour, openness and honesty at all levels. This is an integral part of a culture of safety that supports organisational and personal learning, alongside a commitment to being open and transparent at board level.’

51. The Duty of Candour is a general duty to be open and transparent with people receiving care when something goes wrong. It became a statutory duty in November 2014 and is set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations). It is regulated by the Care Quality Commission (CQC) and applies to every NHS organisation registered with them.

52. Regulation 20(8) defines a notifiable safety incident as:

‘any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in:

(a) the death of the service user, where the death relates directly to the incident rather than to the natural course of the service user's illness or underlying condition, or (b) severe harm, moderate harm or prolonged psychological harm to the service user.’

53. If, after completing a full thorough investigation, an organisation identifies the incident as a notifiable safety incident it must report it to the CQC in line with the statutory Duty of Candour.

54. The Trust categorised the harm caused to Mr B as ‘low’ and therefore decided the mistake was not a notifiable safety incident. The Trust said this was because Mr B did not need ITU intervention. The Trust’s incident reporting policy defines ‘grade 3 moderate–short term harm’ as meaning that the patient required further treatment. This means for someone to be assessed as meeting this threshold then, due to an error, they would have needed to have been given treatment above and beyond what had originally been planned.

55. Our general medicine adviser told us Mr B needed further treatment due to the Trust’s error in not prescribing his desmopressin. Our adviser explained there were two issues with Mr B’s health at the time, one being the cellulitis and the other being the missed medication. Mr B’s NEWS score and sodium levels before the Trust missed his desmopressin were normal. He only started to deteriorate when his sodium increased and then his NEWS score increased. Our adviser said, on balance, his deterioration was because of his sodium and not cellulitis, because nothing had changed regarding the treatment for cellulitis.

56. The records show the further treatment the Trust needed to give Mr B when it found it had not prescribed his desmopressin:

• extra fluids • oxygen • nebulisers • urinary catheter insertion • additional blood tests - urea and electrolytes (U&E’s) tests to assess kidney function every 6 to 12 hours, electrocardiogram (ECG) a test to monitor the heart and X-ray.

57. Our general medicine adviser told us that without the above treatment Mr B would likely have died. They said Mr B experienced a period of significant, but not permanent, harm due to his increase in sodium levels and his loss of over 3 litres of fluid. Our general medicine adviser said that had Mr B been prescribed desmopressin on admission, as should have occurred, he would have not have experienced the more acute symptoms such as increased heart rate, loss of consciousness and loss of fluid. The harm happened over the course of three days and during that time Mr B was noted to be in pain all over.

58. The Trust also recommended Mr B have an X-ray and ECG and questioned if he should be moved to a more appropriate ward. The records are silent on this matter and do not explain whether Mr B should have been moved to a more appropriate ward. Our general medicine adviser also told us that if Mr B had not had any of his comorbidities it is likely he would have been moved to the intensive care unit. This is because the Trust did not think that ICU intervention would add anything to Mr B’s treatment.

59. Our general medicine adviser told us the planned and delivered treatment for the cellulitis for which Mr B was admitted never changed. When he was admitted he did not have a catheter in place. The Trust catheterised him only after the urinary problems he experienced because of the missed desmopressin. Mr B still had this catheter in place when the Trust discharged him on 6 July, over one month later. It is our view that had the Trust given Mr B his desmopressin it is more likely than not he would not have needed to be catheterised. He likely would also not have required the additional treatment set out in paragraph 56.

60. There are indications that the error caused a degree of psychological harm following the incident to Mr B. Sadly, we can no longer ask him about that. Mr A told us that after discharge his brother feared going into hospital and dying and became fixated on not missing his medication. He said this lasted a long time after this admission.

61. Our general medicine adviser told us that the Trust’s error caused Mr B to require at least a moderate increase in treatment to stabilise his condition, including the prolonged catheterisation. We believe this likely meets the definition of a ‘prolonged episode of care’ because of the length of time he needed to be catheterised after the avoidable incident. The Trust’s assessment of the incident as ‘low’ was likely not in line with definitions in the Regulations.

62. It is not clear that the Trust considered all of the above factors when investigating what happened to Mr B. There was more to consider than whether Mr B was moved to the ICU.

63. The CQC guidance on the Regulations says ‘if the notifiable safety incident was not realised at the time but was discovered through a retrospective case review, or as part of a large scale patient recall, the duty still applies.’. We think the Trust should now reactivate its investigation and retake its decisions based on what our investigation has found, to satisfy itself if the original decision was still the right one.

Investigation outcome/apology

64. Mr A says the Trust did not tell his brother about the outcome of its investigation.

65. The Trust’s advanced nurse practitioner spoke to Mr B’s mother on 1 June to obtain a medical history. There is nothing noted to show the Trust explained to Mr B’s mother what had happened, or apologised. We asked the Trust for evidence it apologised to Mr B as soon as it knew about the incident. It told us ‘sadly, the Trust have no documented confirmation of this discussion taking place.’

66. The Trust’s Duty of Candour policy says ‘4.10 All Trust staff – All staff, including temporary, agency or volunteer staff, have a responsibility for identifying actual or potential hazards, safety incidents and risks and reporting/escalating issues in accordance with this and other relevant policies. All communication with the patient, their family or carers must be explicitly and contemporaneously documented in the medical records. All staff involved in an incident, including non-clinical staff, staff from other teams and locum staff should be offered a debrief and be signposted to further sources of support’. In not keeping a contemporaneous record the Trust has failed here to follow its policy.

67. That said, the records on 1 June show the Trust’s endocrinologist spoke to Mr B’s mother and told her about the missed desmopressin. There was, however, no explanation about how this happened, the facts as known at the time, what further enquiries were needed, or an apology. Mr A told us the Trust simply told them his brother had ‘taken a turn for the worse and prepare themselves for the worst’.

68. On 14 June Mr B’s mother asked for a meeting with the Trust’s doctor to discuss the missed desmopressin. This happened on 16 June. The Trust policy (at paragraph 6.2.4) says this discussion should happen as soon as reasonably practicable possible, and that this should be initiated by the Trust. It took over two weeks for the Trust to speak to Mr B’s family in more detail about what had happened, and it was Mr B’s mother who had to initiate this conversation. The Trust should have had this conversation on 1 June after the incident was discovered.

69. On 16 June, when the Trust’s doctor had a meeting with Mr B’s family, they noted no harm had been caused and that the events would be investigated. It is not clear why the Trust did not think there was on-going impact or harm on Mr B given what had happened to him, as detailed above. The Trust did not tell Mr B’s family that they would receive a written letter outlining the investigation outcome and an apology.

70. The Trust told us it did speak to Mr B’s family at the time of the incident, and that the absence of any documentation does not mean it did not happen. When we spoke to Mr A and Mr B’s mother, who were supposedly present at that time, they told us the Trust did not give them a clear account of what happened. They said it just told them to ‘prepare for the worst’. Mr A and Mr B’s mother also asked for a meeting following the incident on 14 June. We consider that if the family already knew what had happened to Mr B it is likely they would not have asked for this meeting. On the balance of probabilities, we think it is more likely the Trust did not have a clear conversation with Mr B’s family that day.

71. Our view is that the Trust did not take proper account of stage one of its duties under the Regulations.

72. We next looked at stage two. The Trust completed its investigation on 14 June 2022. But it did not send Mr B or his family the results of that investigation.

73. In its complaint response on 5 March 2023 the Trust acknowledged this. It said ‘[Mr B], I understand you were advised that would be informed of the outcome of the review, please accept my apologies that this did not happen’. But even that response did not actually provide the outcome or apologise for what had happened.

74. It does not appear that the Trust paid proper account to its responsibilities under the Regulation when completing stage 2. It did not follow up in a reasonable timeframe with a written notification telling Mr B the outcome of its investigation. Not did it give a formal apology. Given Mr B was blind, it should have done this in person with a face-to-face meeting. Even now, it is our view that the Trust’s explanations were not clear or informative and did not go far enough to explain what happened. It did not apologise in an open and honest way. So far, it has only apologised for not providing the report sooner. Not providing an open and honest apology for what had happened was not in line with the duties under the Regulations.

75. The Trust commented that it was not required to tell Mr B’s family they would get an outcome to the investigation as it initially rated the incident low, and its policy does not require it to follow up on low harm incidents. This is in our view a moot point, as the incident was and always should have been categorised as moderate harm.

76. Overall, the Trust failed to tell Mr B about the outcome of the investigation; apologise, and then follow that with a written apology; keep a written record of its investigation and subsequent actions (apology) and offer support in line with the Regulations.

Impact of investigation failings and complaint handling on Mr B

77. We looked at the impacts caused by the Trust in not categorising its investigation correctly, and also in not providing a subsequent apology and outcome and in its handling of Mr B’s complaint.

78. As we have explained above, we do not think the Trust has fully considered all of the evidence. We think the Trust’s failure to take proper account of the impact its actions had on Mr B caused avoidable distress. We think there were earlier chances for the Trust to meet with Mr B. Instead, it waited until Mr B’s family chased for a meeting two weeks after the incident. This contact was not initiated by the Trust but by Mr B’s family. It then took eight months to share the outcome of its investigation, again after Mr B’s family chased the Trust. When something like this happens, it is important that healthcare providers act in an open and honest way, to ensure safety and to build patient trust. This is the very framework of the Duty of Candour. We do not think the Trust during its investigation, or when the incident happened, acted in an open and honest way.

79. Mr A told us that, before he died, his brother was searching for answers to what happened to him during this period of admission. He said his brother passed away not fully knowing what happened. We note the Trust provided the outcome to Mr B in a letter. But Mr B was registered blind. We think it is likely Mr B was not able to read and understand properly what was in that letter. The Trust did make some efforts to take account of Mr B’s needs as it addressed the correspondence to Mr A. But we think the Trust should have gone further than this. The Trust should have offered to meet Mr B in person. Not doing so will likely have caused distress to Mr B at the time.

80. The Trust recognised that it omitted to share the outcome at a time when Mr B was still alive. At this point, they could have apologised to him for the incident. He has now sadly died without obtaining closure on this incident and receiving a proper explanation and apology.

Impact of investigation failings on Mr B’s family

81. The investigation failings will also have caused distress to Mr B’s family. Having to pursue a resolution to these events after Mr B died will have caused his family distress.

82. We understand that the severity of these failings will likely cause further distress to his family. They now have answers but only almost four years after events. They have learnt the care their son and brother received fell severely short of what it should have been. This in and of itself is likely to cause distress.

83. Mr A told us that pursuing the complaint with the Trust impacted his family’s ability to grieve. We note that none of the events described contributed directly to Mr B’s death. At the same time, we do not want to diminish the significance of the loss of Mr B, and the grief that results from bereavement under any circumstances. We entirely recognise how deeply difficult this time would have been and also why pursuing the complaint added to the strain when the family would have had little emotional capacity.

Incident in April 2022

84. During the course of our investigation we saw in the records an entry that said the Trust had missed Mr B’s desmopressin on a previous admission in April 2022. This points to a repeated failing where the Trust has not learned from previous errors. Although we have not investigated what happened in April 2022, we consider it is important contextual information to support our view that the Trust has not done enough to ensure these mistakes are not repeated.

85. We asked both our nursing adviser and general medicine adviser about the Trust’s essential medication policy. Both advisers told us the Trust appears to have failed Mr B in its implementation of the policy and the Trust should urgently review it. We understand the Trust has put in improvements such as adding a drop-down menu and a requirement to take the patient history. But a history was taken from Mr B on admission, and the Trust’s actions still failed Mr B. As it stands, the amendments to the policy do not provide a mechanism to ensure an earlier remedy of the error.

1. We are so sorry to hear from Mr A about his brother’s (Mr B’s) experience at the Trust. From what he has told us events at the Trust were sad and distressing for everyone concerned. We hope our final report helps to explain what happened and whether this was in line with what should have happened.

2. In relation to Mr A’s complaint about the Trust not prescribing Mr B’s desmopressin medication, we find the Trust's actions were not in line with relevant guidelines. We also find it missed three chances to prescribe the medication sooner. This caused Mr B avoidable suffering and meant he needed a catheter.

3. We then looked at the Trust’s investigation and considered if its categorisation of low harm was right. We found errors in the Trust’s investigation, and we believe it did not consider all relevant information at the time. It did not consider that its avoidable actions caused Mr B to have a prolonged period of extra care, he needed a urinary catheter for more than a month, and following the incident it impacted his mental health. Our view is the harm caused to Mr B meets the criteria of the Trust’s policy of ‘moderate harm’, the Trust has agreed with this view. We are therefore asking the Trust to carry out a new duty of candour review based on this investigation and the information that has come to light.

4. We moved onto to look at how the Trust told Mr B before he died about the outcome of its investigation. We find the Trust did not handle this in line with its duty of candour. This is because it was not open and honest with Mr B or his family. Mr B’s family initially had to pursue a complaint to learn what had happened to him and then had to follow up when the Trust did not share the outcome of its investigation fully. The Trust has still not provided a proper apology in line with the framework, or kept a written record of its duty of candour investigation and subsequent actions. It apologised for not providing the investigation outcome sooner in writing, but this apology lacked the depth and sincerity needed to properly acknowledge what went wrong.

5. The Trust needs to look again at its categorisation of the harm caused, in light of what this report has found. We found failings in the Trust’s:

• failure to provide essential medications • delays in providing treatment • poor handovers between clinicians • failure to listen to the concerns of patients or their families.

6. Mr B raised concerns with the Trust before he died to get answers about what happened during his admission. This incident could have resulted in his death and, from what Mr A has told us, impacted his brother’s mental wellbeing. Instead of responding in an open and honest way in line with its obligations, the Trust provided an inadequate response. The Trust should have considered that Mr B was blind and likely offered to meet in person to explain its actions and so he could ask it questions.

7. The Trust failed to listen to Mr B and his family, fully acknowledge or understand the impact its failings had on Mr B, communicate effectively or, most importantly, learn from what had happened. We understand where there is human judgement there will sometimes be human error. But the Trust did not adequately investigate or fully acknowledge its failings and did not apologise in line with its policy and duty. That meant Mr B and Mr A had to go through an unnecessarily long and painful process with the Trust to raise their concerns and then complain to us to get a full answer about what happened to Mr B. This damaged Mr B’s and Mr A’s confidence in the Trust. The Trust’s actions in not meeting in person with him meant Mr B died without closure.

8. We expect Trusts to learn from their mistakes. It is disappointing to note from the records that this was not a one off. The Trust’s previous care of Mr B, in April 2022, had involved medication errors. The Trust’s poor record keeping has prevented us making clear decisions about how it investigated the incident. The Trust’s duty of candour policy clearly requires written records relating to duty of candour. We are disappointed to see this did not happen. We want to be absolutely clear that we have found no evidence that this contributed to Mr B’s death which happened many months later, unrelated to this incident.

9. We therefore uphold this complaint, and make the recommendations outlined in paragraph 86 and 95 of our report. We also ask the Trust to reactivate the duty of candour process, review urgently what happened including its assessment of harm and, if appropriate, notify the CQC of the outcome.

10. We are sorry to share this information with Mr A. We understand this report will be distressing to read, especially when he has told us that he still does not know what happened to Mr B. We hope our report helps the family understand what happened and provides some closure.

11. We want to reassure Mr A that during the course of our investigation we have spoken to senior leaders at the Trust. They have acted promptly and with openness and honesty in our conversations with them. They have accepted responsibility for the actions of the Trust described in this report. Their positive engagement reassures us that the Trust is taking this report seriously and wants to learn in order to make sure these failings are not repeated.

86. We are upholding this complaint, these are the recommendations we are making.

87. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

88. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

89. In line with this we recommend within one month of the date of this report the Trust should acknowledge the failings of this report. That it failed to:

• prescribe Mr B’s desmopressin medication and to correct the error as soon as it was identified • adequately investigate the incident or take account of all relevant information when deciding upon the level of harm caused • be open and honest with Mr B and his family about what had happened • keep a contemporaneous written record of its Duty of Candour investigation and then subsequent actions as per its policy • apologise to Mr B.

The Trust should also apologise for the impact of these failings.

90. We recommend that the Trust re-investigate this matter, in line with its Duty of Candor Policy and consider its actions in light of our adviser’s opinion that it was likely that the actions of the Trust caused moderate harm to Mr B. If, having done that, the Trust finds this incident resulted in moderate harm or above, it should report itself to the CQC in line with the Duty of Candor Regulations.

91. We understand the Trust took some actions as part of its review to improve its essential medication policy. This included adding a drop-down error to its system. We are not currently satisfied this goes far enough to stop this failing happening again. We note this is not the first time this happened to Mr B. The Trust has documented in his medical record that this happened on a previous admission in April the same year. Our general medicine adviser also told us that the desmopressin was not the only missed medication. The Trust also did not prescribe his testosterone gel or his steroids and the Trust was unsure why. We think these errors point to a wider failing in the Trust’s essential medication policy.

92. The Trust should involve its patient safety specialist in carrying out further analysis of what went wrong and what led to the failings identified. The Trust should draw up a further action plan, with the support of its patient safety specialist. The action plan should set out:

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

93. This could include using the Patient Safety Incident Response Framework (PSIRF). This is the NHS's approach to learning from patient safety incidents by focusing on system improvement. It replaces the traditional Serious Incident Investigation model, and uses a learning-focused, systems-based method that prioritises understanding how and why incidents happen to improve safety across the whole organisation.

94. We are unable to resolve the injustice caused to Mr B as he has since passed away. We also think this matter caused his family distress. We therefore think it would be appropriate for us to recommend a financial remedy. 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. Following this review within one month of this report the Trust should pay Mr  A £1,000 in recognition of the avoidable significant distress to Mr B’s family, and how the matter has impacted the family’s ability to obtain closure.

95. We recommend the Trust completes the action plans and other work within three months of this report and send a copy of the action plan to Mr A, this office, NHS England, the Care Quality Commission and its Board.