Frimley Health NHS Foundation Trust

3. Mr A complains about the care provided to his father, Mr B, by Frimley Health NHS Foundation Trust (the Trust) from 18 to 20 November 2024. Specifically:

• there were delays in Mr B being seen when he was sent to hospital by his GP on 18 November 2024 • the Trust failed to carry out CT and MRI scans promptly or appropriately monitor Mr B for risk of stroke • there were delays in the Trust responding to the complaint. The Trust’s investigation of the complaint was overseen by the consultant responsible for the team caring for Mr B and the complaint response contained multiple medical terms which are difficult to understand.

4. Mr A says that his father’s death was a shock as he died suddenly and unexpectedly. Mr A says there were no signs that his father was going to die and this tragic event has left a void in the family.

5. As a set out of outcomes, Mr A wants changes in procedure at the Trust improve awareness of the implications of any failure to provide the correct duty of care for patients and the impact this has on their families. Mr A also wants a financial remedy.

6. Mr B was in his 80s. He attended the Emergency Department (ED) at the Trust on 18 November 2024, arriving at 12:35pm. Mr B had been advised by his GP to attend hospital following the identification of low magnesium and calcium levels. Also, his underlying kidney problems were noted to be getting worse.

7. Mr B was treated with IV fluids and IV magnesium. He was seen by a kidney specialist and dietician on 19 November 2024. They recommended repeat blood tests, vitamins and protein-energy drinks. On the evening of 19 November 2024, Mr B’s condition was noted as stable.

8. In the early hours of 20 November 2024, Mr B was found on the floor after suffering a fall that was heard rather than seen. At 1.33am on 20 November 2024, an arrest call was issued by the Trust.

9. The cardiac arrest team felt Mr B had suffered a catastrophic neurological event, most likely a stroke. Based on their assessment and Mr B’s overall very poor condition, clinicians at the Trust took the view that this was a terminal event, he was likely at the end of his life, and that survival would not be possible. Therefore, Mr B was made not for resuscitation and was put on an end-of-life pathway whereby the priority was to keep him comfortable. Mr B sadly died later that morning.

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone seriously wrong with Mr B’s care.

Delays in initial assessment

14. Mr A says there were delays in Mr B being seen when he was sent to hospital by his GP on 18 November 2024.

15. Having considered Mr A’s complaint dated 19 December 2024 and the Trust’s response of 20 February 2025, we cannot see that Mr A complained about the delays in his father’s initial assessment on 18 November 2024. As such, there was no response to this point from the Trust. Given this, we could consider this point as premature for our purposes as it has not completed local resolution with the Trust.

16. However, we have decided to consider this point as part of our wider consideration of the care Mr B received from the Trust from 18 to 20 November 2024.

17. As we have said, Mr B arrived at hospital at 12:35pm on 18 November 2024. He was triaged by a nurse at 12:56pm. We note from the records that his GP had made considerable efforts to ensure that he would be reviewed directly by the acute medical team on arrival, but there was a significant delay in achieving this which we have considered with support from our A&E adviser.

18. The NHS England guidance for initial assessment in emergency departments advises that patients should undergo an initial assessment within 15 minutes of arrival. This process should include directing patients to the most appropriate service based on their presenting symptoms, chief complaint, and clinical acuity.

19. Unfortunately, Mr B waited approximately two and a half hours until he was seen by an ED doctor at 3:11pm. This was because he was incorrectly placed in the general ED pathway and queue instead of being sent straight to the acute medical team. This must have been confusing and worrying for Mr B at a time when he needed medical attention. We recognise that it will also be concerning for Mr A to hear about this now.

20. Nevertheless, the records reflect that the ED doctor realised what had happened and initiated treatment. Mr B was subsequently reviewed by the acute medical team at 4:08pm, approximately three and a half hours after his presentation to the ED.

21. Following this, the records indicate that a ward bed was requested and was available by 5:08pm. Unfortunately, Mr B was not transferred to the ward until 9:49pm. No explanation for this delay is evident from the records. Therefore, we understand this would have been frustrating for Mr B at the time as he waited for a bed, as well as it being difficult for Mr A to hear now.

22. Therefore, we consider there was a significant delay in Mr B being reviewed by the medical team on 18 November 2024, contrary to the NHS England guidance, despite the arrangements made by his GP. There were also delays in Mr B being transferred to the ward later in the day despite the availability of a bed.

23. Given this, we have asked our A&E adviser about the impact of these delays on Mr B. We note that Mr B received treatment for hypomagnesaemia, hypocalcaemia, and dehydration while under the care of the SDEC service on 18 November 2024. A clinical examination was documented during his assessment in SDEC, and the findings did not indicate focal neurological signs or raise suspicion of an acute intracranial event.

24. There were no immediate concerns for Mr B by the evening of 18 November 2024, but he was noted to be experiencing progressive frailty and reduced oral intake. He was also noted to have an acute kidney injury, hypocalcaemia, and hypomagnesaemia, as we have said. Further investigations were planned to exclude malabsorption syndromes, including coeliac disease, and vitamin D deficiency.

25. A discussion with Mr B and his daughter was documented. During this conversation, it was explained that, in view of his progressive frailty, he would be for active ward-based management but was unlikely to benefit from admission to Intensive Care and would not be for cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest.

26. On the balance of probabilities, while the delays identified represent shortcomings in the timeliness of care and patient flow, there is no evidence that they resulted in any significant clinical harm or adversely affected the overall management of Mr B's condition. In other words, while there are indications of failings in terms of delay with some of Mr B’s care, there is no evidence these delays had any impact on his care. Therefore, the impact is limited to some confusion, worry and frustration for Mr B.

27. We expect NHS hospitals to provide timely care in accordance with relevant guidance, but the unfortunate reality is that this is not always possible in the context of a busy clinical environment. If we had identified any negative impact from these delays on Mr B’s care, we would have raised concerns with the Trust. In the absence of this, there is no further action for us to take on this point.

Scans and monitoring

28. Mr A says the Trust failed to carry out CT and MRI scans promptly or appropriately monitor Mr B for risk of stroke.

29. We appreciate why Mr A feels that these scans should have been offered to his father. Therefore, we have considered this point with support from our physician adviser. Prior to the likely neurological event and fall that Mr B suffered at 1.33am on 20 November 2024, there was no reason for the Trust to carry out CT or MRI scans. This is because Mr B had come into hospital on 18 November 2024 due to electrolyte disturbance and kidney problems which were getting worse. He also had low magnesium, so the priority was to try to correct electrolyte imbalances and stabilise his condition.

30. After his likely neurological event and fall, Mr B could have had a CT or MRI scan to help investigate and establish what happened even though there is no evidence he suffered any head injury but, unfortunately, his condition was never stable enough for him to undergo such investigations. Therefore, it was inappropriate to carry out these investigations.

31. We also understand why Mr A thinks his father should have been monitored for the risk of stroke when he was in hospital. However, it is not definitive that Mr B suffered a stroke when he was in hospital although it is also not unreasonable to suggest that a stroke could have caused the type of event that he suffered. We know that Mr B suffered a likely neurological event in the early hours of 20 November 2024 which could have been a brain stroke (haemorrhage or infarct), but we cannot be sure as no CT or MRI scan could be carried out to investigate what happened for the reasons explained earlier in this statement.

32. Our physician adviser has added that there is no specific process for monitoring the risk of stroke in patients. Stroke management is focussed on trying to minimise the risk of a patient suffering further strokes (i.e., secondary prevention).

33. For Mr B, appropriate secondary prevention measures were already in place - he was on bisoprolol for management of hypertension (high blood pressure), atorvastatin for cholesterol lowering, metformin for control of diabetes and aspirin as an antiplatelet (blood thinner) – and so the Trust did not need to do anything else to reduce the risk of further strokes.

34. As there is no indication of failings on this point, there is no further action for us to take.

Complaint handling

35. Mr A says there were delays in the Trust responding to his complaint. He says the Trust’s investigation of his complaint was overseen by the consultant responsible for the team caring for his father and the complaint response contained multiple medical terms which are difficult to understand.

36. We are sorry to hear that Mr A feels the Trust’s response to his complaint was delayed. We also note his concerns about the consultant who oversaw his father’s care being involved in the complaint response and some of the terminology used in the response being difficult to understand.

37. Having considered what happened during local resolution of Mr A’s complaint, we can see that he complained to the Trust on 19 December 2024 It replied on 20 February 2025, approximately two months later. It offered further local resolution and details for the Ombudsman as potential next steps. Mr A decided to come to the Ombudsman as a next step.

38. Paragraph 14(3) of the NHS Complaints Regulations state: ‘in paragraph (4), “relevant period” means the period of 6 months commencing on the day on which the complaint was received, or such longer period as may be agreed before the expiry of that period by the complainant and the responsible body.’

39. This means the Trust had up to six months to provide a response to the complaint under the NHS complaints process. In Mr A’s case, a response was issued within this period, and he decided to come to us as a next step.

40. In our experience of dealing with NHS complaints, it is not unusual for a consultant who was involved in the affected patient’s care to also be involved in the subsequent complaint response. This is because the Trust often needs clinical input from those involved in the relevant episode of care to formulate its complaint response. That is what appears to have happened here. While we can understand Mr A’s concerns, there are legitimate reasons for the consultant being involved in the complaint response.

41. Finally, if Mr A did not understand some of the medical terms used in the response, we consider he could have requested further clarification and explanation from the Trust. As we have said, further local resolution of the complaint was offered but not accepted by Mr A.

42. As there is no indication of failings regarding the Trust’s handling of Mr A’s complaint, there is no further action for us to take on this point.

43. In summary, we are sorry to hear about Mr B’s experiences when he was in hospital in November 2024. We recognise that this episode of care ended tragically for Mr B and his family and it must have been a traumatic experience for Mr A to witness these sad events.

44. Mr A will be aware that his father had been unwell for a few weeks before he came into hospital. He had been suffering with poor appetite, mobility issues, vomiting and a change in bowel habits. All this had made Mr B weaker, leading to a visit to his GP, who did blood tests. The abnormalities identified, primarily low serum magnesium and calcium levels, prompted the GP to advise Mr B to attend the ED, which he did on 18 November 2024. Also, Mr B’s underlying kidney problems were noted to be getting worse.

45. Mr B was given appropriate care on 18 and 19 November 2024. Unfortunately, he suffered a catastrophic neurological event in the early hours of 20 November 2024 which weakened his clinical condition further to the point where survival was impossible. These tragic events led to the sad death of Mr B.

1. We have carefully considered Mr A’s complaint about Frimley Health NHS Foundation Trust.

-we have seen no indication that anything went seriously wrong with Mr B’s care.

2. We are sorry to hear about the sad circumstances around Mr A’s complaint regarding the care provided to his father, Mr B, by Frimley Health NHS Foundation Trust. We do not underestimate the impact these tragic events had on Mr A and his family, but we have not seen any indication that anything went seriously wrong with the care that Mr B received.