Countess of Chester Hospital NHS Foundation Trust

5. Mr P complains about the care the Trust gave his father, Mr G in October to November 2024. He specifically complains that Hospital A: • failed to provide adequate nutrition, or take appropriate action when he was losing weight • failed to tell the family how unwell their father was prior to 4 November • failed to carry out a mental capacity act assessment soon enough • failed to carry out any blood tests and minimal urine tests.

6. He complains Hospital B failed to treat his sepsis and dehydration on 5 November.

7. He complains the Hospital at Home team failed to send him to hospital between 1 and 4 October.

8. Mr P says the impact of poor nutrition and not carrying out a mental capacity assessment, led to his father being malnourished and not strong enough to fight his illness. He says this led to a distressing death for his father.

9. He says the failure to communicate how unwell he was, caused severe distress for the family.

10. He says the failure to carry out tests and treat his father’s illness was a missed opportunity to treat sepsis and prevent a prolonged distressing death.

11. He says the failure to send him to hospital could have resulted in earlier treatment for his father’s stroke and prevention of his death.

12. The impact of all the above has affected Mr P in witnessing his father having a distressing death.

13. As an outcome, Mr P is seeking an apology and for the Trust to admit its failings. He is seeking service improvements so other families do not have to go through the same experiences.

14. This brief background is only intended to place the key events in context, not provide a full account of everything that happened.

15. Mr G was in his nineties and lived in a care home. He had a background of dementia and diabetes.

16. Between 1 and 4 October, he had falls and lost his mobility. The Hospital at Home team saw him. This is a service the Trust runs to provide care in the community. He developed left sided weakness and the Trust admitted him.

17. The Trust diagnosed him with a stroke, and he was initially on a ward at Hospital B. On 19 October, the Trust transferred him to Hospital A for rehab. During this time, Mr P says his father deteriorated significantly. On 5 November, he insisted the Trust transfer his father back to Hospital B.

18. On transfer, the Trust diagnosed him with sepsis and acute kidney injury. Staff decided to keep him comfortable and stop active treatment. He sadly died five days later.

Hospital at Home team (H@H) 22. Mr P complains the Hospital at Home team failed to send Mr G to hospital between 1 and 4 October, when he had multiple falls.

23. Mr G had an unwitnessed fall on 1 October and paramedics saw him. The H@H team first saw him on 2 October as he was generally unwell, had foul smelling urine and a fall the previous day.

24. The clinician performed a detailed assessment including a neurological examination. Mr G had normal strength in all four limbs. He had milky coloured urine with debris and a strong smell. The clinician sent off a sample and took blood tests. They asked staff to change Mr G’s catheter. They felt it was highly likely Mr G had a urine infection and started antibiotics.

25. On 3 October, the H@H team noted Mr G had another fall the previous night. He now needed a hoist to stand as he was weak. They took more blood tests.

26. On the evening of 3 October, care home staff noted less strength in Mr G’s left arm at 9.42pm. At 10.24, staff documented he had full strength in his arms.

27. On 4 October, the H@H team noted Mr G’s urine sample had grown mixed bacteria. Care home staff informed the H@H team he was weak and needing a hoist to transfer, but there was no concern about specific arm weakness. On assessment, the clinician noted Mr G to be alert and chatty. They sought advice from a microbiologist for the most appropriate antibiotic to treat him.

28. On the afternoon of 4 October, an ambulance took Mr G to Hospital B with left sided weakness.

29. The Silver book explains patients with dementia may have vague symptoms, such as weakness, falls and increased confusion. It also explains acute illness can present with non-specific signs and symptoms such as weakness in older frail patients.

30. It explains clinicians should act proactively in patients in the community by completing a multi-factorial assessment and making a tailor-made plan. Our physician adviser explained the Trust acted in line with this, by assessing Mr G, performing observations, blood tests and urine samples.

31. Our physician adviser explained there were no symptoms of stroke highlighted to the H@H team, as this does not present with fluctuating symptoms.

32. The Silver book explains older adults with dementia in urgent care settings are at increased risk of poor health outcomes. Therefore, clinicians have to carefully consider any risks involved of admitting patients to hospital, if they can manage them safely in the community.

33. The Frailty virtual ward guidance explains patients need hospital care if they need clinical intervention that could only a hospital can offer. This was not the case for Mr G, as the H@H team were managing his urine infection in the community. When his condition changed and he developed signs of a stroke, the Trust admitted him.

34. We have found no failings in the management of Mr G by the Hospital at Home team.

Nutrition and weight loss 35. Mr P says the Trust failed to provide adequate nutrition and hydration to his father when he was in Hospital A. He also says it failed to take appropriate action when he was losing weight.

36. Mr G’s records show he weighed 83.8kg when Hospital B first admitted him on 4 October. By the time of his transfer to Hospital A, his weight had dropped to 71.4kg. This was a weight loss of over 10 percent.

37. The Malnutrition Universal Screening Tool (MUST) helps identify adults who are malnourished or at risk of malnutrition. Patients that have unplanned weight loss of over 10% in the past three to six months get a score of two on MUST. This puts them at high risk of malnutrition. In view of this, staff at Hospital A referred Mr G to a dietician on admission.

38. The Trust’s Nutrition Screening Policy says people who are malnourished or at risk of malnutrition must have a management care plan that aims to meet their nutritional requirements.

39. The Trust’s Nutrition and Hydration policy says, for patients at risk of malnutrition, all food and fluid offered and consumed, should be recorded on a food and fluid chart.

40. A dietician saw Mr G on 24 October. They made a management plan which included encouragement and assistance with food, and to complete food charts. They advised staff should encourage visitors to bring in Mr G’s favourite snacks and drinks.

41. The Trust used food charts during Mr G’s admission but did not always complete them. It also did not document his fluid intake.

42. On 30 October, the dietician noted staff had not documented Mr G’s fluids and snacks. They noted Mr G was refusing food and now had a weight loss of 20% in one to two months. They prescribed oral nutritional supplements.

43. Our nursing adviser explained, when a patient has dementia and is refusing food, family involvement to bring them the foods they enjoy can be beneficial. They explained this is not just from a nutritional perspective, but from a comfort perspective also.

44. Despite the management plan which specified involving visitors, Mr G’s records show no evidence staff told his family about this.

45. In summary, the evidence shows the Trust did not monitor Mr G’s food and drink intake accurately or follow the dietitian management plan. It did not regularly offer snacks or communicate with Mr G’s family and encourage them to bring food in.

46. We have found the Trust did not act in line with relevant guidance in managing Mr G’s nutrition and hydration.

47. Dieticians noted Mr G’s continued weight loss, but as the Trust failed to manage his nutritional needs, we found it did not take sufficient action regarding this.

48. The MSD Manual explains nutrition via a feeding tube or drip, can cause discomfort. It explains it is not indicated for patients who are unable to eat due to dementia. It explains not giving nutritional support may be difficult for family members, but patients are usually more comfortable eating and drinking as they choose.

49. It also explains there is no convincing evidence that tube feeding prolongs life or provides comfort. NICE guidance says staff should not routinely use tube feeding in people living with severe dementia.

50. The Trust’s nutrition and hydration policy explains, in the final phase of dementia, patients often do not recognise food and refuse to open their mouths or turn their heads away when food is offered. Our nursing adviser explained Mr G was refusing food, which is common in dementia. They also explained it is unlikely Mr G would have tolerated a tube.

51. We therefore consider it would not have been in line with guidance to provide artificial feeding to Mr G.

Impact of nutrition and hydration 52. We will now consider the impact of the failings in monitoring Mr G’s food intake and following the dietician’s management plan.

53. Our nursing adviser signposted us to evidence showing the prevalence of weight loss increases with advancing dementia.

54. They explained it is unlikely Mr G would have met his nutritional requirements even with no failings in nutrition and hydration care. This is because he had advanced dementia, had already lost a lot of weight, and was refusing food. Artificial feeding would not have been appropriate as addressed above.

55. The Trust said in its first complaint response it recognised there should have been consideration of alternative routes for nutrition, such as a tube or IV fluids but it is unlikely Mr G would have tolerated these. In its final response, the Trust apologised that staff had not shared the dietician’s recommendations with Mr G’s family or always completed his food charts.

56. We consider the failings are unlikely to have made an impact on Mr G’s condition. We acknowledge how distressing it would have been for Mr P to see his father losing weight and feeling the Trust was not doing enough. We consider this would have led to some emotional distress for Mr P.

57. Our complaint standards say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. We note the Trust apologised, but we have considered if it could take additional actions. We have explained these later in our report.

Family discussions 58. Mr P says the Trust failed to tell him how unwell his father was, during his time at Hospital A.

59. A family meeting took place on 30 October. Mr G’s notes say ‘Prognosis discussed, advanced frailty, end stages of dementia. Advanced care planning advised.’ Mr P told us this meeting focussed on planning Mr G’s discharge and there was no discussion about his father’s medical condition.

60. On 4 November, a doctor spoke to Mr P and apologised that no one had given him a medical update since his admission to Hospital A on 19 October.

61. GMC guidance says doctors ‘must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information’.

62. The notes on 30 October are sparse, and Mr P is clear that staff gave him no detail on his father’s prognosis. The doctor’s entry on 4 November supports Mr P’s position.

63. We have found the Trust failed to act in line with guidance in communicating with Mr G’s family whilst at Hospital A.

64. Mr P says this caused severe distress for the family. We have seen in Mr G’s medical records, Mr P was shocked and upset to discover how unwell his father was.

65. As an outcome for his complaint, Mr P is seeking an apology and for the Trust to admit its failings. He is seeking service improvements so other families do not have to go through the same experiences.

66. In its first complaint response, the Trust apologised that Mr P did not receive the communication expected earlier. In its second response, it said it had taken Mr P’s feedback on board to help improve how it communicates with families in the future.

67. We have considered these against our complaint standards and consider it could take some further actions. We have explained these later in our report.

Mental capacity act assessment 68. Mr P says Hospital A failed to carry out a mental capacity act assessment. He feels that staff were not fully aware of his father’s dementia and lack of capacity. He feels this meant they did not treat him with the additional care he needed, such as leaving food and water without assisting him.

69. The Trust documented Mr G’s lack of capacity in Hospitals A and B. His notes reflect his diagnosis of dementia. We understand Mr P feels that as staff did not mention this in every entry, they may have been unaware, but we do not consider that to be the case.

70. The Trust’s MCA policy says an assessment of a person’s capacity must be based on a specific decision at the time, and not the ability to make decisions in general. It explains all actions undertaken when a patient lacks capacity must be made in their best interests.

71. Our physician adviser explained a formal MCA assessment would not have altered this. The Trust recognised and documented Mr G’s advanced dementia and lack of capacity for complex decision making. There is evidence staff supporting Mr G with his activities of daily living made continuous assessments of his capacity, as capacity is decision specific.

72. There is no indication from the clinical records that staff did not manage his care with the best interests’ principles in mind, as is appropriate in a patient that lacks capacity.

73. We understand Mr P feels staff were unaware of his condition as they left call bells and food for him which he could not use, but we do not consider this shows staff were unaware of Mr G’s condition. We have addressed the issues regarding food and drinks above. We do not consider that staff leaving a call bell indicates a lack of awareness of his condition or had an impact on his care.

74. In line with this, we consider the Trust did not need to complete a formal MCA assessment as Mr G’s lack of capacity was documented and known. The evidence shows staff acted in line with the MCA principles in providing care in his best interests when he was unable to provide consent. We have found no failing here.

Blood and urine tests 75. When Mr G returned to Hospital B on 5 November, staff diagnosed him with sepsis and dehydration. Mr P says Hospital A should have identified this during his stay there, by doing blood and urine tests.

76. On 19 October, Mr G’s transfer checklist said he did not need ongoing blood tests. During his admission to Hospital A, he had observations twice daily. Whenever these were abnormal, staff rechecked and they had normalised.

77. On 4 November, Mr P requested a doctor perform blood tests, but they declined as this would cause distress and not change the outcome for Mr G. Mr P was particularly concerned these were needed due to his father’s low oral intake and weight loss.

78. Mr G had a urinary catheter in place. PHE guidance explains patients need signs of an infection, urinary symptoms or an abnormal temperature to consider if an infection is present. Our physician adviser confirmed Mr G had no symptoms or signs that warranted further investigation for a urine infection.

79. The guidance also says most patients with a urinary catheter will have bacteria present in their urine, without an infection. Therefore, urine tests should not be routinely performed as they are unreliable in these patients.

80. Our physician adviser explained there was no specific reason to perform blood tests on Mr G. He was very frail with advanced dementia and a recent stroke. Nursing interventions caused distress to him, and he would likely not tolerate needles or a cannula. Doctors had to act in his best interests in considering how to proceed.

81. Although he had not been eating or drinking much, staff did not think he was dehydrated. As addressed above, a cannula and IV fluids would not have been in his best interests. Therefore, there was no reason to perform blood tests.

82. GMC guidance says doctors must assess patients’ needs. They must provide clinical care based on their clinical judgement about the likely effectiveness of treatment options.

83. Our physician adviser explained the Trust acted in line with this guidance, by considering the need for blood tests, balancing any benefit from them, and deeming them unnecessary. This is because it would have caused Mr G distress, and further treatment was not in his best interests.

84. We have found no failings in the Trust not carrying out these tests.

Sepsis and dehydration 85. On 5 November, in Hospital B, staff initially treated Mr G’s sepsis and dehydration. After a consultant review, it felt he was approaching the end of his life and stopped active treatment.

86. Mr P says the doctor told him his father was dying, but he then took a further five days to die. He told us how distressing this was to witness. He feels staff should have continued to treat Mr G.

87. A doctor explained to Mr P on 4 November that his father was approaching the end of his life. Mr P wished for the Trust to transfer his father back to Hospital B against medical opinion. On 6 November, the consultant explained to Mr P continued treatment would not change the fact Mr G was approaching the end of his life. They advised stopping active treatment and keeping him comfortable.

88. Our physician adviser explained the Trust acted in line with GMC guidance on providing care in line with a patients’ needs and providing treatment only when treatment will be effective.

89. GMC end of life guidance says, when considering treatments such as antibiotics or artificial nutrition, these treatments may prolong the dying process and cause the patient unnecessary distress.

90. Taking the above into consideration, we have found the Trust acted in line with guidance in withdrawing treatment from Mr G on 6 November. We do not find a failing here.

1. We were very sorry to hear of the circumstances of Mr P’s complaint. He told us how distressing it was to witness his father’s deterioration and death. We extend our sincere condolences on his loss.

2. We have carefully considered all the available evidence. We have found the Trust acted in line with guidance regarding mental capacity assessments, blood and urine tests, the Hospital at Home team, and choosing not to treat his sepsis.

3. We have found failings in the Trust managing his father’s nutrition and hydration, and in communicating with the family. These led to emotional distress for Mr P. We therefore partly uphold the complaint overall.

4. We recommend the Trust provides an action plan to make improvements in the areas of concern.

91. 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.

92. We have identified failings in relation to in relation to managing Mr G’s nutrition and hydration. We have also found failings in the Trust providing an update to Mr G’s family regarding his prognosis. We consider these led to emotional distress for Mr P. The Trust has apologised for both of these but has not explained about any specific service improvements to prevent this happening in the future.

93. With that in mind, we recommend that following this final report the Trust: • explains what action it will take, or has taken, to address these failings by 17 November 2026 – it should do this in the form of an action plan which should be shared with us, Mr P, CQC and NHSE.

94. The Trust should send us evidence it has completed all of the recommendations we have made. We will check the action plan includes the reason for the failing (where possible), what the Trust does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.