Guy's and St Thomas' NHS Foundation Trust

3. Mr E complains about the care and treatment his son (A), received from the Trust between July and August 2023. Mr E complains the Trust:

• discharged A inappropriately at the start of August without making adequate provision for his intravenous (IV) diuretics treatment to continue at home • denied a second opinion when he questioned whether the course of action the Trust was taking was correct and in A’s best interests • did not perform any Mental Capacity Act assessment on A, which meant the Trust made decisions about his care without seeking relevant permission from his parents • did not provide sufficient support once A was at home and his condition was deteriorating • delayed readmission by advising Mr E to continue the current treatment at home • delayed giving A IV diuretics following his readmittance to A&E on 8 August, and did not continue giving further IV diuretics when it was appropriate • did not adequately monitor A when it admitted him to the ward on 9 August, including not using remote monitoring, which would have meant the nurses could have monitored his condition in real time.

4. Mr E says the lack of IV diuretics following A’s discharge caused his son to deteriorate severely. He believes the delay in restarting IV diuretics when A was readmitted on 8 August caused his death. He also believes the other aspects of his son’s care he has complained about all contributed to the deterioration of A’s condition and added to the pain he was suffering. Mr E says he and his wife had to watch their son suffer unnecessarily before he died, and that his family have been totally devastated by A’s death.

5. Mr E is looking for an apology from the Trust. He would also like it to make service improvements so it does not make the same mistakes, and no other parent must go through this in the future.

6. The Trust admitted A to hospital in July 2023. A had a complicated medical history and was well known to the Trust’s Adult Congenital Heart Disease (ACHD) team.

7. Following a Multi-Disciplinary Team (MDT) discussion the Trust made the decision to move A to palliative care.

8. At the start of August, the Trust discharged A home. Mr E complains about this discharge, as while in hospital A was receiving IV diuretics and the family wanted this treatment to continue at home. As the Trust could not arrange this, it discharged A and arranged for him to take diuretics orally at home.

9. Following a deterioration in his health A was admitted to hospital again a few days later. Following readmission his condition continued to deteriorate, and he sadly died the next day.

10. Mr E raised a complaint with the Trust and has also contacted other organisations to raise his ongoing concerns.

11. Mr E currently has ongoing legal action in relation to decisions made by the coroner, Attorney General, General Medical Council (GMC), and the Care Quality Commission (CQC).

13. There will be occasions when we decide there are reasons why we should not consider a complaint. This includes when other organisations are considering the same or closely related issues and it would be more appropriate for us to wait for the outcomes of their work first.

14. We understand that Mr E is challenging the findings of the coroner’s inquest. He is also challenging the decision of the CQC not to commence a criminal investigation. There is also ongoing action in relation to GMC’s decisions not to act against the doctors involved.

15. This ongoing legal action would significantly impact our assessment of Mr E’s complaint. A robust investigation would be very challenging while the outcomes remain unknown, as they could change important underlying facts or the overall scope of Mr E’s complaint.

16. We believe it would be better to wait until all outcomes are known. It is also not in the best interests of Mr E to proceed with an investigation now. If we proceeded now, we would have to base our work on the currently established facts of the case. Mr E is challenging those facts through his court claims.

17. There is also a risk we could interfere with the court process. If we carried out an investigation now, we would need to make further enquiries, and these could overlap with matters before the courts.

18. We consider it important that all matters before the courts are resolved before we make a full assessment of any issues that remain outstanding.

19. We have considered the outcomes Mr E is looking to achieve. He told us that he is looking for an apology and service improvements. It is possible some or all these outcomes will be addressed through the court process.

20. For these reasons we have decided it is not reasonable for us to investigate Mr E’s complaint at this time.

21. We hope the court process and proceedings are helpful to Mr E and achieve the outcomes he is seeking. If he does not achieve these outcomes, he may be able to return to us for our consideration.

22. We hope we have clearly explained the reasons for our decision not to consider the complaint further at this time. We would like to wish Mr E the very best moving forward.

1. We have carefully considered Mr E’s complaint about the Trust. We were very sorry to learn of the reasons for his complaint and would like to take this opportunity to offer our condolences. We cannot consider the complaint further at this time, as legal proceedings are ongoing.

2. We thank Mr E for taking the time to talk to us about what happened and raise his concerns. We explain our decision in more detail below.