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Wye Valley NHS Trust (19 012 735a)

Category : Health > Hospital acute services

Decision : Closed after initial enquiries

Decision date : 19 Feb 2020

The Ombudsman's final decision:

Summary: The Ombudsmen will not investigate Mr K’s complaint about the care and treatment his brother received prior to his death because an investigation is unlikely to add to the responses he has already received.

The complaint

  1. Mr K complains about the care and treatment afforded to his brother Mr G between June and October 2018 by a care home acting on behalf of Hertfordshire Council, Hereford Medical Group (‘the GP’) and Hereford County Hospital (‘the Trust’).
  2. Mr K says the Trust did not treat his brother sufficiently during his admission between 12-14 June 2018 which led to a deterioration in his health. Mr K considers his brother’s health was deteriorating rapidly over the months before his death but that this was not identified by the organisations responsible for his care. He says he has been treated badly by all involved, as he has tried to get answers to his concerns.
  3. Mr K says his brother died as a result of the organisations’ failings.
  4. Mr K says he would like a thorough investigation into his concerns and an apology for the failing.

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The Ombudsmen’s role and powers

  1. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
    • it is unlikely they would find fault, or
    • it is unlikely they could add to any previous investigation by the bodies

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

  1. I have considered information provided by Mr K over the telephone and in writing. I have also considered the complaint responses provided by the Trust, the GP and the care home following queries.
  2. I have also considered Mr K’s comments on a draft version of this decision.

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What I found

  1. Mr G fell out of his chair whilst in the care home on 12 June 2018. He was transferred to the Trust where he was diagnosed with a bleed on the brain and remained there until he was discharged on 14 June 2018.
  2. On 8 October 2018, Mr G experienced severe pain in his left hip and his GP arranged for a transfer to hospital via ambulance. He was returned to the care home on 9 October 2018.
  3. On 11 October 2018, a nurse from the care home identified that Mr G was mildly jaundiced and called the GP for advice. The GP prescribed medication.
  4. On 12 October 2018, Mr G’s GP arranged a hospital admission following no improvement in his condition. He was transferred to the Trust for further treatment. A chest x-ray on final admission showed a small amount of fluid on the lungs. Tests later revealed he was suffering from a urine infection and advanced liver disease, which was causing a decline in Mr G’s brain function
  5. Mr G died from his illness in late October 2018.

Care and treatment

  1. Mr K complains that the Trust, GP and Care Home did not take the necessary steps to prevent a deterioration in his brother’s condition following a fall which caused the brain injury, and later lead to his death.
  2. Following Mr G’s fall on 12 June 2018, the Care Home requested an ambulance which brought Mr G to hospital at the Trust. Mr K was treated by the hospital between 12 and 14 June 2018, after a CT scan revealed blood had collected between his skull and brain (a subdural hematoma) The Trust considered he did not require surgical intervention. Once he was considered medically fit for discharge, he was discharged back to the Care Home on 14 June 2018. There is no evidence Mr G had any involvement with his GP prior to 8 October 2018.
  3. In late October 2018, Mr G died due to a urine infection and advanced liver disease, four months following brain injury. The subdural hematoma he was diagnosed with is an acute event, and if left untreated, the effects are evident sooner. From a lay perspective, it would appear that Mr G’s condition had not deteriorated to such an extent during the period in question to necessitate GP or hospital intervention, rather that the eventual outcome was due to an overall deterioration in Mr G’s already poor health.

Taking this into account, it is likely we would be unable to add anything further to the responses Mr K has already received or find that his brother’s death was avoidable.

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Final decision

  1. The Ombudsmen will not investigate Mr K’s complaint. Further investigation by the Ombudsman is unlikely to add to the responses or make a different finding.

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Investigator's decision on behalf of the Ombudsman

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