Mrs F complained that a GP practice did not refer her husband to hospital soon enough, and that he waited too long in the Trust's emergency department.
What happened
Mr F had multiple sclerosis. The GP visited Mr F at home after Mrs F called the practice because he felt unwell. The GP told Mr F that she thought his symptoms were the result of multiple sclerosis, and asked Mrs F to call 999 if his condition deteriorated.
In the evening, Mrs F telephoned 999 as her husband's condition had worsened. An ambulance arrived and the crew noted that Mr F felt dizzy and lightheaded and had pins and needles. The crew also recorded that Mr F's vital signs were normal apart from high blood pressure.
When Mr F arrived at hospital, staff left him on a stretcher in the corridor outside the emergency department's resuscitation area because no cubicles were available. Mr F's condition suddenly deteriorated and staff moved him to a cubicle, where he stabilised.
Doctors admitted him and monitored him throughout the night and the next morning, but sadly he died later that day.
What we found
The care and treatment the GP and the practice provided for Mr F was in line with recognised quality standards and established good practice.
The care and treatment at the Trust before Mr F's sudden downturn fell so far below standard that it was service failure. However, this did not contribute to Mr F's death.
The Trust did not investigate Mrs F's complaint thoroughly. That was maladministration, which led to an injustice to Mrs F.
Putting it right
The Trust apologised for the injustice.
It agreed to prepare an action plan that described what it had done to learn lessons from this investigation.
University Hospitals Coventry and Warwickshire NHS Trust
A GP practice
West Midlands
Replied with inaccurate or incomplete information
Apology
Recommendation to learn lessons or draw up an action plan