Trust's investigation into complaint failed to address key issues

What happened

Mrs T, a diabetic, was admitted to hospital for amputation of her leg. Although she was initially well after the operation, a few days later she suffered a hypoglycaemic attack (caused by low blood sugar) and collapsed. She was transferred to the high dependency unit but died two days later.

Miss T complained to the Trust to highlight the fact that her sister had received a telephone call from a nurse saying that the night before her collapse, Mrs T had apparently argued about being allowed to test her blood glucose on the ward. Miss T said she was concerned her mother had been prevented from checking her blood glucose and that this had led to her collapse.

The Trust's response provided lots of information about Mrs T's admission but simply said there was no record of any argument.

Miss T complained to us and explained that she felt the Trust had missed the point of her complaint. She also highlighted other concerns about her mother's management.

What we found

We partly upheld this complaint. There was no evidence of any argument taking place. There was, however, clear evidence that Mrs T's blood glucose had been recorded regularly, including on the night before her collapse. Our clinical advisers told us that Mrs T's blood glucose was monitored appropriately and that the recordings would not have given any reason for concern.

However, the Trust had not properly identified or investigated Miss T's main concern. It had not identified or obtained statements from the nurses caring for Mrs T. Its response included some details about Mrs T's recorded blood glucose levels but did not explain when those readings were taken. These failings contributed to Miss T's distress about her mother's death and caused her further anxiety.

Putting it right

The Trust apologised to Miss T and agreed to review how it investigates complaints when individual staff are identified.