Mr C’s sister died during palliative chemotherapy at East and North Hertfordshire NHS Trust (the Trust). Mr C described the impact of her death on his family as ‘immense’and said his surviving sister had ‘not only lost her sister but also her closest friend and soul mate’.

Dissatisfied with the Trust’s response to his complaint, Mr C came to us because he wanted to know exactly what had happened during his sister’s final hours.

Our investigation did not uphold Mr C’s complaint about the Trust’s care of his sister. However, we found very poor complaint handling. The Trust did not review the clinical notes promptly and clarify events while key people’s memories were still fresh. Some written statements taken by the Trust were undated and unsigned, other sources of information they gave to Mr C were unclear, and still further information did not tally with the clinical records. There were no records to back up some of the Trust’s statements.

The Trust used unhelpful medical jargon at a local resolution meeting with Mr C and did not clear up points that Mr C had not understood. The Trust did not apologise to Mr C for their poor record keeping. They also did not refer to professional standards and guidance when investigating his concerns, or when committing themselves to improving the monitoring of observations and record keeping.

Describing to the Trust how their answers to his concerns had affected him and his family, he said, ‘We feel that your avoidance by giving minimal answers has prolonged our suffering’. Mr C was put through two years of distress as he struggled to make sense of what happened to his sister at the end of her life.

The Trust apologised to Mr C and used his case study in training sessions for staff in how to investigate and respond to complaints.