The family of Bill Trotter, whose body remains "on ice" in Newcastle, have been left angry by inconsistencies in what they have been told by authorities as they fight for answers over their dad's death. Washington-born Bill, 73, died following treatment at the Cumberland Infirmary in Carlisle in July 2024.
This saw the family receive documents implying there had been two post-mortem examinations, rather than one, and suggesting that there had been a "lessons learned" review, carried out. In the latter case, no such formal review had taken place, authorities now say.
Family demands full inquest
Mike and Kelly Trotter have been calling for a full inquest to be held since their dad's death. The family have repeatedly raised concerns about his care and are now taking this up with both the Parliamentary and Health Service Ombudsman (PHSO) and the office of the Attorney General.
This is after having raised concerns in the immediate aftermath of Bill's death. The family allege that he was misdiagnosed several times - and that he had a leg amputation they believe may not have been necessary.
Bill, who was born and brought up on Wearside but lived much of his adult life in Cumbria, died after slipping into a diabetic coma. His family has seen medical records showing that his blood sugar levels fell to 1.2 - a serious "hypo" - after he was given a significant amount of medication. Initially, this was not reported to the national records service which tracks severe diabetes harm events and it had initially been referred to in documentations as having only fallen to 2.4.
Police apology over post-mortem error
Last year ChronicleLive reported how Bill's family had his medical records and had been able to show this was not the case. By that time, it was also accepted by NHS bosses that Bill did not have an abscess on his backside at the time he was last admitted to hospital.
Now, the family told ChronicleLive they were tired of feeling like they were being "played for fools" and that they wanted to see greater scrutiny as to why there had been such "miscommunications". Recent developments have seen Northumbria Police officials share an apology after Mike and Kelly were told, erroneously, by officers of an "initial post-mortem" which had in fact never taken place. The family have queried how such a miscommunication came about.
In reality, a single post-mortem took place when the family organised for this to take place privately. The idea that there had been a post-mortem prior to this - that they didn't know about, caused them distress.
Meanwhile, a letter Mike and Kelly received from the Department of Health and Social Care in April said: "The CQC's review found that the Trust had investigated incidents related to your father's treatment, from which lessons were learned." However, in response to legal correspondence from the family, the CQC told them at the beginning of this month: "We can confirm there isn’t a lessons learned report or review, or as such, a contemporaneous record of one."
Family questions 'miscommunication'
Asked to clarify, CQC officials said that the regulator had reviewed evidence relating to Bill Trotter's death and discussed the learning taken from this with the North Cumbria Integrated Care NHS Trust.
The family highlighted their concerns. Mike and Kelly said: "For months we have asked one very simple question: show us the review and show us what lessons were learned.
"We were not asking CQC to create something retrospectively. We wanted to see the contemporaneous evidence behind what the Department of Health and Social Care had been told. Now, after all this time, CQC says there wasn't a lessons-learned report or review, or even a contemporaneous record of one."
They said this raised further questions about what had been communicated between the organisations in connection with the complaints Mike and Kelly have raised. They said: "An apology for 'miscommunication' doesn't answer those questions."
A Northumbria Police spokesperson said: "Our thoughts are with the loved ones of Mr Trotter following his death. We can confirm that a post-mortem was not conducted in Cumbria in relation to him.
"This detail was included in the complaint outcome letter in error following a misunderstanding between our officers, and we sincerely apologise for the inaccuracy and the impact this may have had upon Mr Trotter’s family. It was included in the background section of the complaint response and did not affect the complaint allegation outcomes."
Asked about the conflicting reference to a "lessons learned report", a CQC spokesperson, said: "Our deepest condolences are with the family and friends of Mr William Trotter, following his sad death in July 2024 at the Cumberland Infirmary, run by North Cumbria Integrated Care NHS Foundation Trust.
"CQC has reviewed evidence relating to Mr Trotter’s death and spoken with the trust about the learning they have taken from it and the steps they’ve put in place to ensure people’s safety going forward.
As with all registered healthcare providers, the trust is subject to ongoing monitoring to ensure people are receiving safe care and treatment. As part of that regular ongoing monitoring, CQC inspected urgent and emergency care at Cumberland Infirmary in February and March and this report published in September.
"CQC’s priority is the health and wellbeing of people using health and social care services, and all information we receive informs our monitoring of services and future inspections. We would encourage anyone who has concerns about a health and social care service to let us know. This can be done via our customer service centre on 03000 616161 or enquiries@cqc.org.uk."
