South Tyneside and Sunderland NHS Foundation Trust

4. Mrs N complains that when her husband, Mr N, was an inpatient at the Trust from 29 April to 15 May 2019 with pneumonia, his hip was dislocated. Staff recognised the increasing pain in his leg but Mrs N complains they did not complete any investigations to locate the source of his pain. This was because he was receiving palliative care for a bowel cancer diagnosis and his pain was attributed to the spread of his cancer. Only when Mr N was transferred to a Hospice on 18 May, a possible dislocation or fracture was identified.

5. Mrs N complains there was a missed opportunity for the Trust to reset or provide treatment for the dislocation, or fracture, meaning her husband could receive end of life treatment more comfortably and without the associated pain.

6. She says it was distressing to see her husband uncomfortable and in severe pain towards the end of his life. She believes if the dislocation or fracture was identified earlier, there may have been treatment options available which would have resulted in him living longer.

7. As a result of her complaint, Mrs N wants the Trust to acknowledge the failings in the care it provided to her husband, and an apology.

8. Mr N had a recurrence of bowel cancer in May 2018, for which no further treatment was planned. He was receiving care from the palliative care team and the district nurse.

9. Mr N was taken to the Emergency Department (ED) at the Trust in April 2019. He had a chest X-ray and two computerised tomography (CT) scans, one for his bowel, abdomen and pelvis, and one for his head, as it was thought he had a stroke.

10. The chest X-ray found Mr N had a chest infection which was later diagnosed as pneumonia. He was given intravenous (IV) antibiotics. The head CT showed no signs of a recent stroke, but the bowel CT showed the cancer had spread to his liver and had blocked the tube to one of his kidneys.

11. Mr N was admitted to the Trust’s hospital. He was first seen by a consultant on 2 May. As Mr N appeared to be responding well to the IV antibiotics, his consultant changed him to oral antibiotics. Mrs N says she took this as a sign her husband was improving.

12. Due to previous strokes, Mr N had limited mobility. However, he started complaining of a pain in his left leg on 10 May and could not get out of bed. The physiotherapist tried to transfer Mr N to the chair, but he could not stand as he was in too much pain. The occupational therapists were also called to hoist him but again he was in too much pain to move. He complained to his daughter that he thought his leg was broken.

13. He was reviewed by the palliative care nurse and his pain medication was increased.

14. The Trust managed Mr N’s pain with medication. He was discharged on 15 May to receive end of life care at home. Due to the level of his pain during the two days he was at home, Mr N was admitted to a hospice on 18 May. The consultant there indicated there may be a possible fracture or dislocation to his left hip/leg based on its presentation. As Mr N was so unwell, it was not possible to perform any imaging of his hip as he was approaching the end of his life and it was too painful for him to be moved. The hospice could only make him comfortable and control his pain.

15. Sadly, Mr N died a few days later at the hospice.

21. Mrs N complains that her husband’s hip was injured while he was in hospital. She says the Trust told her that there is no way of knowing if the injury occurred during his admission or during the two days he spent at home following his discharge. Mrs N believes the sudden pain was from an injury sustained while at the Trust, as Mr N was not complaining of pain and had some mobility in his leg prior to the admission.

22. The Trust has provided additional information from the palliative care consultant, that it did not use within its complaint response. In this letter, the consultant identified that the pain in Mr N’s leg could be from either a dislocation or a fracture.

23. Staff at the ED noted Mr N was moving all four limbs when he was assessed there on 29 April, which our orthopaedic adviser said means he was unlikely to have had a fracture then.

24. The reports of the CT scans, done the same day, refer to screws in Mr N’s right hip and tell us the hip was not dislocated at the time. The report does not reference anything abnormal about Mr N’s left hip, which is where he experienced the sudden onset of pain on 10 May. The CT scans do not refer to anything below the hip, so it is likely the area below the hip was not scanned. This means the scans would not show if there was a leg fracture at the time, or if cancer had spread to Mr N’s leg, putting him at risk of an imminent fracture.

25. As a result of the CT scans, a fracture of the L1 vertebra was noted. The L1 vertebra is the topmost section of the lumbar spinal column. This section of the spine contains a portion of the spinal cord. Injuries to the L1 spine can affect hip flexion, cause paraplegia, loss of bowel/bladder control, and/or numbness in the legs. It is not known how or when Mr N sustained this injury.

26. We can see alfentanil was first prescribed on 2 May, to be taken as needed. Alfentanil is a potent opioid analgesic that acts quickly. It is often used to provide pain relief for painful manoeuvres. The first time Mr N complained of leg or hip pain is documented on 10 May by a physiotherapist and occupational therapist, when trying to roll him onto his side and to sit him in a chair. As a result, staff gave him pain relief. There is no mention of leg or hip pain prior to this.

27. Later the same day, Mr N was still complaining of pain when being rolled or changed position. Staff again gave him alfentanil pain relief.

28. In the early hours of 11 May, the records show that Mr N was in a lot of pain when repositioning. In anticipation of pain he was given alfentanil prior to moving, but was noted to still be uncomfortable after an hour.

29. Mr N was discharged on 15 May with an alfentanil driver, for pain in his left leg.

30. Our orthopaedic adviser confirms that the posture of the leg, as described by the doctor in the hospice, raises the suspicion of a fracture. They said it is very unlikely to have been a dislocation. It is also unlikely Mr N’s pain originated from his L1 fracture as there are records of Mr N moving his limbs upon admission, and the L1 fracture was already present and visible on the scan.

31. We cannot be certain about what caused the pain in Mr N’s hip. We have carefully considered the Trust’s comments, the additional information from the palliative care consultant, our clinical advice, and the documented sudden increase in Mr N’s pain after being moved from his bed to a chair on 10 May. On balance, we think it likely he sustained an injury on 10 May, possibly a fracture, and possibly related to a spread of his cancer.

32. Mrs N complains that the Trust did not investigate the source of Mr N’s pain, wrongly attributing his pain to the spread of his cancer.

33. Staff tried to control Mr N’s pain relief but did not investigate the origins of the pain. Based on what Mrs N told us, it appears they attributed it to a spread of his cancer, but this was not evidenced. We saw no evidence the Trust considered investigating the source of Mr N’s pain.

34. Paragraph 28 of the GMC ethical guidelines says clinicians should weigh up the benefits and burdens of any investigation and treatment. We would, therefore, expect to see some consideration of investigating where the pain originated, contained within Mr N’s notes. This could have influenced any treatment given. If investigations had been conducted, and those investigations identified a fractured/dislocated hip, our palliative care clinician told us that surgery, or an anaesthetic nerve block could have been options. Without any investigation by the Trust, it is difficult to know.

35. Had a fracture been identified, the NICE pathway for a hip fracture says that surgery should be considered, even for those who are terminally ill. However, it is possible that Mr N would not have been fit enough for surgery given how frail he was at the time.

36. The NICE end of life care, for people with life-limiting conditions, pathway says treatment decisions must be individualised. That same guidance explains that assessment of signs and symptoms is important when a person is approaching the last days of their life, so responsive and compassionate care can be provided, to ensure that the person is a comfortable as possible if their condition continues to deteriorate.

37. If staff chose not to explore the source of Mr N’s pain and only treat it with pain medication, in line with Paragraph 28 of the GMC ethical guidelines, we would also expect to see this documented along with the reasons why. This did not happen.

38. We do not consider the Trust acted in line with the NICE pathways for end-of-life care for people with life limiting conditions, as there is no evidence to show the Trust’s decision to treat Mr N only with pain medication was individualised. This meant Mr N lost the opportunity, however slim that might have been, to have surgery that may have resolved or at least reduced the pain in his hip and leg.

39. Mrs N says having to witness her husband of many years in severe pain was distressing, and not knowing if anything further could have been done will stay with her. Given how ill Mr N was, we do not know that investigations would have led to a change in treatment. This is because we do not know the source of the pain Mr N experienced. As this is something we cannot determine, we are unable to reassure Mrs N that staff did everything possible to ease his suffering and let him spend the end of his life as comfortably as possible. This leaves her with uncertainty which will no doubt be a source of distress. This is an injustice to her. Therefore, we partly uphold this aspect of the complaint.

40. We have listed below the recommendations to put right the injustice to Mrs N.

1. We found that, on balance, it is likely the sudden increase in Mr N’s pain on 10 May 2019, was from injury sustained at South Tyneside and Sunderland NHS Foundation Trust (the Trust).

2. Following Mr N’s sudden increase in pain, we found that staff tried to control the pain but did not investigate its cause. We do not consider the Trust acted in line with relevant guidance, as there is no evidence to show the Trust’s decision to treat Mr N with pain medication was individualised. This meant Mr N lost the opportunity to have surgery that may have resolved, or at least reduced, the pain in his hip and leg. This caused distress to Mrs N. She will never know if any treatment would have been available for her husband to spend his end of life more comfortably. Therefore, we partly uphold this aspect of this complaint.

3. We recommend the Trust acknowledges the identified failings and apologises for the impact of the failings on Mrs N; recognising her distress at not knowing if her husband could have had treatment to make his end of life more comfortable.

41. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

42. Our principles say that public organisations should look for continuous improvement, and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend that within one month of this report the Trust: • Acknowledges the failings identified within the report, and • Apologises to Mrs N for the distress caused by the identified failings