27. When somebody complains to us about the care they have received, we look for signs of service failure. To do this, we compare what should have happened with what did happen in that situation. We use clinical guidelines and standards to tell us what should have happened. If the care someone received fell short of what should have happened, we may consider this a failing. Where we can see signs of a failing, we then consider the impact this had on the person and what, if anything, the service has done to put things right. We then consider whether this was enough to put right the impact of what went wrong.
28. Where we can see signs of failings that had an impact that has not yet been put right, we may decide to look at these issues again by conducting a detailed investigation.
The Practice’s care of Mrs D
29. Ms L complains her mother’s GP at the Practice:
• did not visit her at home to assess her condition between the end of June and early October 2020 • communicated poorly with the family about her care needs during this time • delayed arranging an end-of-life care plan and providing pain relief.
30. We asked our GP adviser what should have happened after Mrs D contacted the Practice in June 2020 and whether her GP should have visited her at home to assess her condition.
31. Our GP adviser explained that, at the time of these events, NHSE’s ‘Guidance and standard operating procedures (general practice in the context of coronavirus, COVID-19)’ instructed GPs to limit their contact with patients in their own home. This guidance also recommended that GPs liaise with the wider community care team and identify the most appropriate professional to visit patients at home. The guidance also said professionals who did visit should consider if they could perform the duties of other team members to avoid multiple visits. The guidance was very clear that visiting patients at home during this time should be limited as much as possible.
32. The GMC’s ‘Good Medical Practice’ (section 15a) says doctors must adequately assess a patient’s condition and, where necessary, examine them. The GPs should have followed this guidance while applying NHSE’s standard operating procedure for general practice.
33. Mrs D’s GP records clearly show the GPs were consulting their patients over the phone because of COVID-19 guidelines. The records do not show the exact guidance the GPs were following, but the relevant guidance would have been the standard operating procedure. At the end of June, Mrs D’s GP recorded they offered her a face-to-face appointment, but Ms L declined the offer.
34. An out-of-hours GP fully assessed Mrs D in early July. This GP fully examined Mrs D and made their notes available to her GP at the Practice. Mrs D’s GP then discussed the notes with her family the following day. The GP and the family had more discussions over the phone between July and September, again because of pandemic guidelines.
35. In early September, a GP from an organisation contracted to make home visits on behalf of the Practice visited Mrs D at home and fully examined her. Mrs D’s GP reviewed the notes of this home visit and spoke with her family the following day. Mrs D’s GP had six more phone discussions with the family between mid-September and early October. Another out-of-hours GP saw Mrs D in person and assessed her in early October.
36. The evidence shows a GP examined Mrs D at home three times during the period complained about. Out-of-hours GPs did these examinations, not her GP at the Practice. The out-of-hours GPs left full notes of their examinations for her GP at the Practice to review and to help decide how to care for Mrs D.
37. NHS standard operating procedures instructed GPs to limit how many times clinicians visited patients at home during this time. Given that out-of-hours clinicians fully examined Mrs D and noted down their assessments of her condition, there was no clinical reason for Mrs D’s GP to visit her at home. If they had visited her at home, they would have been going against the applicable guidance at the time. Our GP adviser said the clinical notes show the out-of-hours GPs documented enough information to show they had assessed the patient’s condition adequately, including physical examinations, following the GMC’s ‘Good Medical Practice’.
38. In summary, Mrs D’s GP followed the standard operating procedure for general practice at the time to not visit Mrs D at home in person but to use the information from the out-of-hours GPs’ notes instead. We have seen no signs of service failure regarding this part of Ms L’s complaint.
39. Regarding the GPs’ communication with the family, section 14 of the GMC’s ‘Treatment and care towards the end of life: good practice in decision making’ says Mrs D’s GP(s) should have used their specialist knowledge, experience and clinical judgement, together with her views and understanding of her condition, to identify the best options for investigating, treating or managing her condition. They should have explained the options to Mrs D, explained the potential benefits and risks, and Mrs D should then have decided the best option(s) for her.
40. Section 18 outlines the role of relatives and those close to the patient in this process. It says doctors should make sure the care provided includes the family’s needs for support, as far as possible, but that the focus of care should remain on the patient.
41. The records show the GPs treating Mrs D documented that they discussed different options with her family. The primary contact was Mrs D’s children, who were supporting her at that time.
42. Healthcare staff only identified at the end of September that Mrs D was at the end of her life. At first, they thought she had a viral infection. After an examination in early September, the GP offered Mrs D a test to examine a mass in her abdomen, which the family declined. Mrs D said she would prefer a blood test and stool test first.
43. In mid-September, the GP told the family there was blood in the stool test, which could be cancer, but documented Mrs D and her family did not want more tests at that time. The GP documented they had explained the ‘implications’, Mrs D was able to decide and she understood these implications.
44. In late September, the GP spoke with Mrs D’s daughter who reported her mother was not getting out of bed and was getting sores on her buttocks. The GP arranged for the district nurses to visit. The GP spoke with Mrs D’s daughter again at the end of September and identified Mrs D was getting worse and was not eating or drinking much.
45. At the end of September, a GP at the Practice documented they felt Mrs D was likely at the end of her life. In early October, a GP spoke to Mrs D’s daughter about end-of-life medication and plans. They discussed medications to manage Mrs D’s symptoms and her preferences for end-of-life care. The GP prescribed medications and documented Mrs D’s preferred place of death. They also documented an end-of-life care plan for what should happen in the event of several clinical situations. The care plan’s focus was on ‘improving comfort and quality of life’, which was Mrs D’s preference.
46. The records show the communication the GPs had with Mrs D and her family followed the GMC’s ‘Treatment and care towards the end of life: good practice in decision making’. There are several documented discussions with the family from early September, which included discussions about her preferences for more tests and conversations with the family about Mrs D’s nursing and end-of-life needs. When the GP identified at the end of September that Mrs D was likely at the end of her life, the records show a full discussion with her family and the plan clearly reflects Mrs D’s family’s preferences, including what the goal of the end-of-life care plan should be.
47. Overall, the documented communication with Mrs D’s family during this time appears to have followed the GMC’s ‘Treatment and care towards the end of life: good practice in decision making’. We have seen no signs of service failure.
48. Regarding the complaint that the GPs delayed arranging an end-of-life care plan and prescribing medications, the GMC’s ‘Good Medical Practice’ (section 15a) says doctors should adequately assess a patient’s condition, which should include recognising when they are in the last days of their life.
49. Our GP adviser explained that, looking back, we can see Mrs D’s condition was getting worse for a couple of weeks before staff identified she was at the end of her life. However, the GPs did not have the benefit of looking back at the time these events happened. Having reviewed the information in Mrs D’s notes, our GP adviser explained there was not enough clinical information to know Mrs D was at the end of her life earlier than the end of September.
50. Based on Mrs D’s documented clinical symptoms, the GPs’ assessments of her care needs appear to have followed the GMC’s ’Good Medical Practice’. This includes the date at which she was identified as being at the end of her life. Once the GP identified this, a full end-of-life care plan was arranged with Mrs D’s family the following day. We have seen no signs of service failure in when the GP identified Mrs D was at the end of her life or when the end-of-life care plan was arranged.
The Trust’s nursing care
51. Ms L complains the Trust’s district nursing team:
• failed to properly give midazolam and morphine in early October 2020 • did not respond to her family’s calls to the nursing hub, when her mother was distressed and in pain at the end of her life, for 12 hours in early October 2020.
52. We asked our nursing adviser what should have happened regarding the administration of midazolam and morphine in early October. They explained the Royal Pharmaceutical Society’s ‘Professional Guidance on the Administration of Medicines in Healthcare Settings’ (section 15.5.1) advises professionals not to give a drug if the dose of the medicine is not clear.
53. When the GP completed the prescription for midazolam, the records show they did not include a dose with the prescription. They simply put ‘use as directed’. This means the nurse followed the Royal Pharmaceutical Society’s ‘Professional Guidance on the Administration of Medicines in Healthcare Settings’ when she decided not to give this drug until the recommended dose had been confirmed.
54. The Royal Pharmaceutical Society’s ‘Professional Guidance on the Administration of Medicines in Healthcare Settings’ also says any ambiguities or concerns regarding a medicine prescription should be raised with the prescriber or a pharmacy professional without delay. This means the same nurse who declined to give the medicine should have contacted the GP, or another suitable professional, as quickly as possible to discuss the issue.
55. Unfortunately, while the nurse did raise this issue with the shift co-ordinator at the nursing hub after leaving Mrs D’s house in early October, she did not contact the prescriber herself. But we note this nurse was working a night shift and her shift likely ended before the GP practice opened. The nursing hub then got the GP to authorise the prescription later that day.
56. When a different nurse visited Mrs D that afternoon, they took the correct action and contacted her GP directly to clarify the dose. The nurse accepted a verbal authorisation from the GP and gave midazolam during their visit. The nurse who went to the house that evening also arranged a syringe driver (a small battery-powered pump that delivers medication through a tube under the skin) and got authorisation for Mrs D’s medication from a GP at NHS 111.
57. The actions of the first nurse, in not clarifying the dosage as soon as possible, falls short of the Royal Pharmaceutical Society’s ‘Professional Guidance on the Administration of Medicines in Healthcare Settings’. While she would likely not have been able to contact Mrs D’s GP at that time, she could have contacted NHS 111 instead to speak with a GP, but she did not do this. This caused a delay in giving the drug and we can understand why this was distressing for Mrs D and her family for a six-hour period.
58. In its response to Mrs D’s family, the Trust has fully accepted the delay should not have happened and it has offered its apology. Ms L wants the Trust to accept and apologise for the delay, which it has already done, and make service improvements to prevent this from happening again.
59. We do not consider it would be proportionate to ask the Trust to make systemic service improvements to put this right. This is because there is nothing to show this was more than a one-off mistake, although it caused a lot of concern for Mrs D’s family. The nurse who went to Mrs D’s home in the evening did the right thing. If several nurses had failed to take the correct action, broad improvements to service may be needed. But this is not the case. This was an error that one member of staff made, which the nurses who visited Mrs D later in the day quickly put right.
60. As the Trust has already recognised and apologised for the error, and service improvements would not be appropriate for the mistake made, we consider there is no failing that still needs to be corrected. This does not mean the Trust did nothing wrong. It means it made a mistake and took appropriate action to put this right when the issue was brought to its attention.
61. Regarding the nurse’s decision not to give morphine, our nursing adviser explained the nurse should have followed NG31, which outlines patient care in a person’s final days. This guidance says morphine can be used to manage breathlessness and pain in patients who are in their final days of life. The LOROS Hospice’s ‘Guidelines for the management of common symptoms in the last few days of life’, which the Trust uses, say the same thing.
62. When the nurse visited Mrs D that evening in early October, they documented that she did not appear to be in pain or breathless, and so did not give morphine. The LOROS guidelines state if a patient does not appear to be in pain or breathless then morphine is not needed. This means it was appropriate and followed both NICE Guideline NG31 and the LOROS guidelines for the nurse not to give morphine because they observed Mrs D did not have the symptoms morphine is used to treat. We have seen no signs of service failure in the decision not to give morphine at that time.
63. Regarding the calls to the nursing hub, the family says they called the nursing hub frequently in a 12-hour period in early October but did not get a response. In its response, the Trust accepted there was a delay in helping Mrs D in early October. It explained this was due to staffing shortages, resulting from COVID-19, and many urgent visits needed at that time. It says the delay was unavoidable, but confirmed it always tries to help patients within two hours.
64. The records show a healthcare assistant who had sat with Mrs D overnight reported she was in pain and agitated. The nursing hub noted a nurse would visit to give her medication as soon as possible. A nurse did go to the house but did not give medication as the midazolam dose was not given and she felt Mrs D did not need morphine at that time. She documented a request for the nursing team to clarify the medication issue.
65. Mrs D’s daughter then called the hub and asked for an update on her mother’s medication. A nurse called her back and noted Ms L was worried about her mother’s agitation. She asked for a nurse to respond. A nurse went to Mrs D’s home and gave midazolam after receiving verbal authorisation from the GP.
66. Ms L contacted the nursing hub again to ask whether a healthcare assistant was going to sit with Mrs D overnight. She was advised to contact the service that provided the night sitter.
67. Ms L called again to say her mother was agitated and in a lot of pain, and she asked that a nurse come to the house. She called back and said she needed a nurse to come as quickly as possible. The nursing hub called back to say a nurse was trying to get a syringe driver before visiting. The notes show a lot of work was needed to get authorisation for drugs and a syringe driver to manage Mrs D’s symptoms. The local hospice would not provide a syringe driver and the nurse had to get one from another service. She then went to Mrs D’s home and called 111 to ask a doctor to review Mrs D because she was distressed and in pain. The nurse than gave morphine to ease the pain until the dose in the syringe driver took effect, after checking this with the GP.
68. Section 3.2 of the NMC Code, which describes standards of professional practice for all registered nurses, states nurses should respond in a way that shows sympathy to those in the last few days and hours of their lives. This means the nursing hub should have responded to the family’s calls in a way that shows sympathy.
69. The 12-hour period during which Ms L says the nursing hub did not respond to her family’s calls appears to be between when the healthcare assistant asked for a nurse to attend and give medication and when a nurse installed a syringe driver and called a doctor to review Mrs D’s condition. But, during this time, we can see the nursing hub did respond to the family’s calls, with three nurses looking after Mrs D that day. A nurse also got verbal authorisation from a GP to give midazolam during this time.
70. There was some delay in putting right the medication issues, but we can see from the clinical records that the nursing hub was working to put right these issues during this time. We have already considered the medication issue above, and so will not repeat our thinking on this here.
71. Overall, the complaint is that the nursing hub did not respond to the family’s calls for 12 hours. But the evidence shows this was not the case. There was a slight delay between the family’s call in the afternoon and the nurse attending in the evening, and the Trust has explained this was because of staff shortages. This meant Mrs D had to wait for more than an hour more than the Trust’s target response time. The records also show this delay was because the nurse had difficulty getting a syringe driver, but they were actively looking for one between the call and the visit. Overall, we can see the nursing hub responded to each call and did their best to put right the issues raised. We can see how, without having seen the clinical records, it might seem the nursing hub was not responding to the family’s concerns. But we can see that, despite the staffing difficulties, the nursing hub was actively trying to put right the medication issues and find and install a syringe driver during the delay.
72. We have used Mrs D’s clinical records to decide what happened, and we accept the family may have made calls to the nursing hub that were not documented in her records. We have considered this but do not think it changes our conclusion. The complaint is that the nursing hub did not respond for 12 hours, but we can see evidence the nursing hub did respond to the family more than once during this time.
73. In summary, the evidence shows the nursing hub did respond to each of the family’s calls and followed the NMC Code’s expectation that nurses respond to those in the last days of their lives in a way that shows sympathy. It is completely understandable that watching a loved one in pain during their last hours, without knowing what nursing hub staff were doing to help, would be incredibly distressing for all those involved. But the records do not show the nursing hub failed to respond to the family’s calls for 12 hours. We have seen no signs of service failure regarding this issue.