Manchester University NHS Foundation Trust

4. Ms R complains the Trust failed to manage her mother, Mrs E’s, pain in the days leading up to her death in July 2021. She also says the Trust’s poor communication led to her feeling confused about her mother’s care.

5. Ms R says due to the lack of pain medication provided to her mother, both Ms R and her sister witnessed Mrs E in excruciating pain. She says this left them swamped with guilt and regret. She also says poor communication has caused them to lose trust in the NHS.

6. Ms R would like recognition of what went wrong, an apology and financial compensation for the distress caused.

7. Mrs E was admitted to the Trust in July 2021 with severe back pain on the advice of her GP. She was transferred to an acute medical unit. She received pain medication in liquid form through a drip from the day she was admitted. A few days later, in the early hours of the morning, nurses gave her more pain relief and moved her to another ward later that day. Mrs E sadly died the next day.

8. On 3 November 2021, Ms R complained to the Trust. It responded on 28 January 2022.

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If we see evidence something went wrong, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right.

Pain management during end-of-life care

13. Ms R says the Trust failed to manage her mother’s pain in the days leading up to her death in July. She says it left Mrs E in excruciating pain during the early hours of the day before her death, which deprived her of peace during her final days.

14. We recognise it must be very worrying and upsetting for Ms R to have concerns about the standard of care her mother received during her admission to the Trust. We are sorry to hear this has caused Ms R and her family long-term distress. We do not wish to underestimate how difficult it must have been to relive these events and explain her complaint to us. We are grateful for the time and effort she has taken to do this.

15. According to the NMC Standards of Proficiency, nurses should take appropriate action to reduce or minimise pain or discomfort.

16. The RCN Guidance says pain is a subjective, personal experience, really only known to the person who suffers, and assessing and managing pain are essential components of nursing practice.

17. The records we have seen show the Trust monitored and responded to Mrs E’s pain in line with the above guidelines. The records show medical staff saw her frequently and the palliative care team reviewed her daily on the days leading up to and the day of her death.

18. Our adviser explained staff increased and amended Mrs E’s pain relief medications during her admission. The nursing, medical and palliative care records show she was comfortable from the day after her admission and she received pain relief.

19. Ms R was particularly concerned about her mother’s pain management in the early hours of the day before Mrs E’s death, so we specifically looked at this time.

20. Our adviser explained that based on the records and observations from this time, the Trust documented Mrs E’s pain as mild. Our adviser went on to explain the Trust gave pain relief and documented ‘good effect’. This shows the Trust monitored her and managed her pain in line with the above guidelines.

21. Having considered all the information, we are satisfied the Trust acted within the guidelines when managing Mrs E’s pain. Therefore, we have not seen that anything went seriously wrong and will not take further action on this complaint.

Poor communication

22. Ms R says the Trust’s poor communication led her to lose trust in the NHS and left her feeling confused. In particular, she complains the Trust provided conflicting information on visiting policies given her mother was receiving end-of-life care.

23. We were sorry to hear Ms R felt the Trust provided conflicting information. We understand from what she has told us this caused her and her family further distress during an already upsetting time.

24. We can see from the records the Trust allowed Ms R and her sister to see their mother frequently and they were both allowed to be with her when she sadly passed away.

25. According to NMC guidance, nurses must be able to communicate clearly and effectively in English. The guidance also says nurses must check people’s understanding from time to time to keep misunderstanding to a minimum.

26. In the Trust’s response to Ms R’s complaint, it recognised she received inconsistent information during her mother’s admission.

27. The Trust apologised for the miscommunication and said it understood the further distress this may have caused Ms R at this time. It explained it would share Ms R’s case with the nursing team to make sure lessons are learned. It said it has developed a more robust visiting process to make sure relatives of very poorly patients can visit more regularly by appointment.

28. Our Principles say when things have gone wrong, we expect organisations to ‘put things right’. This includes considering offering ‘all forms of remedy’ such as an ‘apology, explanation and remedial action’.

29. We are satisfied the actions of the Trust in recognising the miscommunication, apologising for the confusion and upset caused and taking action to learn and improve are in line with our Principles.

30. Overall, while we did see evidence of some failings in communication, we saw no evidence of these leading to a more severe or prolonged impact. Therefore, we are satisfied the actions the Trust has taken to address these mistakes are enough to put right those mistakes. We will therefore not take further action on this complaint.

31. We understand Ms R’s experience has caused her great distress and we are sorry for this. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance the Trust has taken her complaint seriously and has addressed the failings identified.

1. The Parliamentary and Health Service Ombudsman has carefully considered Ms R’s complaint about Manchester University NHS Foundation Trust (the Trust).

2. We have looked at the evidence Ms R and the Trust provided to us. We were sorry to hear Ms R feels the Trust did not manage her mother’s pain effectively in the days leading up to her death. We recognise this has caused her ongoing guilt that her mother’s pain could have been managed more effectively. We know this has been difficult for her and her family and offer our sincere condolences for their loss.

3. It is disappointing the Trust did not communicate well with Ms R during her mother’s time in hospital. We are pleased the Trust has already recognised and apologised for this in its response. Based on this, we consider it has already taken appropriate steps to put this part of the complaint right. We would also like to reassure Ms R we did not see any signs of failings in the way the Trust managed her mother’s pain. We will explain this in detail below.