GP attendance: 3 February 2023
23. Miss M complains the GP who visited her mother on Friday evening did not prescribe the right end of life medication, or medication in a form Mrs A could take. Miss M feels the GP did not consider that her mother was unable to swallow and should have prescribed a syringe driver at this time.
24. NICE guidelines say, ‘when it is recognised that a person may be entering the last days of life, review their current medicines, consider medicines for symptom control and decide on the most effective route for administering medicines in the last days of life, tailored to the dying person’s condition, their ability to swallow safely and their preferences.’
25. The NICE guidance also says:
• for people starting treatment who have not previously been given medicines for symptom management, start with the lowest effective dose and titrate [slowly increasing the dose of a medicine by very small amounts] as clinically indicated.
• consider using a syringe pump to deliver medicines for continuous symptom control if more than 2 or 3 doses of any ‘as required’ medicines have been given within 24 hours.
26. The clinical records say the GP attended the care home at 6pm on 3 February 2023. They noted Mrs A had severe frailty, and that since her recent admission to hospital her health had deteriorated, she was bedbound, weak, not eating and drinking sufficiently, and was at risk of aspiration (when food or liquid enters a person's airway and eventually the lungs by accident).
27. The GP examined Mrs A and found she had a respiratory rate of 16, but she was not responding normally, cachectic (loss of weight and muscle mass) and lethargic. The GP heard crackles in the lower left lobe of her lung. The GP recorded that Mrs A was on the end-of-life pathway and diagnosed a chest infection.
28. The clinical records say the GP prescribed antibiotics for the chest infection and ten ampoules of morphine sulphate injections, with 2.5mg of morphine being administered every four hours as and when required.
29. Our adviser explained it was appropriate for Mrs A’s medication to start ad-hoc and as required, and if more than two or three injections were needed within 24 hours, it would then be appropriate to consider prescribing a syringe driver to provide a steady flow of morphine.
30. Our adviser told us it is not normally the case for a GP to prescribe a syringe driver straight away unless the patient is in significant pain. We have not seen any evidence in the clinical records which suggests that Mrs A was in significant pain at this time.
31. Our adviser also explained that in some GP practices it is routine to get all medications ready. But NICE guidelines do not say that this should happen. Sadly, it is this case that Mrs A deteriorated quickly over the weekend which resulted in the need to change her palliative care. We understand our explanations do not make what happened any easier for Miss M.
32. Based on the above guidance, the GP examined Mrs A in line with NICE guidelines. They prescribed pain relief and antibiotics, to manage her symptoms at that time, which included morphine injections as Mrs A had swallowing difficulties.
33. For those reasons, there are no failings in the treatment the Provider gave to Mrs A on this date.
End of life medication: 5 February 2023
34. Miss M complains she had to take her mother’s medication chart to the out of hours GP on Sunday 5 February 2023 to facilitate administration of the syringe driver and Oramorph.
35. In its complaint response, the Provider acknowledged this should not happened. The Provider said its nursing team should have taken the medication chart to the out of hours GP and waited for it to be completed.
36. The Provider explained that the nurse was of the understanding that the care home’s off-duty manager was going to take the medication chart to the GP, to enable her to attend her next visit. This is supported by the clinical records we have seen. Sadly, it appears that some form of miscommunication between the Provider and the care home led to this mistake.
37. Miss M says she was told that neither the nurse or care home staff were able to take the medication card to the GP, and she felt obliged to do this. We have no reason to doubt what Miss M has told us. We recognise it must have been terribly difficult for her to see her mother in pain and distress.
38. The NICE guidelines say that if pain is identified clinicians should ‘manage it promptly and effectively’. Whilst we understand the immense pressures that are placed on health services, particularly over the weekend, we think Mrs A medication should have taken priority. By not taking ownership of getting the medication chart signed, the Provider did not manage Mrs A’s pain promptly. Miss M should not have felt that she needed to take time away from her mother to make sure she had the medication she needed to alleviate her pain.
39. The Provider has apologised to Miss M and explained that it has asked its community nursing team to deliver medication card themselves, if they cannot confirm the care home will deliver the card as part of its shared responsibility. It has also asked managers to ensure its Macmillan nurses continue to support GP facilitated meetings to enable its staff to work together to identify patients who may have urgent palliative care needs, which will reduce the need for unplanned care planning via an out of hours GP.
40. The Provider also explained its medicines management team were involved in work surrounding the use of electronic prescriptions for controlled drugs (used as part of end-of-life care). This work was ongoing at the time of the Provider’s final response.
41. We appreciate how distressing it must have been for Miss M when the Provider did not act in line with the NICE guidelines for obtaining the much-needed end-of-life medication.
42. For those reasons, we uphold this part of the complaint. We will go on to discuss the effect this had on Miss M and her mother later in this report.
Complaint handling
43. Miss M complains the complaint response did not identify all the failings in the care it provided to her mother.
44. Our NHS complaints standards say organisations should take a thorough, proportionate, and balanced look into the issues raised in a complaint, give people fair and open answers to their questions based on the facts, and take full accountability for mistakes identified.
45. Miss M complained to the Provider on 14 April 2023 expressing her dissatisfaction with the delivery of end-of-life medication and asked five questions in relation to her concerns. The Provider investigated her complaint and sent its response on 30 May 2023. This response included brief answers to Miss M’s questions. Given the nature of Miss M’s complaint, we understand why she would be upset with this response.
46. On 3 June 2023, Miss M emailed the Provider explaining that she felt its response did not fully address her complaint or the concerns she has about how the Provider will approach end of life patient care in the future. Miss M raised four follow-up questions which resulted in the Provider re-opening the complaint, reviewing records, and making further enquiries with its service lead and the care home.
47. On 26 June 2023, the Provider sent a further response to Miss M providing a more detailed explanation on the outcome of its investigation in answering Miss M’s follow-up questions.
48. We realise what a stressful time this was for Miss M and recognise how difficult it must have been for her to go through the details of the complaint again.
49. Across both complaint responses, the Provider has acknowledged it made mistakes on 5 February 2023 and that this was not the service it aspired to deliver. From the evidence we have seen, this is the only potential incident of service failure in the care the Provider provided to Mrs A.
50. The Provider had prescribed end-of-life medication to Mrs A in line with NICE guidelines, in form she could take, and the first dose was administered on 4 February 2023. Sadly, by the next morning Mrs A health had deteriorated and the medication was no longer providing effective pain relief. At that point, it became necessary to change her care plan which is when the Provider fell short in the service it provided.
51. As the Provider has included all relevant information across both complaint responses, we consider there is no service failure in this part of the complaint.
Impact
52. We have considered the impact on Miss M, and her mother, as a result of the Provider failing to follow the correct process on 5 February 2023.
53. We accept Mrs A experienced some pain on this date whilst she was waiting for the syringe driver to be introduced, but we cannot link three days of unnecessary pain to the failings we have identified.
54. The clinical records show Mrs A’s pain was controlled with morphine injections until around 11.46am on 5 February 2023, when Mrs A was complaining of pain all over and was very distressed, but it was too early for the nurse to administer another morphine injection. The nurse gave Mrs A an injection of midazolam instead and a morphine injection at 1.26pm. The nurse then introduced the syringe driver at 4.26pm.
55. The clinical records confirm Mrs A experienced significant distress. It is accepted that Mrs A was left alone in her room whilst her daughter went to the out of hours GP and local pharmacy, this is likely to have added to the distress and anxiety she experienced. We recognise this is deeply upsetting for Miss M.
56. We accept what happened has had a significant impact on Miss M, as she very sadly lost the opportunity to be with her mother and comfort her during her final conscious hours. This was a vital time in both their lives which they will never be able to get back. The fact Miss M lost the opportunity to have any final meaningful conversations with her mother is likely to have a lasting impact on her. We are truly sorry for how events unfolded.
57. Miss M told us she experienced significant distress, worry, hurt, and anger, she feels the Provider failed her mum at such a vital point in her life and death. Miss M says she has lost faith in the Provider and the NHS, and she worries about other people who might be at end of life. We think it is reasonable for Miss M to feel all these emotions given the Provider’s mistake in facilitating end-of-life medication for her mother.
Conclusion
58. Based on the evidence, we partly uphold this complaint.