Pain relief management
10. 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. We have done this and have not found any indications that something has gone wrong.
11. Mrs I complains her mother hardly received pain relief medication whilst on palliative care. This left Ms A in unnecessary pain with the family left trying to manage her needs.
12. We reviewed all of Mrs A’s medical notes which show there was proper involvement from the palliative care team when managing her pain medication. From the records, the Trust provided stronger opioids (such as fentanyl, buprenorphine, oxycodone) alongside paracetamol at various intervals.
13. We asked a clinical adviser about Mrs. A’s pain management, and they confirmed it was right based on the records. Her notes suggest the Trust followed the WHO analgesic ladder, the national gold standard for pain management. This says when you have pain you start with paracetamol. If the pain persists or worsens then clinicians prescribe weak opioids like codeine. If the pain continues to worsen or is on the higher end of the pain score, then clinicians prescribe stronger opioids like oxytocin or buprenorphine.
14. The Trust recorded Mrs A’s pain score periodically as shown in her medical record. Whenever the Trust recorded Mrs A’s pain score as being above seven, it regularly gave her a buprenorphine patch 10 microgram hourly which is a low dose opioid. When her pain score was lower the Trust regularly gave her paracetamol and lower dose pain medications. At times it did so via her RIG.
15. So, the records suggest the Trust followed this structure in Mrs A’s care, in line with the WHO guidance.
16. We understand the family's concerns about the Trust only prescribing Mrs A paracetamol at times. However, the records show the Trust provided stronger medication when needed, adjusting her care rather than using a fixed plan. There is also no evidence in her notes to suggest Mrs A raised concerns about her medications.
17. Overall, the records suggest the Trust carefully monitored and managed Mrs A’s pain. We hope this reassures Mrs I about the pain relief her mother had under the Trusts care. We have seen no indications of failings in this part of the complaint.
Dr T offered Mrs A a feeding tube and radiotherapy.
18. When we have looked at the evidence here, we have not seen any indications something has gone wrong.
19. Mrs I complains Dr T went outside of the agreed treatment plan when they offered Mrs A a RIG. She does not think Dr T should have made the decision because they were not the lead clinician. Mrs I says the decision to insert the RIG caused her mother undue pain and distress when it became infected and deteriorated her overall health.
20. Records show a multi-disciplinary (MDT) meeting on 9 February 2023 discussed Mrs A’s care, recommending a RIG if her calorie intake dropped due to the throat mass. A follow-up MDT on 9 March considered palliative radiotherapy to relieve her symptoms. As a gastroenterologist, Dr T shared the meeting outcomes with Mrs A and her daughters on 10 February and 12 March 2023. Records confirm he did not make these decisions on Mrs A’s care alone.
21. NICE CKS on managing oesophago-gastric cancer says to offer a self-expanding RIG or radiotherapy to people with throat and gastric cancer depending on the degree of dysphagia and its impact on the patient’s quality of life. Looking at Mrs A’s full clinical picture we can see her dysphagia and overall condition worsened making her a strong candidate for this treatment.
22. RCR guidance on radiotherapy in palliative cancer patients says, ‘advanced disease can cause local symptoms such as dysphagia, bleeding and pain…’. Trusts routinely use palliative radiotherapy in these instances to relieve and control cancer symptoms. Mrs A had dysphagia (problems swallowing) and pain, so she fit the criteria before the Trust to consider her for palliative radiotherapy.
23. We asked a clinical adviser if Dr T was the right person to discuss the RIG and palliative radiotherapy plan, and if the plan was right for Mrs A. The adviser confirmed that, as a gastroenterologist, Dr T was suitable to communicate the treatments, and the care plan aligned with national guidance to meet Mrs A’s needs.
24. The Trust planned to only offer these treatments if Mrs A’s condition worsened, which it did. National guidance supports both treatments were right for managing her symptoms, and Mrs A gave her consent.
25. After careful review of the records, guidance, and specialist advice, we can see no evidence Dr T acted on his own when he suggested the RIG and radiotherapy. We appreciate the Trust may not have communicated clearly enough at the time, but we can reassure Mrs I there are clear records this decision stemmed from joint clinical input during an MDT meeting.
26. There are no indications of failings by the Trust on this part of the complaint. We hope how we have reached our view is clear and offers some assurances on the decisions made in Mrs A’s care.
Poor communication with Mrs A and family
27. When we have looked at this part of the complaint, we cannot see indication the Trust got something wrong.
28. Mrs I says the Trust communicated poorly with her family about her mother’s condition. She claims they never received Mrs A’s scan results and recalls staff saying her mother was in good spirits. However, when the family arrived at the hospital, it was clear she was not doing well, and she died later that afternoon.
29. GMC guidance on patients, partnership and communication says clinicians should offer explanations for the treatments offered and give information to those close to a patient.
30. The Trust did not respond about the nurse’s alleged comments on the day Mrs A died. There is also no documentary record of the conversation taking place. The only evidence is Mrs A’s recollection. This is not enough evidence for us to take a clear view on what the nurse said and the context, or whether that was appropriate.
31. When we look at the records to assess if the Trust gave the family enough information on Mrs A’s condition, we could see a good number of entries showing clinicians discussing Mrs A’s needs with her and her daughters.
32. After assessments on 26 January 2023, records show the Trust told Mrs A on 30 January she likely had cancer in her upper oesophagus and offered support. Further calls with the family on 10, 15 and 17 February provided updates, support, and emphasized the cancer was incurable, with treatment being palliative. The Trust confirmed this metastatic disease (when cancerous masses are in different parts of the body) in a call with the family on 24 and 28 February.
33. Records also show the Trust flagged Mrs A for fast-track palliative discharge in line with her preferred end of life (EOL) plan. Our adviser explained EOL patients often fluctuate. It is not uncommon for patients to appear brighter and improved just before they die. While it was clear from early on in her care the Trust had relayed her cancer was incurable, it would have been very difficult for clinicians to say exactly when she would die.
34. In view of guidance and when we weigh up all the evidence, we think there has been transparent documented communication between various clinicians and Mrs A’s family. While we cannot see any evidence the Trust sent the family the physical CT scans, we can see it repeatedly relayed the results of these assessments and Mrs A’s diagnosis to the family. As a result, we think the Trust appropriately communicated Mrs A’s clinical picture.
35. We do understand the messages the clinical team were giving the family were difficult for them to hear, and it is clear the family did not fully appreciate the gravity of the situation. Again, when we weigh up the evidence, we cannot say this was because the Trust failed to communicate properly with them.
36. It is clear from Mrs I’s account how difficult these events were for her and her family. We do not intend for our decision to take away from that. We sincerely hope she can take some reassurance from our view that, overall, the Trust cared for her mother as it should have.