17. We first look at whether there are signs the Trust has got something wrong. We do this by comparing what should have happened with what did happen. We have done this, and we hope to assure Mrs C we have not found any indication of failings.
Eating and nausea 18. Mrs C complains the Trust did not manage her husband’s lack of eating and nausea appropriately. Having reviewed the records in detail, we can see the Trust fully appreciated Mr C’s nutritional status, from his admission. We can see the Trust took appropriate steps in referring Mr C to dieticians and by monitoring his oral intake.
19. Our adviser says the Trust’s monitoring of Mr C’s oral intake was above average in his experience, compared to most general wards. In addition, NICE guidance on nutrition recommends screening, care planning and involving the patient and their family. We find these elements of care were well provided for, in Mr C’s case.
20. We know Mrs C is concerned that her husband reported feeling sick after eating. Mrs C complains ondansetron, an anti-sickness medication, was only given once. We hope to assure Mrs C we find evidence to show the Trust gave Mr C an alternative medication, haloperidol, to help with his nausea. It was therefore not the case that he was left without appropriate medical management for his nausea. Our adviser confirms haloperidol was a good choice in this situation and given in line with BNF recommendations.
21. Our adviser says unfortunately, given Mr C’s medical problems with the oesophagus, it was not unexpected that he had a degree of nausea, vomiting and nutritional issues. Our adviser says the next appropriate step was to assess Mr C for tube (PEG) feeding. We find this did happen, with the Trust conducting an assessment at a reasonable time. Our adviser agrees the conclusion was reasonable, that PEG feeding was not appropriate in Mr C’s case.
22. The Trust’s ongoing awareness of Mr C’s nutritional difficulties, its provision of medication, monitoring, and acting in line with advice given by dieticians was all appropriate in this circumstance. We do not find any indications of service failure here.
Communication about end-of-life care 23. Mrs C complains the Trust insensitively spoke about palliative end-of-life care in from of her husband. We know this is an understandably difficult issue to discuss, for patients and their relatives, and it can be for healthcare professionals too. This is why there is a wide variety of guidelines and standards on this issue, in hopes of making these difficult decisions as effective and supportive as possible.
24. One of the key recommendations in One Chance guidance is for the healthcare professional to involve the patient in discussions and decision-making at the end of their life, where this is possible.
25. We recognise Mrs C’s distress that discussions about end-of-life care were held with her husband, and respect that she may have perhaps preferred him not to have been involved. However, records show us Mr C had capacity to take part in these discussions and it was therefore appropriate, in line with One Chance guidance. Our adviser explains it would have been unethical not to include him.
26. It is difficult for us to judge the sensitivity of discussions from the information documented in medical records. From speaking with Mrs C, we know she is concerned about a comment made that Mr C may not return home. We do not underestimate how distressing this must have been to hear. We do not think it an inaccurate statement to have been made, in considering how unwell Mr C was. From the information available to us, we think these difficult discussions were held with a reasonable degree of sensitivity and we do not find any indications of service failure here.
MidazolamMrs C complains the Trust gave her husband midazolam. She told us she believes this is used to put patients to sleep and she is concerned due to its use overseas.
27. We cannot comment on any actions taken abroad. We must consider the application of guidance in the NHS. Midazolam has been licenced for use by the NHS for many decades. It is used to ease and alleviate distressing symptoms patients can experience at the end of their life.
28. Records note Mr C was experiencing some agitation and in response, the Trust gave midazolam for symptom control. Our adviser confirms the use of midazolam in this context was reasonable, and in line with BNF prescribing advice. We can assure Mrs C the dose given was appropriate and not excessive. We do not find any indications of service failure here.
Contact before death 29. Mrs C complains the Trust did not call her before her husband died, to allow her to be with him at the end.
30. In conversations with us, she said staff must have known he was in his last hours and therefore should have called. Whilst this is Mrs C’s belief of what must have happened, our adviser says in their extensive experience it is often difficult to predict when an end-of-life patient is likely to die. Our adviser comments this is in fact often the preferred situation, as it usually indicates the patient has a peaceful death.
31. Having carefully reviewed the records, we do not see anything to suggest Mr C’s death could have been anticipated, with sufficient precision to enable Trust staff to alert Mrs C in time for her to attend to be at his side. We know this leaves Mrs C with distress, that she was not there. We hope to provide her some comfort, with the knowledge this was not something staff could have reasonably predicted, to have called her beforehand. We do not find any indications of service failure here.