13. 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 there is an indication things went wrong we will consider the impact and what the organisation has done to resolve things.
14. We have done this and have not found any indications things went wrong with some issues. Where there may have been failings we consider we cannot link the claimed impact or the Trust has done enough to put things right.
Care in place at home 15. Ms Y complains occupational therapy staff wrongly said there was not a package of care in place for Mrs E at home. She says Mrs E had been discharged from hospital in April and Mrs E’s home was deemed appropriate for her needs then. She says occupational therapy’s view meant her mother was not discharged home from hospital.
16. The Trust’s complaint response acknowledged Ms Y’s account of the care in place at home and recognised Ms Y felt the assessment lacked family involvement. The Trust agreed to discuss this problem with the therapy team to see if there were changes they could make to ensure documents contained a true representation of the patient's living situation.
17. We acknowledge how strongly Ms Y disagrees with how staff recorded the care in place for her mother at home. We have looked at the impact Ms Y has associated with this claimed failing.
18. In considering this impact we have spoken to a consultant physician. They explained when making a decision on whether to discharge a patient, NHS organisations should follow national discharge guidance.
19. This guidance sets out discharge should happen when the patient no longer needs acute care in a hospital setting. When making this decision the discharge team should ensure that any safeguarding concerns have been resolved.
20. Our adviser explained following Mrs E’s operation doctors assessed her as having periods of confusion, and she was receiving oxygen and intravenous antibiotics. Mrs E’s son also raised concerns about how well his mother was coping at home and explained there were seven steps up to the house.
21. On 21 September staff recorded Mrs E raised concerns of a safeguarding nature about Ms Y. We know how strenuously Ms Y rejected the concerns at the time and since. Despite the challenges and the possibility that Mrs E raised the concerns in a period of confusion, it was still appropriate for staff to fully investigate them before deciding if it was safe to discharge Mrs E home.
22. Unfortunately these safeguarding concerns could not be fully investigated before Mrs E sadly died. These concerns, coupled with periods of necessary acute care and limited mobility meant that Mrs E was never fit enough for discharge.
23. We therefore consider that even if the occupational therapists were wrong about the package of care in place at home, we are unable to link any possible failings to the impact Ms Y has claimed. Unfortunately Mrs E was never fit enough to leave hospital even if staff were aware of the arrangements for looking after her at home.
24. We understand how upsetting Ms Y has found these events. We hope this decision will bring some comfort that Mrs E was in the right place for the care she needed.
Safeguarding referral 25. The Trust’s complaint response explained Mrs E had raised safeguarding concerns during her time in hospital and it was appropriate for staff to act on these. The complaint response also explained it would not be appropriate to share the specific concerns with Ms Y in respect of her mother’s wishes.
26. The complaint response added they had a private conversation with Mrs E in the corridor away from other patients to avoid it being overheard. It added there were no patients nearby in the corridor there was no side room available as an alternative location.
27. The Trust’s Safeguarding Adults at Risk Policy sets out, ‘Any safeguarding concerns raised about an adult who has care and support needs must be reported… so that a decision can be made about whether it is necessary to carry out a safeguarding inquiry. This process must always include the adult about whom there are concerns, so that their wishes and preferences can be acted on as far as is possible and in keeping with the principles of ‘Making Safeguarding Personal’.
28. The policy goes onto say, ‘Regardless of how the concern comes to light, it is imperative that once someone becomes aware of the possible abuse of an Adult at Risk, immediate action is taken to safeguard the adult and report the abuse. In order to ensure the immediate safety of the adult, it is essential that information about the allegation is not shared with the person alleged to have committed the abuse.’
29. In short, staff have a responsibility to report concerns about an individual’s safeguarding. The policy adds, ‘This means that in any safeguarding situation the wellbeing of an adult at risk must be promoted, and their wishes and feelings always taken into account.’
30. Having considered the safeguarding referral we are satisfied staff acted in line with the Trust’s policy. Further, when investigating these concerns staff spoke to Mrs E privately. This was a reasonable step to protect her wellbeing and ensure she felt safe to provide information that would help staff get the right information about risks to her safeguarding.
31. With respect for the Trust’s policy and Mrs E, we have made the conscious decision not to share the reasons for the safeguarding referral. We recognise Ms Y disagrees she was a risk to her mother. We understand the distress this event has caused her and recognise how upsetting it has been.
Communication with Ms Y 32. Ms Y complains she was not told when or why doctors put her mother on morphine. She says this meant she was uninformed about her mother’s care, and would like service improvements to stop the same thing happening again.
33. The Trust’s complaint apologised for the concern Ms Y had experienced. It explained Mrs E was given Oramorph (oral morphine – an opiate painkiller) ‘as required’. It said this was given for breakthrough pain relief, when regular painkillers are not enough. The response added nurses would not necessarily inform family when as required medication was administered.
34. Ms Y met Trust staff for a complaint resolution meeting. It identified changes to stop the same problem happening again and agreed to an action plan ensuring ward staff inform families when patients are given anticipatory medication and why.
35. As the Trust’s complaint response has agreed to put service improvements in place, it appears that things should have happened differently. It is reasonable that Ms Y would feel uninformed if nurses did not tell her about the medication her mother had been given.
36. With this in mind, we have considered what the Trust has done to put things right.
37. The NHS complaint standards say organisations should welcome complaints in a positive way. They should explain why things went wrong and identify suitable ways to put things right for people. Putting things right can include action to stop the same problem happening again.
38. To achieve these improvements the Trust supported ward nurses to attend an ‘End of Life study day’. The Trust also provided awareness of specialist teams staff can contact if they need support when explaining End of Life care.
39. Having considered the Trust’s response to Ms Y’s complaint we consider it has welcomed her complaint in a positive way. It explained how the issues arose and acknowledged the impact this had on Ms Y.
40. Crucially, the Trust has identified an area that could improve and taken appropriate steps to ensure the problems do not happen again.
41. As the Trust has already achieved the outcome Ms Y wants there is no further action we could recommend. We understand why this issue means so much for Ms Y. We hope our view of the Trust’s response can provide some reassurance to her.
End of life medication 42. Ms Y believes the medication given to her mother on 25 September was inappropriate and caused her death.
43. The Trust explained that to ensure a patient is comfortable towards the end of their life, doctors will prescribe anticipatory medication. This is intended to provide timely control of distressing symptoms like pain, breathlessness, nausea and vomiting, agitation and respiratory secretions.
44. It explained the doctor gave Mrs E Oxycodone (an opiate painkiller for severe pain) to help alleviate any pain, and hyoscine bromide to reduce respiratory secretions. It said these medications are not lethal and would not have caused Mrs E any pain or sped up her death.
45. The guidance also explains that when someone is close to death they can produce respiratory secretions. This can lead to their breathing making a ‘rattling sound’ and be a source of distress. In these instances medication such as hyoscine butylbromide or glycopyrronium bromide may be of some benefit.
46. Section 1.5 of Care of dying adults in the last days of life sets out pharmacological interventions. This sets out that pain should be assessed and the medicine given is matched to this pain.
47. Specifically, 1.5.5 says, ‘Consider prescribing different routes of administering medicine if the dying person is unable to take or tolerate oral medicines. Avoid giving intramuscular injections and give either subcutaneous or intravenous injections.’
48. The adviser explained that during Mrs E’s time in hospital, doctors often gave opiate medicine to help manage her pain and discomfort. This included regular doses of codeine, and four doses of Orapmorph between 22 and 24 September. This was to help her pain, discomfort and breathlessness.
49. The clinical adviser we spoke to referred to relevant guidance Prescribing in palliative care. This sets out that 1.25mg of subcutaneous Oxycodone is equivalent to approximately 2.5mg of oral morphine. A dose this size is relatively small dose.
50. On the day she died, doctors gave Mrs E 1.25mg of Oxycodone and 20mg of hyoscine bromide at 7.50pm. Nursing notes from the time show that Mrs E was drowsy and unable to take the medication orally, so they were given via an injection instead.
51. Our adviser explained at the point this medication was given doctors had decided Mrs E was already in the final stages of her life and this was not going to reverse. The medication would not have harmful effects or sped up her death. Instead, the painkiller was given to deal with the acute pain she was experiencing at that time.
52. Ms Y has asked us if the Trust has an assisted dying policy, and if it was following this at the time her mother died. We have seen no indication of such policy.
53. We consider the medication given to Mrs E at the end of her life was appropriate to manage the acute symptoms she was experiencing. This was given at an appropriate time and via an appropriate route of administration. We are therefore satisfied the medication doctors gave was in line with guidance.
54. We understand the heartbreak Ms Y has experienced due to what happened. The events she told us about have been understandably upsetting for her and her family. We would like to thank her for bringing her complaint to us and hope it is clear why we have decided not to investigate it further.