Oral morphine
15. 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 seen any indications something has gone wrong.
16. Mrs V says that the Trust gave her husband too much oral morphine and as a result his organs shut down and slurred his speech. The Trust maintain their approach was appropriate but noted the slurred speech was likely due to his metastatic cancer and liver failure induced encephalopathy, although they accepted morphine can cause drowsiness.
17. We note the complaint raised was not about the type of analgesic (morphine) just the way it was given. Therefore, we note both the complainant, and the Trust accept that morphine was an appropriate pain relief to provide.
18. There are two questions here. First, whether the dose of morphine given orally was appropriate and second, whether that caused his organs to shut down and slurred his speech. Regarding the delivery method and dose, we have looked to the relevant guidance to see what should have happened.
19. Our adviser explained that Morphine is used, amongst other uses, where the patient is in severe pain. Looking at the BNF about Morphine we can see it is indicated for acute pain and the presumption is that it should be provided orally unless there is any other basis to suggest otherwise.
20. We note there were no concerns raised about the patient’s ability to swallow neither do the records mention any difficulty swallowing. Given the absence of any indications of any reasons not to provide morphine orally, we have no basis to suggest there was a failing in providing it this way. We have looked to see whether the morphine dose given was in line with guidelines.
21. For acute pain, the NICE BNF guidelines - Morphine recommend (for adults) for both orally and by injection to start with 10mg every four hours, use reduced dose 5 mg every four hours in frail patients. They also recommend the dose be adjusted according to response; dose can be given more frequently during titration.
22. Therefore, we would expect the Trust to administer morphine in line with the BNF guidelines and start with 10mg every four hours or use a reduced dose every four hours in frail patients. We note the guidelines allow for the dose to be adjusted depending on the situation.
23. Looking at the records, we can see when morphine was prescribed.
24. The clinical summary reports the patient attended the Emergency Department (ED) on 30 September and was given a 2mg dose of morphine via IV, at 11.22pm. We note this dose does not exceed the recommended 10mg amount.
25. The following day, on 1 October 2022, the records state ‘pain relief – cautious use of morphine 5mg Oramorph 4 hourly (prescribed)’. However, the medication charts also on 1 October 2022, state that morphine was prescribed PRN. This is a Latin phrase ‘Pro re nata’ meaning ‘as the circumstance arises’. This means that morphine (orally) would be given as needed.
26. However, the records appear to reflect the provision of medication did not exceed the above guidelines indicating 10mg every four hours as we can see that he received 5mg of oral morphine at 05.52am and again ten hours later on 16.03pm on 1 October 2022.
27. On 3 October 2022, the records show he received only one 5mg dose of oral morphine at 9.27am. The following day on 4 October 2022, he received two doses an oral one at 2.52am of 5mg and an injection of 2.5mg a 5.10pm.
28. We note the records do not report any further administration of morphine beyond 4 October 2022 as it was switched to codeine. Mrs V did not raise any complains about codeine and therefore we have not investigated anything relating to its dose or administration.
29. Considering the available evidence in line with the BNF guidelines, we can see the Trust administered both oral and injections of morphine if and when needed. Moreover, the dose appears to be within the limits of the BNF guidelines. Therefore, we are satisfied the Trust provided appropriate levels of oral morphine. As such, we have seen no basis to suggest a failing in its provision.
30. However, we appreciate Mrs V’s fears that the morphine being given orally caused her husband’s organs to shut down and slurred his speech. Accordingly, we have considered if there is any basis to suggest a link here.
31. The records show his clinical presentation was visibly jaundiced, and was experiencing general weakness, lethargy and overall body pain. On admission the presumption further to the previous doctor’s opinion in Trinidad was non-fatty liver disease. However, during his admission it became apparent that he had cancer. Our adviser explained he was experiencing organ failure, further to the cancer.
32. Our adviser also explained there is no indication that morphine would cause the organ failure. To reassure ourselves, we have looked at the morphine dose he received and as mentioned above, this was within the limits of the BNF guidelines. Therefore, there are no indications to suggest the morphine dose caused any organ failure.
33. In relation to his slurred speech, our understanding is that morphine is a strong analgetic of which slurred speech or drowsiness could be a possible side effect. That, in itself, would not be supportive of anything gone wrong, but simply a side effect.
34. We appreciate this was a very difficult time for Mrs V and her family. We have not identified any indications of failings in the way morphine was administered by the Trust.
Not draining kidneys
35. Mrs V says that the Trust did not drain her husband’s kidneys which caused his legs to swell. The Trust’s response does not specify whether the kidneys were drained however, we can see from the records the patient was catheterised.
36. The Trust says that he developed a kidney injury (kidneys not working optimally) as part of acute renal failure due to cancer. It further explained that this is common in terminal conditions.
37. Catheterisation is used to drain urine from the bladder but can also be used to drain the kidneys. Hydronephrosis is the term used to describe a build-up of fluid in the kidneys. We can see the Trust initially suspected kidney damage and completed blood tests and CT scans which described the kidneys as ‘unremarkable’. As such we can see the Trust considered whether there was a urine build but could see no indication of such that would require draining.
38. Over the duration of his stay, he deteriorated, and further tests diagnosed him with metastatic cancer. However, on 7 October we can see that a catheter was inserted. This was further to concerns about fluid build-up and to mitigate swelling. Catheterisation here would attempt to help minimise the fluid build-up in the body.
39. According to the advice we received, the cancer damaged other organs like the liver and lungs. In turn, this damage caused kidney failure. Our adviser explained that as a result of the liver failure from the cancer Mr A experienced fluid retention in his legs. They noted this can happen where the liver is failing even if the kidney function is normal. As such, we have seen no basis to suggest signs Mr A’s kidneys needed draining were missed. We are satisfied, the Trust used a catheter to help manage his fluid retention and aid the kidneys as well as performing various tests to diagnose the underlying cause of his symptoms which was cancer.
40. We appreciate Mrs V would be upset witnessing her husband’s visible and fast deterioration. We hope it provides some reassurance that there is no basis to suggest a clinical failing contributing to that.
Confusing information regarding diagnosis
41. Mrs V says that the Trust gave confusing information regarding his diagnosis. She said that they were initially told it was an infection, then cancer, and that there seemed to be a disagreement between the doctors about the diagnosis.
42. The Trust do not clearly identify there was a failing but do indicate they understand the information provided will have seemed inconsistent and confusing. However, they maintained it was not inappropriate as the diagnosis was unclear and his overall presentation was very challenging. As a result, they have apologised about the communication.
43. We have seen (in the background above) that there was clearly a difference in opinions about possible diagnoses as they were working through what may be causing his diagnosis. It is clear this will have been confusing for the family as they have described. As such, we are proceeding on the basis that communication fell below what the Trust would aim for. We can see the Trust have apologised. We appreciate they have said apologised ‘if staff members gave them contradicting information’ which can be taken to be a qualified apology. However, in this case we are satisfied that this is not unreasonable.
44. According to our Principles for Remedy, we would expect the Trust to be open and accountable and put things right. We are satisfied to see the Trust has acknowledged if staff gave them confusing information and apologised for any distress this had caused. We appreciate how distressing, receiving confusing information about the diagnosis, would have been for Mrs V and her family. However, we also appreciate this was a developing clinical picture and by its nature the Trust would be limited in how clear they could be. Given the Trust’s acknowledgment and apology, we are of the view that no further action is necessary.
Treatment of body
45. Mrs V says that the Trust left the cannula and catheter (the lines) in situ until the autopsy took place. She also says they put his body on thaw without her instructions until the autopsy which led to decomposition and by the time she got the body in December 2022 it had swollen, and it ‘stank’.
Lines left in situ
46. Mrs V complains the Trust left the cannula and catheter (the lines) in situ when the autopsy took place. She says the autopsy was done on 19 October 2022, ten days after her husband died and it’s noted in the pathologist’s report that the lines were in situ. She says the decision for an autopsy was made a couple of days after he died, and this means the Trust never removed the lines in the first place.
47. The Trust explained that its usual practice to leave the cannula and catheter in situ as it prevents leakage. It said that once the pathologist completed his examination those were removed.
48. We have not been able to identify any relevant guidelines for this. We have asked our mortuary adviser who confirmed there are not any guidelines regarding the removal of lines. However, the Human Tissue Authority (HTA) is the body responsible for governing all mortuaries in England and publish their Post-mortem Examination Standards and Guidance (the Standards) which states the Standards’ purpose is to reinforce the Human Tissue Act (2004) intention that the dignity of the person, whether living or deceased, is maintained. Therefore, we would expect that mortuaries treat bodies with dignity.
49. The question is whether leaving the lines in situ fall outside the HTA standards. In our view, this does not fall that short of the standards as keeping the lines in situ likely prevented possible leakage and further deterioration and therefore maintained the dignity of the deceased. Moreover, the records show the lines were removed prior to the body being collected by the funeral director therefore, we are satisfied the Trust acted within the spirit of the HTA standards. Whilst we have not seen an indication of a failing, we do appreciate this was upsetting for the family.
Thawing
50. Mrs V complains the Trust ‘put his body on thaw’ without her instructions until the autopsy on 19 October 2022. She says this led to decomposition and by the time she got the body in December 2022 it had swollen it stank.
51. The Trust said that mortuary staff were not aware of her intentions of finding a private pathologist, nor were they asked to wait for her instructions about this matter.
52. According to the HTA’s Standards (PFE2 c) ‘the HTA advises that bodies should be moved into frozen storage after 30 days in refrigerated storage if there is no indication they are soon to be released or further examined, or before, depending on the condition of the body.’ Therefore, we would expect the body to be moved to the freezer after 30 days in refrigerated storage.
53. The available files show Mr A’s body was transferred from the ward to the mortuary refrigerated storage on 9 October 2022 when he died. It remained there until 19 October 2022, when the autopsy was done by the family’s private pathologist. It was then returned to the refrigerated storage where it remained until 7 November 2022. The 7 November 2022 marked 30 days of the body being in refrigerated storage and it was moved to frozen storage.
54. To clarify, there is a difference between refrigerated and frozen storage. In refrigerated storage the body is kept in a near freezing environment to prevent decomposition and can last up to four weeks. Whereas in frozen storage, the body is kept in freezing conditions for long term storage. Freezing/thawing in medicine refers to a process where cells, tissues, or substances are cooled to extremely low temperatures and then gradually warmed up. Therefore, our understanding is that a body is put to thaw once its frozen not refrigerated.
55. Therefore, there is no evidence to suggest the body was put to thaw between 9 October 2022 (day of death) and 19 October 2022 when the autopsy took place. This is because the body was kept in a refrigerated storage not a frozen storage. The body was moved out of frozen storage and back to refrigerated storage to thaw on 30 November 2022 after the funeral home directors asked to prepare the body.
56. We do not dispute Mrs V’s accounts about the state of the body (being swollen and having a smell such that it ‘stank’). From the records, we know that Mr A had swollen legs prior to his death which is likely that this remained the case after his death. In relation to the smell, we asked our mortuary adviser about the cause of this. Our adviser explained that when a person dies, their body will inevitably start to smell and that it is common that when the body is left to thaw to start smelling again. Therefore, although we acknowledge how upsetting this would have been for Mrs V and her family to receive his body in that state, we have not been able to identify any indications that the body was not treated in line with HTA’s Standards.