Telephone call: 28 September 2022
11. Mr E says a doctor asked him to come to hospital urgently to discuss his mother’s care as her health had deteriorated. He says he told the doctor he had been unwell during the night and asked for more time, but the doctor refused. Mr E says the doctor gave the impression his mother could die very soon. Mr E told us he rushed to hospital very worried, and when he arrived, his mother was sat up in bed eating lunch.
12. In its complaint response the Trust says the doctor asked Mr E to come to hospital sooner, as they wanted to speak with him as soon as possible in case of any further deterioration. The Trust says Mrs F wished to have a discussion with her family about whether she should continue or stop all active treatment, and Mr E is her next of kin.
13. In this case we are unable to favour one account over the other. In the absence of an objective source of evidence, such as an audio recording of the telephone call, we would struggle to make a decision about which account is more accurate.
14. We are sorry for Mr E’s experience of the telephone call and how it affected him. We recognise the nature of the telephone call would have been distressing. As we were not present during the telephone call, we cannot determine what was said by whom, to whom, or in what context, concerning the extent of Mrs F’s deterioration at that time.
15. There is no other evidence we believe we can request that will help sway our decision one way or the other. For this reason, we will decline to consider this complaint any further, as we do not think we will be able to reach a robust decision because of a lack of evidence.
Care and Treatment: 1 October 2022
16. Mr E complains that he told a doctor on 28 September 2022 of his mother’s wishes to be made comfortable for a couple more days, but the Trust failed to give his mother the prescribed palliative medication when she it was needed.
17. Mr E says his niece arrived at hospital at 6am on 1 October 2022, and his mother was experiencing a lot of pain, distress and clutching her chest. Mr E’s niece spoke with a nurse, who then gave Mrs F morphine. A palliative care nurse came later that day and arranged additional medication and a syringe driver.
18. Mr E also complains that staff were dismissive of his concerns. Mr E says he asked a nurse to call a doctor, but they refused and said he had to wait for ward round two hours later. Mr E told us he raised concerns and his frustration with staff, and a doctor came to review his mother within 45 minutes.
19. In response to the complaint, the Trust said Mrs F was admitted to hospital with shortness of breath, no chest pain but she was taking paracetamol. The Trust says it does not have any record of Mrs F or her family raising concerns about pain relief, but a doctor prescribed stronger analgesia overnight on 26 September 2022, because of a sudden deterioration and respiratory distress.
20. The Trust said its respiratory team sees some patients who do not experience significant pain even when cancer is advanced, and pain relief is prescribed as indicated if the patient experiences pain, and medical staff are guided by symptoms.
21. We have not considered in detail the Trust’s actions on 1 October 2022, but we have explored with Mr E whether there was an impact as a result of the claimed failings. Mr E feels that his mother was left to suffer and did not have a dignified death, and this caused his family anger and upset. We are truly sorry for Mr E’s experience.
22. We are unable to link this injustice to the claimed failings. We can see that the Trust prepared palliative medication which was stored in a fridge so that it was available when needed, and a nurse gave Mrs F morphine as soon as they were aware she was in pain.
23. For that reason, we can see no indication the Trust’s actions had an impact on Mrs F. Our decision is not intended to undermine Mrs F’s, or her family’s, experience. We recognise that a close relative approaching end of life is a very upsetting and traumatic time.
24. We understand Mr E feels the nurse was dismissive of his concerns when he asked to see a doctor urgently, and he expressed his anger and frustration. We can see that a doctor came to review Mrs F sooner than planned, and within 45 minutes. Whilst Mr E experienced initial anger and frustration; we can see no indication of any other impact either to Mrs F or her family.
25. Whilst there is no indication of any injustice to Mrs F of her family, the Trust says it has taken learning from the complaint and considered whether any changes could be made to improve inpatient end of life care. As a result, the Trust is now carrying out a review of deaths in its respiratory mortality meeting, and its staff will ensure there is clear documentation regarding pain and analgesia as part of the ward rounds.
26. Our NHS complaints standards says organisations should ‘promote a learning culture by supporting the whole organisation to see complaints as an opportunity to develop and improve its services and people’ and ‘give fair and accountable responses and take action to make sure any learning is identified and used to improve services’
27. We consider that the Trust has acted in line with NHS Complaints Standards. The Trust has provided an explanation and details of the learning and action it has taken, we would not expect it to do anything else to address these concerns.
28. In summary, we consider there are no indications that the Trust’s actions had any impact on Mrs F or her family, regardless of this the Trust has already made service improvements with the aim of preventing concerns about pain relief for patients at end of life. Therefore, we will not consider this complaint any further.
Delay in palliative care
29. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
30. Mr E complains there was an eight-day delay in the palliative care nurses visiting his mother.
31. In its complaint response, the Trust said it referred Mrs F to its specialist palliative care service on 23 September 2022. A palliative care nurse attended the ward the next day, reviewed the medical notes and decided a lung nurse specialist should visit Mrs F. The palliative care nurse spoke with doctors throughout Mrs F’s admission to provide advice on treatment.
32. On 29 September 2022, the ward sent a second referral to the palliative care service, and a nurse visited Mrs F following a telephone call with a doctor.
33. The Trust has not acknowledged a delay in palliative care, but it accepts its specialist palliative care service should have spoken with Mrs F, or her next of kin, after the review on 24 September 2022 to explain its decision. The Trust has apologised that this did not happen.
34. The Trust says it has taken learning from the complaint to improve inpatient end of life care, and as a result it has made the following changes:
• the telephone message retrieval system has been improved, and a member of the specialist palliative care service is assigned to retrieve phone messages daily • patients and/or relatives will receive a visit from the palliative care team if they feel a referral to their team is not appropriate, to help explain the reason for the decision • the concerns will be discussed during the palliative care team and governance meetings for reflection and learning • the concerns will be discussed at the respiratory clinical group meeting for shared learning.
35. We have not considered in detail the actions the Trust took between 23 September and 1 October 2022, but we have considered the impact on Mrs F and her family. We can see that the breakdown in communication caused Mrs F and her family worry and distress, as they were waiting for the specialist palliative care service to review Mrs F.
36. Although the specialist palliative care service was liaising with doctors throughout, as far as the family was concerned, the review did not happen until 1 October 2022, when Mrs F was very poorly and approaching end of life. We understand this was a very difficult and worrying time for Mrs F and her family which would not have been helped by believing the palliative care team had not reviewed Mrs F.
37. Our Principles for Remedy say organisations should offer appropriate remedies when things have gone wrong. That could include an apology, explanation and acknowledgement of responsibility, or remedial action including revising procedures to prevent the same thing happening again and training or supervising staff. The Trust has done that and, therefore, we do not see any indications there is anything remaining for Trust to do in relation to the shortterm worry and distress Mrs F and her family experienced from the Trust’s failure to consult with them after the palliative care review on 24 September 2022.
38. For those reasons, we have decided we will not consider this complaint any further.
39. We realise how difficult and distressing this matter has been for Mr E. We thank Mr E for bringing his complaint to us.