3. Mrs O complains that on 6 July 2022 the Practice prescribed her husband, Mr O, medication that was used for end-of-life care without speaking to him, examining him, or discussing with his family why it prescribed the medication.
4. She says the family were shocked and upset that the Practice prescribed this medication when Mr O was due to start treatment for pancreatic cancer.
5. Mrs O wants the Practice to accept what it got wrong, to apologise and improve its service.
6. Mr O was due to start treatment for pancreatic cancer at a private health organisation. On 5 July 2022 a nurse went to his house to take blood and urine samples before he started treatment for his cancer. They noticed Mr O had a very low blood count and needed a blood transfusion before treatment could start.
7. On 6 July, Mr O’s daughter called for an ambulance as he was finding it hard to breathe and felt unwell. A paramedic came and spent about an hour with Mr O speaking to him and examining him. Mr O’s daughter told the paramedic what the nurse had said the day before. The paramedic phoned the Practice and spoke to Mr O’s GP. The GP did a prescription for morphine after speaking to the paramedic.
8. The paramedic said it would not be safe for Mr O to be taken to hospital because of COVID-19, and his blood count was not low enough for a transfusion on the NHS. They advised the family to collect the prescription from the Practice.
9. After getting the medication from the Practice, the family found out they were morphine injections for end-of-life care.
10. Mr O died a week later due to unrelated reasons.
13. The Practice is not saying it did not get anything wrong. It said there was not enough communication with the family when giving the morphine prescription. It said it should have explained the reasons to the family clearly.
14. The Practice said that by prescribing the morphine it was not preparing for Mr O’s death. It said it knew he was having ongoing treatment as well as care from a hospice, but the medication was ‘just in case’ his condition got worse. If that happened, then his family would not have to wait for medication to help care for him.
15. The Practice only gave this explanation after Mrs O made a complaint. The Practice said it understood it was a difficult time for the family, and it could have handled the situation better.
16. Our ‘Principles of Good Complaint Handling’ say to put things right, organisations should ‘provide an apology, explanation, and an acknowledgement of responsibility, as well as remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these.’
17. The Practice has acted in line with this. It accepted there was not enough communication, explained what happened and it has apologised. The Practice said it looks at complaints to see if changes are needed to improve the care it gives. It said this complaint will be included in its review. We think this is enough to put right this failing in communication.
18. We will not take further action on this complaint as there are no reasons for the Practice to do more than it has.
1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs O’s complaint about a practice in the Kent area (the Practice). We are sorry for Mrs O’s loss and we understand this was distressing time for her.
2. After careful consideration, we will not consider the complaint further because we think the Practice has taken action to put right what it got wrong. We will explain our decision in detail below.