Northern Care Alliance NHS Foundation Trust

4. Mrs L complains about aspects of the care and treatment the Trust provided to her mother, Ms R. Mrs L says the Trust failed to provide adequate end-of-life care in February 2023. Specifically, Mrs L says the Trust failed to promptly administer a syringe driver of morphine to Ms R.

5. Mrs L also says the Trust did not inform Ms R about the long-term risks when it prescribed steroid medication (dexamethasone) to her in January 2023 and did not provide appropriate advice to Ms R surrounding the dose she should take.

6. Mrs L says the Trust’s failure to disclose the risks of the steroid medication it gave to Ms R meant she was not able to make an informed decision about whether to take it. Mrs L told us this was a contributory factor in her mother’s death and, if she had known the risks, she would not have taken it and may have been afforded a better clinical outcome. Mrs L has told us the Trust’s actions meant her mother was not given the care and treatment she needed. She has told us of the trauma and emotional turmoil losing her mother has had on her and her family.

7. To resolve her complaint, Mrs L is seeking financial compensation.

8. In January 2023 Ms R was diagnosed with three brain tumours and received targeted radiation treatment on 7 February 2023. Ms R was prescribed steroids (dexamethasone) as part of her radiotherapy treatment. On 27 January 2023 she received a letter from her oncologist recommending she gradually stop her steroid medication. Ms R finished this medication on 18 February 2023.

9. On 20 February 2023 Ms R was admitted to the Trust with pain in both of her hips and in her lower abdomen. She was also struggling to sleep and was feeling increasingly weak.

10. On her admission, the Trust reviewed Ms R and obtained further investigations, including an MRI scan which ruled out her cancer spreading to her spinal cord. The following day, a palliative care consultant reviewed Ms R and started her on morphine to help with her pain and shortness of breath. The Trust also treated Ms R for pneumonia with antibiotics.

11. On 21 February the Trust prescribed Ms R with pain relief of morphine via a syringe driver. It noted Ms R’s stats had not improved and she had low oxygen levels.

12. On 24 February the Trust obtained some further investigations and found Ms R had a partial collapse of her upper right lung. A few days later, after discussing Ms R at a radiology meeting, the Trust suggested further tests to rule out pneumocystis jirovecii pneumonia (PJP), which is a serious lung infection caused by a fungus.

13. On 2 March the Trust stopped administering the syringe driver to Ms R and started giving her regular morphine to help manage her symptoms.

14. On 5 March 2023 staff treating Ms R identified her condition had not improved and she was placed on end-of-life care.

15. On 6 March, the Trust re-prescribed the syringe driver of morphine to Ms R.

16. Sadly, Ms R died whilst an inpatient at the Trust on 7 March 2023. On 8 March 2023 a sample the Trust had taken from Ms R confirmed she had PJP. This was listed as her cause of death, along with metastatic lung cancer.

Delays with syringe driver

21. When we consider 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 we find a significant difference, we look at whether this caused any impact or injustice. In this case, we think the Trust did not always act in line with applicable guidance, but we have not seen this caused a significant clinical impact to Ms R or contributed to her death.

22. Mrs L says the Trust failed to provide adequate end-of-life care by not administering a syringe driver to her mother in a timely manner.

23. In its response to Mrs L, the Trust explained it prescribed a syringe driver of morphine for Ms R at 3.24pm on 21 February 2023 and administered at this at 6.30pm. It apologised for the delay. It said this was due to a wait for the pump from the pharmacy. The Trust said Ms R’s morphine dosage was increased on 22 February at 4.40pm and started at 6pm. The syringe driver was discontinued on 2 March at 12.58pm after over a week of continuous infusion, and oral modified release morphine was started instead.

24. On 6 March, the morphine via syringe driver was re-prescribed at 1.05am and commenced at 2am. The Trust explained that syringe drivers are stocked in the pharmacy during the day and in the out-of-hours stock cupboard at night.

25. NMC guidance says nursing staff should make sure any treatment, assistance or care for which they are responsible for is delivered without undue delay.

26. From the evidence available, we can see the Trust departed from the NMC guidance. On 21 February the Trust delayed by approximately three hours in giving Ms R her syringe driver, and on 22 February delayed by one hour and 20 minutes. On 6 March, when the Trust re-prescribed Ms R’s syringe driver we can see there was a further delay of nearly one hour. As such, we can see the Trust delays left Ms R without optimal pain relief for a short period on both occasions, meaning she was likely not as comfortable as she would otherwise have been, which would have caused some worry to Mrs L.

27. We are aware Mrs L has concerns that there might be a greater clinical impact as a result of these delays, and we are glad we can reassure her with the benefit of our independent nursing advice that there is nothing to indicate this was the case.

28. We have thought about the impact, as identified above, and looked at what the Trust has done to put things right. We note that the Trust recognised the delays, apologised to Mrs L, and confirmed it had shared her concerns with its staff for reflection.

29. The NHS Complaints Standards say organisations should openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. Our Guidance on Financial Remedy indicates that where the impact of an error ‘is of short duration, and where there are no other adverse effects or ongoing wider impact’ an apology is usually an appropriate remedy.

30. We consider that in acknowledging the delays and explaining what caused them, along with apologising and sharing Mrs L’s feedback with the team that cared for Ms R, the Trust has acted in line with the Complaint Standards and has done enough to put things right

31. With this in mind, we will take no further action with this part of Mrs L’s complaint. We remain very sorry to have learned about Mrs L’s concerns and we thank her for bringing her complaint for our consideration.

Steroid medication

32. Mrs L says the Trust failed to tell her mother the steroid medication she was prescribed would harm her immune system and put her at risk of acquiring serious infections. Mrs L believes the risks of taking this medication should have been disclosed to her mother so they could both make an informed decision about whether this was appropriate for her.

33. In its response to Mrs L, the Trust explained it is well-known among clinicians that steroids have negative effects on immunity. It says it is usual to give patients information about the side effects of steroid medication, including the need to be vigilant for infections. It said the clinician could not recall whether Ms R was given specific information about this and apologised if this did not happen. It said it had contacted its pharmacy service to confirm the usual policy for giving our care cards.

34. The GMC’s ‘Good Medical Practice’ says that clinicians should ‘propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs’. It also says ‘You must give patients the information they want or need in a way they can understand’, including ‘the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option’.

35. Upon review of Ms R’s clinical records, we can see the steroid medication was first prescribed for her cancer, which had sadly spread to her brain, in January 2023. This medication was prescribed by a consultant under a different Trust (Trust B).

36. Our Lead Clinician has confirmed that the responsibility for the consent and communication at that time surrounding Ms R’s steroid medication would not lie with the Trust; rather, it would lie with Trust B. We understand it would be the responsibility of Trust B to explain the risks associated with the steroid medication when it was first prescribed to Ms R, along with the dosages. Based on the information we have seen, we do not consider there to be any indications of failings with this aspect of Mrs L’s complaint about the Trust, as there is nothing to indicate it has failed to act in line with its own responsibilities as set out in both parts of the GMC guidance mentioned above. As such, we will take no further action here.

37. We hope Mrs L is reassured by the explanations we have provided and the steps we have taken to explore her concerns. We recognise that this experience has been extremely upsetting for Mrs L, and we thank her for sharing details of what happened. We hope this statement has clearly explained the reasons for our decision and why we will not be considering her complaint further.

1. We thank Mrs L for bringing her complaint to us. We recognise how important the complaint is to her and the effort she has made to share her experience with us. We would like to offer our sincere condolences to Mrs L and her family for their sad loss.

2. We carefully reviewed Mrs L’s complaints about the care her mother received. We have seen the Trust did delay in administering a syringe driver to Ms R, and this is an indication of a failing. We have not seen anything to indicate this contributed to Ms R’s death or had a long-lasting negative impact on her.

3. We have not seen any indications of failings relating to the management of Ms R’s steroid medication, including the Trust’s communication of its risks or the guidance provided on the appropriate dosage for Ms R. For these reasons, we will take no further action.